Introduction to Medical-Surgical Nursing, 6e 6th Edition by Linton test Bank

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Introduction to Medical-Surgical Nursing, 6e 6th Edition by Linton test Bank

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WITH ANSWERS
Introduction to Medical-Surgical Nursing, 6e 6th Edition by Linton test Bank

Chapter 03: Legal and Ethical Considerations

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. A good friend of a licensed practical/vocational nurse (LPN/LVN) confides that she is in a serious romantic relationship with a man the LPN/LVN had as a patient when he was diagnosed with the human immunodeficiency virus (HIV). The policies of the Health Insurance Portability and Accountability Act (HIPAA) prevent the nurse from warning her friend. What is this situation considered?
a. Moral dilemma
b. Moral uncertainty
c. Moral distress
d. Moral outrage

 

 

ANS:  C

Moral distress occurs when a nurse feels powerless because moral beliefs cannot be honored because of institutional or other barriers.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 32              OBJ:   1

TOP:   Moral Distress                                           KEY:              Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A nurse reminds a resident in a long-term care facility that he has autonomy in many aspects of his institutionalization. What is an example of autonomy?
a. Selection of medication times
b. Availability of his own small electrical appliances
c. Smoking in the privacy of his own room
d. Application of advance directives

 

 

ANS:  D

The application of advance directives is an autonomous decision. Agency protocols relative to medication times, access to private electrical devices, and smoking are rarely waived; these policies are not in the control of the resident.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 32              OBJ:   2

TOP:   Autonomy      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. How might an LPN/LVN exhibit beneficence?
a. Remove defective equipment from the patients room.
b. Willingly work extra shifts during a staff shortage.
c. Adhere to agency policy.
d. Join the National Association for Practical Nurse Education and Service (NAPNES) and attend educational seminars.

 

 

ANS:  A

Beneficence means promoting good and reducing harm. Removing defective equipment demonstrates that the LPN/LVN is reducing possible harm to the patient. Working extra shifts, adhering to policy, and joining NAPNES are personal values, not beneficence.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 32              OBJ:   2

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

 

  1. An LPN/LVN is educating a group of nursing students regarding values demonstrated in their nursing practice. Where will the LPN/LVN indicate the base of these values is derived?
a. Nursing school education
b. Family influence
c. Peer relationships
d. Agency policies

 

 

ANS:  B

The family shapes values that are demonstrated in later life. These values may be enhanced or challenged by life experiences, but the base is forged in the family.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 32              OBJ:   3

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

 

  1. One obstetric nurse remarks, I dont see how these young single women can keep on having babies without being married. Everyone knows a child needs a father. What is this nurse exhibiting?
a. Ethnocentrism
b. Moral uncertainty
c. Values clarification
d. Professional concern

 

 

ANS:  A

Ethnocentricity is the belief that ones own culture and values are superior to those of another. Such statements are based on values clarification and, perhaps, on moral outrage.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 33              OBJ:   5

TOP:   Ethnocentrism/Values Clarification                                           KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nursing student asks the instructor to define the philosophic stand of utilitarianism. What example should the instructor provide?
a. An army officer sacrifices six paratroopers to save 100 prisoners of war.
b. A priest burns down his church because it was defiled by Satanists.
c. A mother jumps off a cliff with her baby to avoid being captured by Indians.
d. A soldier murders captured enemies to prevent their divulging military secrets.

 

 

ANS:  A

The sacrifice of six to save 100 is an example of the greater good. The other options are based on the philosophy of deontology.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 33              OBJ:   6

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

MSC:  NCLEX: N/A

 

  1. An LPN/LVN explains to a patient that the hospital has an institutional ethics committee. What is the main function of this committee?
a. Preside over policy implementation.
b. Revoke the license of someone who violates the law.
c. Solve personnel disputes.
d. Ensure that hiring adheres to ethnic equality.

 

 

ANS:  A

The main job of the institutional ethics committee is to preside over the implementation of agency policy.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 34              OBJ:   8

TOP:   Institutional Ethics Committee        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. An LPN/LVN charts that the patient is drunk and acting in a crazy manner. The team leader cautions the LPN/LVN that this documentation is not appropriate. What charges of commission of the intentional tort is this an example of?
a. Assault
b. Wrongful publication
c. Defamation of character
d. Invasion of privacy

 

 

ANS:  C

Charting or saying unsupported defamatory statements can lead to tort litigation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 38              OBJ:   2

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

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. When an LPN/LVN assists an older woman to stand after a fall in a shopping mall parking lot, the woman twists and sprains her ankle. What protects the LPN/LVN from litigation or an unintentional tort?
a. Hospital malpractice insurance
b. Good faith agreement
c. Good Samaritan law
d. Personal professional insurance

 

 

ANS:  C

The Good Samaritan law protects individuals who assist at an accident scene if they act in good faith. Professional insurance is not in effect because the actions were not performed while the LPN/LVN was on duty.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 39              OBJ:   2

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

 

  1. An LPN/LVN trimmed the toenails of a patient with diabetes too short, which results in a toe amputation from infections. What is the LPN/LVN guilty of?
a. Unintentional tort
b. Intentional tort
c. Negligence
d. Malpractice

 

 

ANS:  D

Malpractice occurs when an unintentional tort causes an injury to a patient.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 39              OBJ:   2

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

 

  1. What must an LPN/LVN acquiring a signature on a surgical informed consent document ensure?
a. The patient is not sedated.
b. The physician is present.
c. The family member is a witness.
d. The signature is in ink.

 

 

ANS:  A

Before surgery, the consent form must be signed before any preoperative sedation is administered. A sedated person cannot give a valid consent.

 

DIF:    Cognitive Level: Application          REF:   p. 40              OBJ:   9

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

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A physician has written an order for Synthroid, 137 mg. The LPN/LVN is aware that the drug is measured in micrograms. What action should the nurse implement?
a. Transcribe the order as if it were written in micrograms.
b. Notify the nursing supervisor.
c. Transcribe the order as written.
d. Call the prescribing physician.

 

 

ANS:  D

The LPN/LVN may call the physician to clarify the order but may not alter the written order in any way. The order for the correct dose will be written as a new order.

 

DIF:    Cognitive Level: Application          REF:   p. 40              OBJ:   12

TOP:   Doctors Orders                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A physician has written an order for morphine sulfate, 100 mg. The LPN/LVN inquires if he meant to write 10 mg. The physician confirms that he meant 100 mg. What action should the LPN/LVN implement?
a. Call a member of the hospital administration.
b. Refuse to transcribe the order.
c. Call the pharmacist.
d. Notify the nursing supervisor.

 

 

ANS:  D

In the event of a physicians refusal to clarify a questionable order, the LPN/LVN should notify the nursing supervisor to intervene.

 

DIF:    Cognitive Level: Application          REF:   p. 40              OBJ:   12

TOP:   Doctors Orders                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

MULTIPLE RESPONSE

 

  1. On what are health care ethics based? (Select all that apply.)
a. Autonomy
b. Fidelity
c. Professionalism
d. Justice
e. Nonmaleficence

 

 

ANS:  A, B, D, E

Health care ethics are based on autonomy, fidelity, beneficence, justice, and nonmaleficence

 

DIF:    Cognitive Level: Knowledge          REF:   p. 32              OBJ:   2

TOP:   Health Care Ethics                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. How does values clarification support nursing practice? (Select all that apply.)
a. Guides decision making
b. Gives insight to patients
c. Enhances peer relationships
d. Helps understand him or herself
e. Gains the confidence of supervisors

 

 

ANS:  A, B, D

Values clarification gives a person a foundation for moral decisions and insight into self and others.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 33              OBJ:   4

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

MSC:  NCLEX: N/A

 

  1. An LPN/LVN arrives on duty at 0700 and is faced with the ethical dilemma of inadequate staffing for the day shift. How should the LPN/LVN invoke a safe harbor? (Select all that apply.)
a. Immediately file a written protest with administration.
b. Leave duty.
c. Refuse the assignment.
d. Call hospital administration.
e. Suggest that the nursing assistants (NAs) file a written protest.

 

 

ANS:  A, E

Filing a written protest relative to short staffing provides the safe harbor for the LPN/LVN and protects his or her license. Nonacceptance of the assignment or leaving duty is considered abandonment. Suggesting that the NA file a similar protest is an effective action.

 

DIF:    Cognitive Level: Application          REF:   p. 40              OBJ:   N/A

TOP:   Inadequate Staffing                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

COMPLETION

 

  1. The values that direct human behavior and are concerned with defining right from wrong are known as _____.

 

ANS:

ethics

An individuals ability to define right from wrong is based on a value system called ethics.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 31              OBJ:   1

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

MSC:  NCLEX: Psychosocial Integrity

 

OTHER

 

  1. Prioritize the steps in solving an ethical dilemma. (Separate the letters with a comma and space: A, B, C, D.)
  2. Evaluate the outcome.
  3. Plan an approach.
  4. Visualize the consequences.
  5. Take action.
  6. Identify the problem.

 

ANS:

E, B, C, D, A

To solve an ethical dilemma, one must clearly identify the problem, plan an approach, visualize the consequences, take action, and evaluate the outcome.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 34              OBJ:   7

TOP:   Solving an Ethical Dilemma           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

Chapter 19: Shock

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. What are the four types of shock?
a. Multiple organ, cardiogenic, renal, and anaphylactic
b. Cardiogenic, renal, hypovolemic, and septic
c. Renal, hypervolemic, obstructive shock, and neurogenic
d. Hypovolemic, cardiogenic, obstructive shock, and vasogenic

 

 

ANS:  D

The four large categories of shock are hypovolemic (low-circulating volume), cardiogenic (low-cardiac output), obstructive (occluded vascular pathway), and vasogenic (massive vasodilation).

 

DIF:    Cognitive Level: Knowledge          REF:   p. 301            OBJ:   1

TOP:   Types of Shock                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Although several life-supporting systems of the body are involved in the pathophysiologic characteristics of shock, shock itself results from failure of which system?
a. Circulatory
b. Endocrine
c. Neurologic
d. Respiratory

 

 

ANS:  A

When the heart fails as a pump, the lack of tissue perfusion follows and deprives all the bodys cells of oxygen and the removal of wastes.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 301            OBJ:   2

TOP:   Definition of Shock                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse is assessing a patient who is in shock. What should the nurse be aware that one common sign will be, regardless of the cause of the shock?
a. The skin is cool and dry with cyanotic nail beds.
b. The skin is cool and moist with cyanotic nail beds.
c. The nail beds are reddened, and the skin is moist and warm.
d. The nail beds are reddened, and the skin is dry and warm.

 

 

ANS:  B

Venous blood pools in the extremities of the fingers as a result of the lack of adequate perfusion of tissues, which makes the skin cool and moist from a lack of oxygen and waste exchanges.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 304-305     OBJ:   3

TOP:   Common Signs of Shock                KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What should a nurse assessing a patient in the progressive stage of shock expect to find?
a. Bounding pulse, decreased respirations, and decreased blood pressure
b. Bounding pulse, shallow respirations, and significantly increased blood pressure
c. Thready pulse and deep respirations with decreased blood pressure
d. Thready pulse and irregular respirations with increased blood pressure

 

 

ANS:  C

When the heart fails as a pump, the pulse is weak; the respirations increase in an effort to decrease the carbon dioxide level; and, with less volume being pumped, the blood pressure falls.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 304            OBJ:   3

TOP:   Signs of Shock                               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What should a nurse expect of a patients respirations caused by the falling blood pressure and impaired blood circulation during the refractory stage of shock?
a. Rapid and deep
b. Rapid and shallow
c. Slow and deep
d. Slow and shallow

 

 

ANS:  D

During the refractory stage of shock, as the body systems are failing, the respirations become slow, shallow, and irregular. Death is imminent at this stage.

 

DIF:    Cognitive Level: Application          REF:   p. 305            OBJ:   2

TOP:   Respirations in Shock                               KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A licensed practical/vocational nurse (LPN/LVN) is assisting in developing a nursing care plan for a patient in shock. Which nursing diagnosis should be included?
a. Increased cardiac output, related to hypertension
b. Increased cardiac output, related to hypotension
c. Decreased cardiac output, related to hypovolemia
d. Decreased cardiac output, related to hypertension

 

 

ANS:  C

Decreased amount of blood is ejected from the heart because of a decreased volume of fluid in the intravascular compartment.

 

DIF:    Cognitive Level: Application          REF:   p. 308            OBJ:   7

TOP:   Nursing Diagnosis for Patients in Shock

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. How does the intraaortic balloon pump (IABP) assist a patient who is in cardiogenic shock to increase cardiac output?
a. Provides generalized vasoconstriction
b. Inflates during the diastole phase
c. Constricts the vena cava
d. Adds hypertonic fluid to the circulating volume

 

 

ANS:  B

The IABP inflates during diastole (relaxation) phase and deflates during the systole (constriction) phase, which improves cardiac output.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 306 | p. 308

OBJ:   6                    TOP:   IABP              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse is explaining to a family member the pathophysiologic characteristic of vasogenic shock. What information should the nurse include?
a. The intravascular compartment fills beyond capacity, allowing fluid to leak out, compressing vital organs.
b. The circulating volume causes excessive constriction of the vessels, causing blood pooling.
c. Widely fluctuating blood pressures stimulate vascular collapse, causing severe alterations in peripheral perfusion.
d. Although the circulating volume is intact, excessive vascular dilation causes drastic drops in the blood pressure.

 

 

ANS:  D

Blood pooling from dilated vessels drops the blood pressure without loss of circulating volume.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 302            OBJ:   2

TOP:   Vasogenic Shock                            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse is caring for a patient who has a cervical spine injury and assesses progressive hypotension. What does this signify?
a. Anaphylaxis
b. Respiratory alkalosis
c. Multiple organ dysfunction syndrome (MODS)
d. Neurogenic shock

 

 

ANS:  D

Gradually decreasing blood pressure in a person with a spinal injury is an indicator of neurogenic shock related to the parasympathetic stimulation, which causes generalized vasodilation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 303            OBJ:   3

TOP:   Implementation                              KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. While shopping in the mall, a nurse sees a lady suddenly fall to the floor. On immediate assessment, the nurse realizes she is not in cardiac arrest and has no need for cardiopulmonary resuscitation (CPR). What should be the immediate actions by the nurse?
a. Check the pulse and respirations and call for a blood pressure cuff.
b. Check the pulse, respirations, skin color, and temperature.
c. Call for help and check the pulse, respiration, and mental status.
d. Ask someone to help place large blankets or coats under her legs and trunk.

 

 

ANS:  C

Shock treatment requires expert medical implementation. However, the nurse may provide first-line support until such help arrives. Circulatory collapse has to be monitored first; pulse, respiration, and mental status should be assessed to evaluate whether oxygen is reaching the brain.

 

DIF:    Cognitive Level: Application          REF:   p. 305            OBJ:   4

TOP:   Emergency Aid for Shock Victim   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse is explaining the rationale behind the use of Hypothermic devices to a patients family. When relaying information what explanation should the nurse provide when asked why this garment provides compression to the legs and abdomen?
a. To help restore cellular perfusion
b. Decreases internal hemorrhage
c. Cools the patient to create less metabolic demand
d. Applies pressure during the systole phase and relax pressure during the diastole phase

 

 

ANS:  A

Hypothermic devices compress the vessels in the legs and abdomen to increase both blood pressure and cardiac output.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 308            OBJ:   6

TOP:   Hypothermic devices                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse is speaking to the family of a 65-year-old Latino woman. To whom should the nurse address most of the conversation to keeping in mind cultural considerations?
a. 66-year-old husband
b. Entire family, in general
c. 42-year-old daughter (oldest child)
d. 40-year-old son (only son)

 

 

ANS:  A

Many older Latino families recognize the older men in the family, the father or husband, as the decision makers.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 310            OBJ:   7

TOP:   Cultural Considerations                  KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. In treating a person outside of a medical facility, a nurse knows that immediate circulatory support for the vital organs must begin as quickly as possible because, without oxygen, the brain cells will begin to die in how many minutes?
a. 4
b. 6
c. 14
d. 24

 

 

ANS:  A

Brain cells must have oxygen to live; they are very sensitive to lack of oxygen and begin to die in 4 minutes.

 

DIF:    Cognitive Level: Knowledge          REF:   N/A                OBJ:   2

TOP:   Brain Death without Oxygen          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The stages of shock proceed in a definite sequence. What is the correct order?
a. Progressive, compensatory, refractory
b. Refractory, progressive, compensatory
c. Compensatory, progressive, refractory
d. Distributive, compensatory, refractory

 

 

ANS:  C

Understanding the sequence of the progression of shock allows the medical team to plan and implement the correct steps to reverse it.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 303            OBJ:   1

TOP:   Stages of Shock                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What causes the cool, damp skin of patients in compensatory shock?
a. Constriction of peripheral blood vessels because of the shunting of blood to the vital organs
b. Action of the antidiuretic hormone released in shock by the adrenal glands
c. Decreasing levels of arterial carbon dioxide, which are pooling in the arms and legs
d. Activation of the baroreceptors in the renal arteries

 

 

ANS:  A

When overall blood volume is reduced in shock, the remaining blood volume is shunted to vital organs.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 303-304     OBJ:   2

TOP:   Rationale for Skin Changes in Compensatory Shock

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which position enhances cerebral blood flow to counteract the symptoms of compensatory shock?
a. Fowler
b. Trendelenburg
c. Gravity neutral
d. Side lying

 

 

ANS:  B

The Trendelenburg position, with the patients head down, allows gravity to pull blood to the cerebrum. All other positions are ineffective for improving cerebral perfusion.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 311            OBJ:   5

TOP:   Positions to Counteract Shock        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse is administering heparin, subcutaneous twice daily, to a patient in cardiogenic shock. What is the expected action of this drug?
a. Inotropic to improve cardiac contractibility
b. Anticoagulant to prevent blood clots
c. Antidysrhythmic to restore normal cardiac contractibility
d. Vasopressor to increase blood pressure

 

 

ANS:  B

Cardiogenic shock may produce clots because of blood stasis, and the heparin will delay clot formation.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 311            OBJ:   5 | 6

TOP:   Heparin for Anticoagulation           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. Which nursing interventions will best assist a patient cope with decreased cardiac output?
a. Dovetailing nursing care tasks allows rest periods for the patient.
b. Maintaining enough cover prevents the patient from shivering.
c. Turning, coughing, deep breathing, and ambulating the patient every 2 hours reduce the risk of embolism.
d. Analgesics should be administered cautiously.

 

 

ANS:  A

Care should be designed to reduce the metabolic demands on the failing heart. Shivering and physical activity increase the demands; analgesics may reduce output more.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 308            OBJ:   6

TOP:   Nursing Patients with Decreased Cardiac Output

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. One of the most important assessments that a nurse makes is to check urine output. Which value objectively validates minimal acceptable renal perfusion for the average-size person?
a. 0.5 mL/kg/hr
b. 0.5 mL/lb/hr
c. 1 mL/lb/hr
d. 0.2 mL/kg/hr

 

 

ANS:  A

When the kidneys produce at least 0.5 mL/kg/hr of urine, the indication is that the vital organs are also being perfused.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 308            OBJ:   5

TOP:   Urine Output As Measure of Tissue Perfusion

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient is in the compensatory stage of shock. What symptoms displayed by the patient would indicate the need to implement immediate nursing action?
a. Irritable and restless
b. Listless and confused
c. Unconscious
d. Anxious and fearful

 

 

ANS:  A

An irritable and restless patient is at definite risk for falling or hurting him- or herself.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 303            OBJ:   3

TOP:   Compensatory Stage Symptoms     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A patient in the progressive stage of shock is receiving medication to manage the symptoms. What is the desired effect of the medication?
a. Increase in cardiac output
b. Decrease in blood pressure
c. Decrease in urine output
d. Lower temperature

 

 

ANS:  A

Increasing cardiac output requires aggressive action to prevent MODS. Dopamine increases heart contractibility and rate.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 304-307     OBJ:   6

TOP:   Treatment of Progressive Shock     KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A family member asks why her father, who is being treated for cardiogenic shock, needs parenteral feeding because he is capable of eating small amounts. What is the best response by the nurse?
a. Parenteral feedings reduce the risk of constipation.
b. Parenteral feedings meet the patients hypermetabolic needs.
c. Parenteral feedings are more convenient and less time consuming.
d. Parenteral feedings decrease the hazard of infection.

 

 

ANS:  B

Hyperbolic nutritional needs of the person in shock are best met by parenteral feedings, which guarantee adequate calories.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 312            OBJ:   6

TOP:   Parenteral Feedings                         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A patients family voices concern regarding the purpose of some of the interventions for systemic inflammatory response syndrome (SIRS). What explanation by the nurse is most appropriate when explaining the rationale of treatment?
a. Applying a MAST garment is mandatory to promote and conserve body heat.
b. Inserting an IABP is required to decrease fluid leaking into the extravascular space.
c. Maintaining strict isolation is vital to prevent an overlying bacterial infection.
d. Aggressive treatment is necessary to support the multiple failing organs.

 

 

ANS:  D

SIRS is the final and possibly fatal stage of shock. The bodys defenses are supported aggressively and rapidly. MAST and IABP are measures used to increase circulating volume. Isolation is not indicated.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 312            OBJ:   6

TOP:   SIRS Treatment                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk

 

  1. An older Japanese patient in progressive shock lingers on the verge of death. What intervention does the patients cultural background dictate?
a. Allow any and all cultural rituals at the bedside.
b. Encourage the family to talk to the patient who can be comforted by their familiar voices.
c. Restrict the ministrations of the folk healer.
d. Suggest that small children not see the patient.

 

 

ANS:  B

Japanese cultural behavior for the dying patient advocates that the entire family be in attendance and take part in the nursing care.

 

DIF:    Cognitive Level: Application          REF:   p. 310            OBJ:   7

TOP:   Psychologic Care of the Patient in Shock

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

COMPLETION

 

  1. A nurse explains that pericardial tamponade and pulmonary embolus can place the patient at risk for _____ shock.

 

ANS:

obstructive

Obstructive shock can result from pericardial tamponade or pulmonary embolus.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 301-302     OBJ:   1 | 2

TOP:   Obstructive Shock                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse explains that when shock forces the body into anaerobic metabolism, organ damage is caused by a product of that metabolism, which is _____.

 

ANS:

lactic acid

Lactic acid, a by-product of anaerobic metabolism, can cause organ damage in the patient who is in shock.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 304            OBJ:   2

TOP:   Lactic Acid    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse explains that the minimal acceptable hourly urine output for a patient in shock who weighs 220 lb is _____.

 

ANS:

5 mL

220 lb 2.2 lb = 10 kg; 0.5 mL/kg/hr 10 = 5 mL.

 

DIF:    Cognitive Level: Analysis               REF:   p. 309            OBJ:   7

TOP:   Minimum Urine Output                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse is aware that immobility and insertion of urinary catheters, although therapeutic, also places the patient at risk for _____.

 

ANS:

infection

The insertion of a Foley catheter and long-term immobility can cause infections.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 309            OBJ:   6

TOP:   Infection        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Reduction of Risk

 

Chapter 39: Upper Digestive Tract Disorders

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. A nurse is preparing to give a tube feeding using a large syringe. What action should the nurse implement before starting the infusion?
a. Roll the patient flat.
b. Check for a residual formula and return the residual to his or her stomach.
c. Place the end of the tube in water and check for bubbles.
d. Flush the tube.

 

 

ANS:  B

Verifying tube placement by pulling up the residual formula is a standard of care for a tube feeding.

 

DIF:    Cognitive Level: Application          REF:   p. 788            OBJ:   4

TOP:   Tube Feeding                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. After receiving a tube feeding, a nurse assesses the patient to be sweaty with abdominal distention and diarrhea. What is the most likely cause of this response?
a. Expected reaction to the tube feeding
b. Dumping syndrome
c. Gastric reflux syndrome
d. Onset of gastroenteritis

 

 

ANS:  B

Dumping syndrome is caused by infusing a tube feeding too fast or infusing a tube feeding that is too rich a formula.

 

DIF:    Cognitive Level: Application          REF:   p. 788            OBJ:   3

TOP:   Dumping Syndrome                       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse is assessing a patient for risk factors that increase the chances of developing oral cancer. Which information from this patients history indicates a risk factor?
a. Alcohol consumption
b. Chewing gum
c. Environmental pollution
d. Consumption of a high-fat diet

 

 

ANS:  A

Alcohol is statistically proven to be a factor because of irritation of the oral mucosa.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 801            OBJ:   2

TOP:   Oral Cancer    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A home health nurse observes a patient with esophageal cancer tilt his head back while eating. What might this cause?
a. Narrowing of the esophagus
b. Limiting the types of food that can be consumed
c. Increased risk of aspiration
d. A neck injury

 

 

ANS:  C

Tilting the head back not only makes it more difficult to eat, but it also increases the risk of aspiration.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 805            OBJ:   3

TOP:   Feeding Technique with Esophageal Cancer

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse is caring for a patient with esophageal surgery who has had stents placed in the esophagus and instructs the patient how best to avoid regurgitation. What should the nurse include in this instruction?
a. Keep the bed flat.
b. Eat only small meals.
c. Lie on the right side after meals.
d. Drink 3 glasses of fluid with each meal.

 

 

ANS:  B

Eating small meals will help with reflux. Keeping the head of the bed raised and not taking in excessive fluid with meals should be practiced.

 

DIF:    Cognitive Level: Application          REF:   p. 806            OBJ:   4

TOP:   Gastroesophageal Reflux                KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse administers promethazine (Phenergan) for nausea. Which extra precautionary action should the nurse implement because of the common side effect of antiemetic medications?
a. Check vital signs for erratic blood pressure.
b. Add a blanket to prevent chilling.
c. Provide extra water to combat thirst.
d. Put up side rails to prevent falls.

 

 

ANS:  D

Most antiemetic medications cause drowsiness because of their effects on the central nervous system, resulting in dizziness and confusion.

 

DIF:    Cognitive Level: Application          REF:   p. 806            OBJ:   4

TOP:   Antiemetic Therapy                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A nurse is construc

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