Medica Surgical Nursing Preparation For Practice 2nd Ed By Osborn Test Bank

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Medica Surgical Nursing Preparation For Practice 2nd Ed By Osborn Test Bank

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WITH ANSWERS
Medica Surgical Nursing Preparation For Practice 2nd Ed By Osborn Test Bank

Osborn, Medical-Surgical Nursing, 2e
Chapter 02

Question 1

Type: MCSA

The nurse is a member of a committee that is studying the frequency of medication errors. Other committee members include a health care provider, pharmacist, pharmacy technician, and nurse manager. The nurse is most likely participating in which specific type of quality process?

  1. Total quality management
  2. Continuous quality improvement
  3. Quality improvement
  4. Quality assurance

Correct Answer: 2

Rationale 1: Total quality management is a way to ensure customer satisfaction by involving all employees in the improvement of the quality of every product or service.

Rationale 2: Continuous quality improvement is the process of improving a system by using multidisciplinary teams to analyze the system, collect measurements, and propose changes.

Rationale 3: Quality improvement programs are large programs that focus on accountability to the payer and consumer.

Rationale 4: Quality assurance refers to an organizations efforts to provide services that follow professional standards and guarantee or ensure quality of care.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-1

 

Question 2

Type: MCSA

At the end of a scheduled work shift, the nurse asks each of his patients if there was anything he could have done to make their day more comfortable. The nurse is most likely participating in which process?

  1. Quality improvement
  2. Self-assessment
  3. Continuous quality improvement study
  4. Departmental assessment

Correct Answer: 1

Rationale 1: At the level of the individual nurse and patient, the quality improvement process is an appraisal of how the nurse performed in taking care of the patients.

Rationale 2: Self-assessment is not the best description of this activity.

Rationale 3: A continuous quality improvement study is conducted by a multidisciplinary team to analyze a system, collect data, and propose changes.

Rationale 4: There is no evidence to suggest a departmental assessment.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-1

 

Question 3

Type: MCSA

The hospital benefits manager describes a health care program in which the nurse employee will pay a certain amount of money each month for comprehensive health services. The nurse will have a primary physician who will direct care within a specific network of providers. The nurses heath care must be provided by these in-network physicians. The nurse will have which type of health care?

  1. Health maintenance organization (HMO)
  2. Traditional insurance service plan
  3. Independent practice association (IPA) coverage
  4. Preferred provider organization (PPO)

Correct Answer: 1

Rationale 1: An HMO is a group health agency that provides basic and supplemental health treatment with a fee being set without regard to the amount or kind of service provided.

Rationale 2: Traditional insurance service plans contract with providers to accept payment based on a fee schedule. The insured may have some restrictions on providers, and the provider is paid directly by the plan.

Rationale 3: An IPA is a group of health care providers who join together to offer services to managed care organizations; the fees are collected and distributed according to fee-for-service arrangements. The physicians remain independent contractors.

Rationale 4: In a PPO, a network of physicians provide care. For a higher deductible, the insured can contract to be able to see providers outside the network.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-2

 

Question 4

Type: MCSA

A patient tells the nurse that her primary care provider wants her to see a specialist, but the specialist is out of the network and her deductible will be higher. The nurse realizes the patient is a member of which type of health care organization?

  1. Medicare
  2. Health maintenance organization (HMO)
  3. Independent practice association (IPA)
  4. Preferred provider organization (PPO)

Correct Answer: 4

Rationale 1: Medicare is the national health insurance program that covers people 65 years of age or older, some people under 65 with disabilities, and people with end-stage renal disease.

Rationale 2: HMOs deliver comprehensive care for fixed prepaid fees or capitation; they typically restrict access to a specific network of providers.

Rationale 3: An IPA is a type of health care provider business structure in which physicians contract with an HMO to provide services but remain independent contractors with separate practices. This business model does not match the described scenario.

Rationale 4: PPOs provide reimbursement for covered care to non-network providers but at a different rate, and the patient may have to pay a higher deductible.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-2

 

Question 5

Type: MCSA

A 46-year-old patient, unemployed and diagnosed with kidney disease, tells the nurse that he is having difficulty with his medical bills. What should the nurse do to help this patient?

  1. Work with the pharmacist to determine which medications the patient can discontinue and still maintain an acceptable level of health.
  2. Suggest the patient take prescribed medications every other day to make the prescription last longer.
  3. Ask social services to discuss Medicare as a health care coverage option.
  4. Assure the patient that the nurse will ask the health care provider if the patient can be quickly discharged to home.

Correct Answer: 3

Rationale 1: Encouraging the patient to discontinue medications is not an acceptable nursing practice.

Rationale 2: The nurse should not suggest that the patient skip doses. This practice would not constitute good care.

Rationale 3: The nurse should find out from social services whether the patient is eligible for Medicare coverage. Medicare is the national health insurance program that covers people 65 years or older, some people under age 65 with disabilities, and people with end-stage renal disease.

Rationale 4: The patient should remain hospitalized as long as necessary to receive essential care.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-2

 

Question 6

Type: MCMA

A patient brought into the emergency department tells the nurse that she does not need anything because she cannot pay for any health services. The nurses assessment is that the patient is very ill and needs care. What nursing actions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Provide paperwork for the patient to sign out of the hospital against medical advice.
  2. Explain that all care will be covered by the Emergency Medical Treatment and Labor Act (EMTALA).
  3. Ask the health care provider for medication because the patient is confused.
  4. Encourage the patient to stay until care is provided.
  5. Agree that services cannot be delivered without pay and refer the patient to the local free clinic.

Correct Answer: 1,4

Rationale 1: If the patient cannot be persuaded to receive services, the nurse should be certain paperwork is signed to indicate the patient is aware of the risks associated with leaving against medical advice.

Rationale 2: EMTALA does not reimburse the hospital for care provided.

Rationale 3: There is no indication that this patient is confused.

Rationale 4: The nurse should encourage the patient to receive care. Contact with social services may be suggested.

Rationale 5: The hospital cannot turn away a patient who requires emergency care services.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-1

 

Question 7

Type: MCSA

The state board of nursing has notified a hospital about the changes in mandatory continuing education requirements for the nurses. The administration realizes these changes would impact which activity?

  1. Regulations
  2. Accreditation
  3. Licensure
  4. Life safety

Correct Answer: 3

Rationale 1: Regulations are rules or laws that govern delivery of care or maintenance of the facility or work environment.

Rationale 2: Accreditation is the process of evaluating actual care delivered to patients, the hospitals performance as an organization, and the outcomes of treatment for patients.

Rationale 3: Licensing regulations differ from state to state and impact the delivery of care, including the credentials and competency of employees.

Rationale 4: Life safety standards and regulations vary from state to state and include having the facility checked for building code compliance and safety standards.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2-4

 

Question 8

Type: MCSA

A patient tells the nurse that he had made some decisions about his care when he thought he was going to die, but now that he knows he isnt, he wants all possible medical treatment. Which nursing action is indicated?

  1. Tell the patient that he cannot change is mind or treatment plan.
  2. Change the patients classification in the medical record.
  3. Contact social services to discuss the change in plans.
  4. Contact the health care provider for the patient to discuss the patients decision.

Correct Answer: 4

Rationale 1: Advance directives can be changed as the individuals needs and goals change.

Rationale 2: Simply changing this classification will not result in wide dissemination of the decision.

Rationale 3: There is no reason to contact social services.

Rationale 4: The patient should discuss this change with the health care provider.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-7

 

Question 9

Type: MCSA

A patient tells the nurse that if he does not wake up after surgery, his friend should be contacted because the friend knows what should be done concerning his health care needs. After referring to the patients medical record, the nurse realizes that the friend has which relationship with the patient?

  1. The patients best friend
  2. The patients health care power of attorney
  3. The patients next-door neighbor
  4. The patients brother

Correct Answer: 2

Rationale 1: There is not enough information to determine if this person is the patients best friend.

Rationale 2: The health care power of attorney is a legal document that establishes a surrogate decision maker to make medical decisions for the patient should he become incapacitated. The nurse reviewed the patients medical record to ensure that information about the friend was documented.

Rationale 3: There is not enough information to determine if the friend is the patients next-door neighbor.

Rationale 4: There is not enough information to determine if the friend is the patients brother.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-7

 

Question 10

Type: MCSA

A patient cries quietly while undergoing a painful treatment. The nurse realizes that although the treatment is painful, it is necessary for the patients healing and recovery. Which ethical principle does this situation exemplify?

  1. Paternalism
  2. Nonmaleficence
  3. Veracity
  4. Respect for others

Correct Answer: 2

Rationale 1: Paternalism allows one to make decisions for another.

Rationale 2: Even though the principle of nonmaleficence states that a person should do no harm, the focus of the projected treatment or procedure is on the consequences of the benefits to the patient, not on the harm that occurs at the time of the intervention.

Rationale 3: Veracity is the concept that individuals should always tell the truth.

Rationale 4: Respect for others acknowledges the right of individuals to make decisions and to live by those decisions.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-5

 

Question 11

Type: MCSA

The health care team is confronted with an ethical dilemma surrounding the types of care available for a particular patient. The team decides to apply ethical principles to determine the best course of action for this patient. This is an example of which ethical theory?

  1. Deontological theories
  2. Principlism
  3. Utilitarianism
  4. Teleological

Correct Answer: 2

Rationale 1: Deontological theories derive norms and rules from the duties human beings owe to one another by virtue of commitments made and roles assumed.

Rationale 2: Principlism incorporates existing ethical principles and attempts to resolve conflicts by applying one or more of the principles.

Rationale 3: Utilitarianism is another term for teleological theories and can be divided into rule and act utilitarianism.

Rationale 4: Teleological theories derive norms or rules for conduct from the consequences of actions.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-5

 

Question 12

Type: MCMA

A patient asks the nurse to promise that nothing bad will happen while the patient is under anesthesia for a surgical procedure. The patient is creating a conflict in which of the nurses ethical principles?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Fidelity
  2. Respect for others
  3. Paternalism
  4. Veracity
  5. Autonomy

Correct Answer: 1,4

Rationale 1: Fidelity means keeping ones promises or commitments. The patient is putting the nurse in the middle of a potentially conflicting situation. The nurse cannot promise that nothing bad will happen to the patient under anesthesia.

Rationale 2: Respect for others acknowledges the right of individuals to make decisions and to live by these decisions.

Rationale 3: Paternalism allows one person to make decisions for another.

Rationale 4: Veracity is the concept that one should always tell the truth. The nurse cannot truthfully make the statement that nothing bad will happen to the patient.

Rationale 5: Autonomy addresses personal freedom and the right of an individual to choose what will happen to herself. The nurses personal autonomy is not at risk in this situation as the nurse is expected to provide safe and effective care.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-5

 

Question 13

Type: MCSA

A health care provider is reviewing the steps taken to address an ethical issue with a patient. Within which step of the MORAL model is this health care provider working?

  1. Massage the dilemma.
  2. Look back and evaluate.
  3. Outline the options.
  4. Act by applying the chosen option.

Correct Answer: 2

Rationale 1: Massaging the dilemma means identifying the issues.

Rationale 2: The health care provider is looking back and evaluating. This is the process of reviewing and reexamining whether desired outcomes were attained and whether new options need to be implemented.

Rationale 3: Outlining the options means fully examining the options, including those that are less realistic.

Rationale 4: Acting by applying the chosen option means implementing the chosen option to resolve the dilemma.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-5

 

Question 14

Type: MCSA

A patient is telling the nurse manager that she believes a wrongful act occurred when she was given the wrong medication. Which type of law would the nurse expect to address this issue?

  1. Criminal law
  2. Common law
  3. Civil law
  4. Tort law

Correct Answer: 4

Rationale 1: Criminal law is public law that involves the prosecution by the government of a person for an act that has been classified as a crime.

Rationale 2: Common law is derived from principles rather than rules and regulations. It is based on precedent rather than statutory laws.

Rationale 3: Civil law is based on normative principles that are codified in codes and statutes.

Rationale 4: A tort is a wrongful act committed against another person or the persons property and resulting in injury or harm, thereby constituting the basis for a claim by the injured party. Although some torts are crimes punishable by imprisonment, the primary aim of tort law is to provide relief for the damages incurred and to deter others from committing the same harms. The injured person may sue for an injunction to prevent the continuation of the tortuous conduct or for monetary damages.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-6

 

Question 15

Type: MCSA

A patient tells the nurse that he had money in the top drawer of his bedside table that is now missing. He is phoning his attorney and plans to press charges. The nurse realizes this patient is planning to implement which type of law?

  1. Contract law
  2. Tort law
  3. Common law
  4. Criminal law

Correct Answer: 4

Rationale 1: Contract law is a way to govern promises or agreements made between two parties.

Rationale 2: A tort is a wrongful act committed against another person or the persons property. The primary aim of tort law is to provide relief for damages.

Rationale 3: Common law is a system of law based on precedent rather than statutory laws.

Rationale 4: Criminal law involves the prosecution by the government of a person for an act that has been classified as a crime. The patient is claiming that money was stolen, which is a crime.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-6

 

Question 16

Type: MCSA

The nursing staff at a local hospital are unable to get to work because of deteriorating weather conditions. The administration realizes the lack of staff to provide care will impact which quality standard?

  1. Improvement
  2. Structure
  3. Outcome
  4. Process

Correct Answer: 2

Rationale 1: Quality improvement is an overall umbrella term that measures and evaluates all three quality standards.

Rationale 2: Structure standards focus on the internal characteristics of the organization and the personnel.

Rationale 3: Outcome standards measure the effectiveness, quality, and time allocated for care.

Rationale 4: Process standards focus on whether the activities within an organization are being conducted appropriately.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-3

 

Question 17

Type: MCMA

The nurse is reviewing activities to assess the quality of care provided for a group of patients. Which situation would be used to measure a process standard?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The patient is able to ambulate without assistance.
  2. Every nurse scheduled to work has current cardiopulmonary resuscitation certification.
  3. A patients output is 2400 cc after receiving one dose of a diuretic.
  4. Nurses turn and reposition patients on bed rest every 2 hours and as needed.
  5. Morning assessments will be completed and documented by 0800.

Correct Answer: 4,5

Rationale 1: A patients ability to ambulate would be considered an outcome standard.

Rationale 2: Evidence of current CPR certification would be considered a structure standard.

Rationale 3: A patients urine output after a medication is administered would be considered an outcome standard.

Rationale 4: Process standards focus on nursing activities, interventions, and the sequence of caregiving events.

Rationale 5: Process standards focus on activities, interventions, and the sequence of caregiving events.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2-3

 

Question 18

Type: MCMA

The nurse has been asked to join a group reviewing patient-focused functions in the hospital. Which situations would the nurse anticipate reviewing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Number of cases reviewed by the ethics committee over the last year
  2. How information is managed in the hospital
  3. Processes used to identify patients at risk for infection after surgery
  4. The hospitals hiring practices
  5. Implementation of a new drug distribution system

Correct Answer: 1,3,5

Rationale 1: Ethics, rights, and responsibilities are patient-focused functions.

Rationale 2: Management of information is an organization function.

Rationale 3: Surveillance, prevention, and control of infection are patient-focused functions.

Rationale 4: Human resources manages hiring practices. Management of human resources is an organization function.

Rationale 5: Medication management is a patient-focused function.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2-4

 

Question 19

Type: MCMA

A patient tells the nurse manager that he is going to charge a nurse with battery for actions that occurred in the emergency department. Which characteristics of battery should the manager consider when formulating a response?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. For battery to occur, actual contact must be made.
  2. Battery could not have occurred unless the patient specifically told the nurse not to touch him just before the contact occurred.
  3. Battery can occur even if the patient is not touched.
  4. For the patient to prove battery, an injury must have occurred.
  5. It will be difficult for the patient to prove battery occurred because he gave consent for treatment.

Correct Answer: 1,3,5

Rationale 1: Battery is actual contact with another person or the persons property.

Rationale 2: The patient does not have to be awake or alert for battery to occur.

Rationale 3: Battery has occurred if someone touches the patient, something the patient is holding, or the patients belongings.

Rationale 4: The patient does not need to experience any harm, injury, or pain to claim that battery has occurred.

Rationale 5: For battery to occur, there must be an absence of legal consent on the part of the patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2-6

 

Question 20

Type: MCMA

A patient in the emergency department required resuscitation, including administration of medications, blood products, and intravenous fluids. The next day, the patient threatens legal action because blood was administered without consent. What questions should the nurse manager ask when investigating this situation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Was the patient conscious when admitted?
  2. Did the patient say he did not want blood products?
  3. Would the patient have died if the blood product had not been administered?
  4. Was another form of treatment other than administration of blood possible?
  5. What is the experience level of the providers caring for this patient?

Correct Answer: 1,2

Rationale 1: If the patient was conscious and participated in treatment, the doctrine of implied consent may apply.

Rationale 2: The manager should determine if the patient refused blood and then was given blood after becoming unconscious.

Rationale 3: If the patient is of age and competent and refuses any treatment, the treatment cannot be administered no matter the urgency.

Rationale 4: The possibility of another form of treatment is not significant in this case.

Rationale 5: The experience level of the providers is not a factor in this case.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-6

 

Osborn, Medical-Surgical Nursing, 2e
Chapter 16

Question 1

Type: MCMA

A patients peripheral intravenous catheter has infiltrated several times during an 8-hour shift. The nurse realizes that the patient needs a central venous access device. Which intravascular devices could a properly trained nurse insert under the guidelines of the infusion nursing standards of practice?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. A triple-lumen catheter
  2. A peripherally inserted central catheter
  3. A tunneled noncuffed catheter
  4. An implanted port
  5. A midline catheter

Correct Answer: 2,5

Rationale 1: A triple-lumen catheter is inserted by a physician.

Rationale 2: This catheter can be inserted by nurses educated and skilled in the procedure.

Rationale 3: A tunneled noncuffed catheter is used for long-term therapy and requires an operative procedure for insertion.

Rationale 4: An implanted port is used for long-term therapy and requires an operative procedure for insertion.

Rationale 5: A midline catheter can be inserted by nurses educated and skilled in the procedure.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-1

 

Question 2

Type: MCSA

Which nursing diagnosis would explain the purpose of using a self-sheathing stylet catheter?

  1. Risk for Fluid Volume Deficit
  2. Risk for Injury
  3. Risk for Altered Nutrition
  4. Risk for Infection

Correct Answer: 2

Rationale 1: Using a self-sheathing stylet catheter does not improve therapy for fluid volume deficit.

Rationale 2: Risk for Injury is the nursing diagnosis that explains the purpose of the self-sheathing catheter. It is engineered with a safety mechanism that encases the needle in a protective chamber upon removal from the inserted catheter, thus preventing a needle-stick injury.

Rationale 3: The use of a self-sheathing stylet catheter is not related to nutritional status.

Rationale 4: The self-sheathing stylet catheter does not prevent infection.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-1

 

Question 3

Type: MCSA

The nurse is preparing to discharge a patient after infusing chemotherapy through an implanted port. What instructions for port care would the nurse provide?

  1. Apply a nonadhering dressing weekly.
  2. Apply a sterile dressing every 2 days.
  3. Place a clean bandage daily.
  4. No dressings are necessary.

Correct Answer: 4

Rationale 1: Use of a nonadhering dressing is not recommended.

Rationale 2: There is no need to use a sterile dressing.

Rationale 3: Bandaging is not necessary.

Rationale 4: No dressings are necessary because the port is completely under the skin.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

 

Question 4

Type: MCSA

A patient receiving peripheral intravenous therapy is mobile but having difficulty maneuvering the intravenous infusion pump. The nurse would choose which add-on device to allow greater mobility for the patient?

  1. A multiflow adapter
  2. An extension set
  3. A stopcock
  4. A filter device

Correct Answer: 2

Rationale 1: A multiflow adapter is used for the administration of two or more infusates simultaneously and does not increase tubing length.

Rationale 2: An extension set is a device that adds length to the existing administration set and allows the patient to move more freely without having to push the intravenous pump.

Rationale 3: A stopcock is used to direct flow of an infusate and would not increase tubing length.

Rationale 4: A filter device provides sterility to the infused parenteral medication or solution but does not increase the tubing length.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

 

Question 5

Type: MCMA

The alarm of a patients infusion delivery system is sounding. The nurse should assess for which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Air in the line
  2. Occlusion of the tubing
  3. Infusion complete
  4. Wrong fluid being infused
  5. Free flow

Correct Answer: 1,2,3,5

Rationale 1: The infusion pump detects the presence of air in the fluid pathway of the set.

Rationale 2: Infusion pumps detect disruptions of flow above the catheter and resistance to flow below the device.

Rationale 3: The preset volume limit has been reached, which sounds the alarm.

Rationale 4: There is no alarm to indicate that the wrong intravenous fluid is infusing.

Rationale 5: The device detects rapid infusion of fluid and sounds the alarm.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-1

 

Question 6

Type: MCMA

Prior to initiating infusion therapy, which nursing diagnosis is the nurse most likely to incorporate into the patients plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Risk for Infection
  2. Alteration in Comfort
  3. Impaired Gas Exchange
  4. Fluid Volume Deficit
  5. Ineffective Individual Coping

Correct Answer: 1,4

Rationale 1: There are inherent risks associated with the invasive nature of infusion therapy. Knowledge of infection control principles is essential for minimizing and preventing complications from infection.

Rationale 2: There is often minimal short-term discomfort to the patient during insertion of the device for infusion therapy.

Rationale 3: This diagnosis does not reflect the purpose of infusion therapy and reflects the respiratory status of the patient.

Rationale 4: Infusion therapy directly reflects the patients fluid volume and electrolyte status.

Rationale 5: The patients coping does not reflect the reason the patient needs infusion therapy.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 16-2

 

Question 7

Type: MCSA

The nurse would initiate which method to facilitate drying of the antiseptic solution applied to the intravenous site?

  1. Fan the area
  2. Blot the area
  3. Blow on the area
  4. Allow the area to dry itself

Correct Answer: 4

Rationale 1: Fanning the area is contraindicated as it would increase the risk of infection.

Rationale 2: Blotting the prepped area is contraindicated, as it would increase the risk of infection to the site.

Rationale 3: Blowing on the prepped area is contraindicated, as it would increase the risk of infection to the site.

Rationale 4: Allowing the area to dry itself is the infusion therapy standard of practice.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

 

Question 8

Type: MCMA

The nurse has successfully completed insertion of a peripheral venous catheter. Documentation following the procedure includes which information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Method of securing the catheter
  2. Size, length, and type of catheter
  3. Patient complaints of pain during the procedure
  4. Patient participation in the procedure
  5. Complications of the procedure

Correct Answer: 1,2,3,5

Rationale 1: Documentation of the method of securing the catheter objectively describes the care rendered during the procedure. It also allows for tracking patient outcomes and monitoring care.

Rationale 2: Documentation of the size, length, and type of catheter objectively describes the care rendered during the procedure. It also allows for tracking patient outcomes and monitoring care.

Rationale 3: Documentation of patient complaints of pain during the procedure objectively describes the care rendered during the procedure and the patients response to the procedure. It also allows for tracking patient outcomes and monitoring care.

Rationale 4: Patient participation in the procedure is not considered pertinent information that should be documented when an infusion-therapy-related procedure has been performed.

Rationale 5: Accurate documentation of complications objectively describes the care rendered during the procedure. It also allows for tracking patient outcomes and monitoring care.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

 

Question 9

Type: MCMA

The nurse inspects the intravenous catheter after removal. Documentation would include which information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Length of catheter
  2. Condition of access caps
  3. Type of catheter
  4. Condition of catheter
  5. Size of catheter

Correct Answer: 1,3,4,5

Rationale 1: Documentation of the length of the catheter is necessary after discontinuation of an intravenous catheter to verify that the catheter did not get sheared or broken when entering the patients vascular system.

Rationale 2: This portion of intravenous catheter insertion does not enter the patients vascular system.

Rationale 3: Documentation of the type of catheter is necessary after discontinuation of an intravenous catheter.

Rationale 4: Documentation of the condition of the catheter is necessary after discontinuation of an intravenous catheter because this data will verify that the catheter was intact and was not sheared or broken when entering the patients vascular system.

Rationale 5: Documentation of the size of the catheter is necessary after discontinuation of an intravenous catheter to verify that the catheter did not get sheared or broken when entering the patients vascular system.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

 

Question 10

Type: MCSA

A patient complains of heaviness and swelling in the extremity of the intravenous infusion. The nurse assesses that the skin around the site is stretched, firm, and cool. What primary nursing intervention is indicated?

  1. Flush the catheter.
  2. Document the finding.
  3. Notify the physician.
  4. Discontinue the catheter.

Correct Answer: 4

Rationale 1: Flushing the catheter will cause further irritation of the surrounding tissue.

Rationale 2: Documenting the finding is necessary; however, it is not the initial intervention that should be implemented.

Rationale 3: Notifying the health care provider is necessary to obtain treatment of the infiltration, but this is not the initial intervention that would be performed.

Rationale 4: These findings indicate that the catheter is infiltrated. It should be discontinued.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

 

Question 11

Type: MCSA

Which nursing diagnosis would the nurse include in the plan of care for a patient with a catheter embolism?

  1. Ineffective Coping
  2. Fluid Volume Deficit
  3. Impaired Skin Integrity
  4. Alteration in Comfort

Correct Answer: 4

Rationale 1: The manner in which a patient copes does not impact this life-threatening emergency.

Rationale 2: A catheter embolism does not reflect signs of fluid loss but rather of decreased vascular perfusion.

Rationale 3: The catheter has broken inside the patients vasculature, and skin integrity will not be altered.

Rationale 4: The patient often experiences chest pain with a catheter embolism.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 16-3

 

Question 12

Type: MCSA

Following insertion of a peripheral vascular device, the patient immediately complains of shortness of breath, chest pain, and palpitations. What is the nurses initial intervention?

  1. Obtain radiographic studies.
  2. Notify the physician.
  3. Place a tourniquet proximal to the site.
  4. Obtain vital signs.

Correct Answer: 3

Rationale 1: Radiographic studies may be indicated, but this is not the initial intervention.

Rationale 2: The physician should be notified, but this is not the initial intervention.

Rationale 3: If a catheter embolism is suspected, immediate interventions must be initiated; the nurse would secure a tourniquet on the patients arm to minimize movement of the catheter.

Rationale 4: Vital signs should be obtained, but this is not the initial intervention.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

 

Question 13

Type: FIB

The flow rate for an IV line is ordered at 60 mL/hr via gravity. The nurse starts the infusion with an infusion set with a drip factor of 10 gtts/mL. The IV should run at _______ drops per minute.

Standard Text:

Correct Answer: 10

Rationale : 60 mL/hr x 10 gtts/mL = 600. 600/ 60(time in minutes) = 10 gtts/min

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

 

Question 14

Type: MCSA

The nurse is caring for a patient receiving medication directly into the cerebrospinal fluid. The nurse correctly describes this procedure as involving which type of catheter?

  1. An intraspinal catheter
  2. An intrathecal catheter
  3. A subcutaneous infusion set
  4. An intraosseous catheter

Correct Answer: 2

Rationale 1: An intraspinal catheter is used for procedures such as the delivery of anesthesia, diagnostic testing, and infusions that involve the spine.

Rationale 2: An intrathecal catheter allows for administration of medications directly into the cerebrospinal fluid.

Rationale 3: Subcutaneous infusion sets are designed to deliver medication into the subcutaneous tissues either intermittently or continuously.

Rationale 4: An intraosseous catheter is inserted into the bones of the long legs or iliac crest to treat thermal injuries, trauma, cardiac arrest, or other life-threatening illnesses until the traditional vascular access can be obtained.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-1

 

Question 15

Type: MCSA

Which intervention would the nurse perform to help prevent an air embolism in a patient receiving intravenous fluid therapy?

  1. Open the clamps on administration sets as they are being changed.
  2. Wait until solution containers are empty before changing.
  3. Use irrigation-type connections on all tubing.
  4. Purge air from the system before initiating the infusion.

Correct Answer: 4

Rationale 1: The clamps should be closed.

Rationale 2: Solution containers should be changed before they are totally empty.

Rationale 3: Luer-Lok connections should be used to prevent accidental disconnection of the tubing.

Rationale 4: Infusion systems must be purged of air before the infusion is initiated.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

 

Question 16

Type: MCSA

The patient asks why the physician ordered only red blood cells (packed RBCs) instead of the entire unit of whole blood. What rationale should the nurse provide?

  1. RBCs are useful for patients who are experiencing a depletion of clotting factors.
  2. It is the only blood that is left in the blood bank.
  3. It is an optimal method of transfusing only the specific component needed by the patient.
  4. RBCs are useful in preventing transfusion reactions.

Correct Answer: 3

Rationale 1: Cryoprecipitates, plasma, and platelets are used to replace clotting factors.

Rationale 2: Using the only blood left in the blood bank would never be the rationale for a blood transfusion.

Rationale 3: Using only the needed component is a safe and economical use of the blood supply.

Rationale 4: RBCs cannot prevent a transfusion reaction.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-4

 

Question 17

Type: MCSA

The nurse is caring for an 80-year-old patient who is receiving a unit of whole blood. During the transfusion the nurse prioritizes assessment for which possible complication?

  1. Liver failure
  2. Infection
  3. Fluid overload
  4. Thrombosis

Correct Answer: 3

Rationale 1: Liver failure is not associated with blood transfusions.

Rationale 2: The clinical manifestations of bacterial contamination may not occur until the transfusion is complete, or in some instances several hours later, depending on the virulence of the infecting organism. This is not the most critical assessment during the transfusion.

Rationale 3: Older patients are at high risk for fluid volume overload during blood transfusions. Whole blood has the most volume, so it also carries the highest risk of causing fluid overload.

Rationale 4: An increased risk for thrombosis is not common during blood transfusion.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-5

 

Question 18

Type: MCMA

A patient admitted 14 hours ago following a motorcycle accident has received 20 units of blood due to massive hemorrhage. Nursing assessment for which complications is essential?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Coagulation imbalances
  2. Acid-base imbalance
  3. Hypocalcemia
  4. Elevated blood ammonia titers
  5. Hypokalemia

Correct Answer: 1,2,3,4

Rationale 1: Patients who have repeated exposure to blood products and the preservatives used to store blood products have an increased risk of developing coagulation imbalances.

Rationale 2: Patients who have repeated exposure to blood products and the preservatives used to store blood products have an increased risk of developing acid-base imbalance.

Rationale 3: Patients who have repeated exposure to blood products and the preservatives used to store blood products have an increased risk of developing hypocalcemia.

Rationale 4: Patients who have repeated exposure to blood products and the preservatives used to store blood products have an increased risk of developing elevated blood ammonia titers.

Rationale 5: Patients who have repeated exposure to blood products and the preservatives used to store blood products have an increased risk of developing hyperkalemia, not hypokalemia.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-5

 

Question 19

Type: MCSA

The nurse understands that the osmotic makeup of the blood has an effect on the composition of interstitial spaces. Because of this factor, the nurse plans to assess the patient for which complication?

  1. Transfusion reaction
  2. Hypovolemia
  3. Infection
  4. Circulatory overload

Correct Answer: 4

Rationale 1: Transfusion reactions are not associated with the osmotic makeup of the blood.

Rationale 2: Hypovolemia is not a consideration because the volume is being increased, not decreased.

Rationale 3: Infections do not manifest themselves until after the completion of the transfusion and are not related to the osmolality of the blood.

Rationale 4: Circulatory overload can occur with transfusions because the increased osmotic makeup of the blood causes fluid to be mobilized from the interstitial space, thereby increasing intravascular volume well beyond that given during the transfusion. High-risk patients include the elderly and those individuals who already have increased circulatory volume or who have a history of heart failure.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-5

 

Question 20

Type: MCSA

The nurse is caring for a patient who suddenly developed severe respiratory distress after a blood transfusion. The health provider makes the diagnosis of transfusion-related acute lung injury (TRALI). The nurse explains which implication of this diagnosis?

  1. The patient can never have another transfusion again from any donor.
  2. If transfusions are necessary, it will be important to use specially screened blood from which white blood cells have been removed.
  3. The patient can never have another transfusion from the same donor.
  4. Close family members of the patient should never have a blood transfusion.

Correct Answer: 3

Rationale 1: It is acceptable for the patient to have another transfusion from another donor.

Rationale 2: There is no indication that specially screened blood or blood with no white blood cells is required.

Rationale 3: The exact cause of this complication is not fully understood. One prevailing theory is that TRALI is caused by the presence of granulocyte antibodies and biologically active lipids in the donor plasma that the recipient reacts to. If antibodies are present in the donors plasma, they stimulate the WBCs in the recipients blood. Once TRALI has occurred, the recipient should not receive any more transfusions from the same donor.

Rationale 4: Family members should be informed, but this is not an indication that they should not have transfusions.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-5

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