Test bank for current medical diagnosis and treatment 2023 2024 62nd edition by by maxine papadakis (1).pdf Test bank for current medical diagnosis and treatment 2023 2024 62nd edition by by maxine papadakis (1).pdf

1. Test Bank For Current Medical Diagnosis And Treatment
2024, 63rd Edition
By Maxine Papadakis, Stephen Mcphee
Chapters 1 - 42

2. Chapter 1. Disease Prevention & Health Promotion
1. Which of the following behaviors indicates the highest potential for spreading infections among
clients? The nurse:
1) disinfects dirty hands with antibacterial soap.
2) allows alcohol-based rub to dry for 10 seconds.
3) washes hands only after leaving each room.
4) uses cold water for medical asepsis.
2. What is the most frequent cause of the spread of infection among institutionalized
patients?
1) Airborne microbes from other patients
2) Contact with contaminated equipment
3) Hands of healthcare workers
4) Exposure from family members
3. Which of the following nursing activities is of highest priority for maintaining medical asepsis?
1) Washing hands
2) Donning gloves
3) Applying sterile drapes
4) Wearing a gown
4. A patient infected with a virus but who does not have any outward sign of the disease is
considered a:
1) pathogen.
2) fomite.
3) vector.
4) carrier.
5. A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute
when caring for this patient?
1) Droplet transmission
2) Airborne transmission
3) Direct contact
4) Indirect contact

3. 6. A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics
to treat a systemic infection. Which type of infection has the patient developed?
1) Endogenous nosocomial
2) Exogenous nosocomial
3) Latent
4) Primary
7.The nurse assists a surgeon with central venous catheter insertion. Which action is
necessary to help maintain sterile technique?
1) Closing the patients door to limit room traffic while preparing the sterile field
2) Using clean procedure gloves to handle sterile equipment
3) Placing the nonsterile syringes containing flush solution on the sterile field
4) Remaining 6 inches away from the sterile field during the procedure
8.A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2
days. His condition has stabilized, and his temperature has returned to normal. Which stage of
infection is the patient most likely experiencing?
1) Incubation
2) Prodromal
3) Decline
4) Convalescence
5) 8.
9. A patient develops localized heat and erythema over an area on the lower leg. These
findings are indicative of which secondary defense against infection?
1) Phagocytosis
2) Complement cascade
3) Inflammation
4) Immunity
10. The patient suddenly develops hives, shortness of breath, and wheezing after receiving
an antibiotic. Which antibody is primarily responsible for this patients response?
1) IgA
2) IgE
3) IgG
4) IgM
11. What type of immunity is provided by intravenous (IV) administration of
immunoglobulin G?
1) Cell-mediated
2) Passive
3) Humoral
4) Active

4. 12. A patient asks the nurse why there is no vaccine available for the common cold. Which response
by the nurse is correct?
1) The virus mutates too rapidly to develop a vaccine.
2) Vaccines are developed only for very serious illnesses.
3) Researchers are focusing efforts on an HIV vaccine.
4) The virus for the common cold has not been identified.
1 . A patient who has a temperature of 101F (38.3C) most likely requires:
1) acetaminophen (Tylenol).
2) increased fluids.
3) bedrest.
4) tepid bath.
14. Why is a lotion without petroleum preferred over a petroleum-based product as a skin
protectant? It:
1) Prevents microorganisms from adhering to the skin.
2) Facilitates the absorption of latex proteins through the skin.
3) Decreases the risk of latex allergies.
4) Prevents the skin from drying and chaffing.
15. For which range of time must a nurse wash her hands before working in the operating
room?
1) 1 to 2 minutes
2) 2 to 4 minutes
3) 2 to 6 minutes
4) 6 to 10 minutes
16. How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation?
1) Place the tray in a specially marked trash can inside the patients room.
Place the tray in a special isolation bag held by a second healthcare worker at the
2) patients door.
Return the tray with a note to dietary services so it can be cleaned and reused for the
3) next meal.
Carrythe tray to an isolation trash receptacle located in the dirty utility room and
4) dispose of it there.
1 . How much liquid soap should the nurse use for effective hand washing? At least:
1) 2 mL
2) 3 mL
3) 6 mL
4) 7 mL

5. 18. To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution
over all surfaces of the hands?
1) When fingers feel sticky
2) After 5 to 10 seconds
3) When leaving the clients room
4) Once fingers and hands feel dry
19. A patient is admitted to the hospital for chemotherapy and has a low white blood cell
count. Which precaution should the staff take with this patient?
1) Contact
2) Protective
3) Droplet
4) Airborne
20. While donning sterile gloves, the nurse notices the edges of the glove package are
slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on
the outside of the glove package. What is the best action for the nurse to take at this point?
1) Continue using the gloves inside the package because the package is intact.
2) Remove gloves from sterile field and use a new pair of sterile gloves.
3) Throw all supplies away that were to be used and begin again.
4) Use the gloves and make sure the yellow edges of the package do not touch the client.
21. The nurse is removing personal protective equipment (PPE). Which item should be
removed first?
1) Gown
2) Gloves
3) Face shield
4) Hair covering
22. A nurse is splashed in the face by body fluid during a procedure. Prioritize the nurses
actions, listing the most important one first.
A. Contact employee health
B. Complete an incident report
C. Wash the exposed area
D.Report to another nurse that she is leaving the immediate area.
1) 1, 2, 3, 4
2) 2, 3, 4, 1
3) 3, 4, 1, 2
4) 4, 1, 2, 3
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. In which situation would using standard precautions be adequate? Select all that apply.

6. 1) While interviewing a client with a productive cough
2) While helping a client to perform his own hygiene care
3) While aiding a client to ambulate after surgery
4) While inserting a peripheral intravenous catheter
2. Which of the following protect(s) the body against infection? Select all that apply.
1) Eating a healthy well-balanced diet
2) Being an older adult or an infant
3) Leisure activities three times a week
4) Exercising for 30 minutes 5 days a week
3. The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about
proper hand washing. The nurse will know that the teaching was effective if the NAP
demonstrate what? Select all that apply. The NAP:
1) uses a paper towel to turn off the faucet.
2) holds fingertips above the wrists while rinsing off the soap.
3) removes all rings and watch before washing hands.
4) cleans underneath each fingernail.
4. Alcohol-based solutions for hand hygiene can be used to combat which types of
organisms? Select all that apply.
1) Virus
2) Bacterial spores
3) Yeast
4) Mold
5. A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse
proceed? Select all that apply.
1) Question the order because the patient must remain in isolation.
2) Place an N-95 respirator mask on the patient and transport him to the test.
3) Place a surgical mask on the patient and transport him to CT lab.
4) Notify the computed tomography department about precautions prior to transport.
True/False
Indicate whether the statement is true or false.
1. Bacteria are necessary for human health and well-being.
Chapter 1. Disease prevention
Answer Section
MULTIPLE CHOICE
1. ANSWER: 3
Patients acquire infection by contact with other patients, family members, and healthcare
equipment. But most infection among patients is spread through the hands of healthcare workers.
Hand washing interrupts the transmission and should be done before and after all contact with

7. patients, regardless of the diagnosis. When the hands are soiled, healthcare staff should use
antibacterial soap with warm water to remove dirt and debris from the skin surface. When no visible
dirt is present, an alcohol-based rub should be applied and allowed to dry for 10 to 15 seconds.
2. ANSWER: 3
Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other
patients, family members, and contaminated healthcare equipment. Some of these are pathogenic
(cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing
infection among patients are spread by direct contact on the hands of healthcare workers.
3. ANSWER: 1
Scrupulous hand washing is the most important part of medical asepsis. Donning gloves,
applying sterile drapes before procedures, and wearing a protective gown may be needed to
ensure asepsis, but they are not the mostimportant aspect because microbes causing most
healthcare-related infections are transmitted by lack of or ineffective hand washing.
4. ANSWER: 4
Some people might harbor a pathogenic organism, such as the human immunodeficiency virus
within their body, and yet do not acquire the disease/infection. These individuals, called carriers,
have no outward sign of active disease, yet they can pass the infection to others. A pathogen is an
organism capable of causing disease. A fomite is a contaminated object that transfers a pathogen,
such as pens, stethoscopes, and contaminated needles. A vector is an organism that carries a
pathogen to a susceptible host through a portal for entry into the body. An example of a vector is a
mosquito or tick that bites or stings.
5. ANSWER: 2
The organisms responsible for measles and tuberculosis, as well as many fungal infections, are
spread through airborne transmission. Neisseria meningitidis, the organism that causes meningitis, is
spread through droplet transmission. Pathogens that cause diarrhea, such
as Clostridium difficile, are spread by direct contact. The common cold can be spread by indirect
contact or droplet transmission.
6. ANSWER: 1
Thrush in this patient is an example of an endogenous, nosocomial infection. This type of infection
arises from suppression of the patients normal flora as a result of some form of treatment, such as
antibiotics. Normal flora usually keep yeast from growing in the mouth. In exogenous nosocomial
infection, the pathogen arises from the healthcare environment. A latent infection causes no
symptoms for long periods. An example of a latent infection is human immunodeficiency virus
infection. A primary infection is the first infection that occurs in a patient.
7. ANSWER: 3
The stage of decline occurs when the patients immune defenses, along with any medical therapies
(in this case antibiotics), are successfully reducing the number of pathogenic microbes. As a result,
the signs and symptoms of infection begin to fade. Incubation is the stage between the invasion by
the organism and the onset of symptoms. During the incubation stage, the patient does not know he
is infected and is capable of infecting others. The prodromal stage is characterized by the first
appearance of vague symptoms. Convalescence is characterized by tissue repair and a return to heal
as the organisms disappear.
8. ANSWER: 1

8. To maintain sterile technique, the nurse should close the patients door and limit the number of
persons entering and exiting the room because air currents can carry dust and microorganisms.
Sterile gloves, not clean gloves, should be used to handle sterile equipment. Placing nonsterile
syringes on the sterile field contaminates the field. One foot, not 6 inches, is required between
people and the sterile field to prevent contamination.
9. ANSWER: 3
The classic signs of inflammation, a secondary defense against infection, are erythema (redness) and
localized heat. The secondary defenses phagocytosis (process by which white blood cells engulf and
destroy pathogens) and the complement cascade (process by which blood proteins trigger the
release of chemicals that attack the cell membranes of pathogens) do not produce visible findings.
Immunity is a tertiary defense that protects the body from future infection.
10. ANSWER: 2
The patient is most likely experiencing an allergic response to the antibiotic. IgE is the antibody
primarily responsible for this allergic response. The antibodies IgA, IgG, and IgM are not involved
in the allergic response. IgA antibodies protect the body from in fighting viral and bacterial
infections. IgG antibioties are the only type that cross the placenta in a pregnant women to protect
her unborn baby (fetus). IgM are the first antibodies made in response to infection.
11. ANSWER: 2
Intravenous administration of immunoglobulin G provides the patient with passive immunity.
Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passive immunity
occurs when antibodies are transferred by antibodies from an immune host, such as from a
placenta to a fetus. Passive immunity is short-lived. Active immunity is longer lived and comes
from the host itself. Humoral immunity occurs by secreted antibodies binding to antigens. Cell-
mediated immunity does not involve antibodies but rather fight infection from macrophages that
kills pathogens.
12. ANSWER: 1
More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly to
develop a vaccine. Although some researchers are focusing efforts on a vaccine for HIV infection,
others continue to research the common cold.
13. ANSWER: 2
Fever, a common defense against infection, increases water loss; therefore, additional fluid is
needed to supplement this loss. Acetaminophen and a tepid bath are not necessary for this low-
grade fever because fever is beneficial in fighting infection. Adequate rest, not necessarily bedrest, is
necessary with a fever.
14. ANSWER: 3
Nonpetroleum-based lotion is preferred because it prevents the absorption of latex proteins
through the skin, which can cause latex allergy. Both types of lotion prevent the skin from drying
and becoming chafed. Neither prevents microorganisms from adhering to the skin.
15. ANSWER: 3
In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of soap
used.
16. ANSWER: 2
Patients who require airborne isolation are served meals on disposable dishes and trays. To dispose
of the tray, the nurse inside the room must wear protective garb and place the tray and its

9. contents inside a special isolation bag that is held by a second healthcare worker at the patients
door. The items must be placed on the inside of the bag without touching the outside of the bag.
17. ANSWER: 2
APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing.
18. ANSWER: 4
The nurse should rub the antiseptic hand solution over all surfaces of the hands until the solution
dries, usually 10 to 15 seconds, to ensure effectiveness.
19. ANSWER: 2
Protective isolation is used to protect those patients who are unusually vulnerable to organisms
brought in by healthcare workers. Such patients include those with low white blood cell counts,
with burns, and undergoing chemotherapy. Some hospital units, such as neonatal intensive care
units and labor and delivery suites, also use forms of protective isolation.
20. ANSWER: 2
The gloves should be thrown away because the gloves are likely to be contaminated from an outside
source. The supplies do not have to be thrown away because they have not been contaminated.
21. ANSWER: 2
The gloves are removed first because they are usually the most contaminated PPE and must be
removed to avoid contamination of clean areas of the other PPE during their removal. The gown is
removed second, then the mask or face shield, and finally, the hair covering.
22. ANSWER: 3
If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse she is
leaving the area, contact the infection control or employee health nurse immediately, and complete
an incident report. It is most important to remove the source of contamination (body fluid) as soon
as possible after exposure to help prevent the nurses from becoming infected. The other activities
can wait until that is done.
MULTIPLE RESPONSE
1. ANSWER: 3, 4
Standard precautions should be instituted with all clients whenever there is a possibility of coming
in contact with blood, body fluids (except sweat), excretions, secretions, mucous membranes, and
breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a client, if the disease is
not spread by air or droplets, there is no likelihood of the nurses encountering body fluids. If the
disease is spread by air or droplets, then droplet or airborne precautions would be needed in
addition to standard precautions. If giving a complete bed bath or performing oral hygiene, the
nurse would need to use standard precautions (gloves); if merely assisting a client to perform those
ADLs, it is not necessary. No exposure to body fluids is likely when helping a client to ambulate
after surgery.
2. ANSWER: 1, 3, 4
Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the bodyagainst
infection. Illness, injury, medical treatment, infancy or old age, frequent public contact, and various
lifestyle factors can make the body more susceptible to infection.
3. ANSWER: 1, 3, 4
Hand washing requires at least 15 seconds of washing, which includes lathering all surfaces of the
hands and fingers to be effective. The fingers should be held lower than the wrists.
4. ANSWER: 1, 3, 4

10. If there is potential for contact with bacterial spores, hands must be washed with soap and water;
alcohol-based solutions are ineffective against bacterial spores.
5. ANSWER: 3, 4
Transporting a patient who requires airborne precautions should be limited; however, when
necessary the patient should wear a surgical mask (an N-95 respirator mask is not required) that
covers the mouth and nose to prevent the spread of infection. Moreover, the department where the
patient is being transported should be notified about the precautions before transport.
TRUE/FALSE
1. ANSWER: T
Organisms that normally inhabit the body, called normal flora, are essential for human health and
well-being. They keep pathogens in check. In the intestine, these flora function to aid digestion and
promote the release of vitamin K, vitamin B12, thiamine, and riboflavin.
Chapter 1 Health Promotion (Part 2)
1. A client informs the nurse that he has quit smoking because his father died from lung
cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an
example of which of the following?
1) Healthy living
2) Health promotion
3) Wellness behaviors
4) Health protection
2. A patient with morbid obesity was enrolled in a weight loss program last month and has
attended four weekly meetings. But now he believes he no longer needs to attend meetings
because he has learned what to do. He informs the nurse facilitator about his decision to quit the
program. What should the nurse tell him?
By now you have successfully completed the steps of the change process. You should be
1) able to successfully lose the rest of the weight on your own.
Although you have learned some healthy habits, you will need at least another 6 weeks
2) before you can quit the program and have success.
You have done well in this program. However, it is important to continue in the program to
learn how to maintain weight loss. Otherwise, you are likely to return to your previous
3) lifestyle.
You have entered the determination stage and are ready to make positive changes that you
can keep for the rest of your life. If you need additional help, you can come back at
4) a later time.
3. The school nurse at a local elementary school is performing physical fitness assessments
on the third-grade children. When assessing students cardiorespiratory fitness, the most
appropriate test is to have the students:
1) Step up and down on a 12-inch bench.
2) Perform the sit-and-reach test.
3) Run a mile without stopping, if they can.
4) Perform range-of-motion exercises.

11. 4. In the Leavell and Clark model of health protection, the chief distinction between the
levels of prevention is:
1) The point in the disease process at which they occur.
2) Placement on the Wheels of Wellness.
3) The level of activity required to achieve them.
4) Placement in the Model of Change.
5. The muscle strength of a woman weighing 132 pounds who is able to lift 72 pounds
would be recorded as which of the following?
1) 1.83
2) Moderate
3) 0.55
4) 18.3%
6. Which is one of the greatest concerns with heavy and chronic use of alcohol in teens and young
adults?
1) Liver damage
2) Unintentional death
3) Tobacco use
4) Obesity
7. A 55-year-old man suffered a myocardial infarction (heart attack) three months ago.
During his hospitalization, he had stents inserted in two locations in the coronary arteries. He was
also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is
he receiving?
1) Primary prevention
2) Secondary prevention
3) Tertiary prevention
4) Health promotion
8 Health screening activities are designed to:
1) Detect disease at an early stage.
2) Determine treatment options.
3) Assess lifestyle habits.
4) Identify healthcare beliefs.
9 Which individuals should receive annual lipid screening?
1) All overweight children
2) All adults 20 years and older
3) Persons with total cholesterol greater than 150 mg/dL
4) Persons with HDL less than 40 mg/dL

12. 10. A mother of three young children is newly diagnosed with breast cancer. She is intensely
committed to fighting the cancer. She believes she can control her cancer to some degree with a
positive attitude and feelings of inner strength. Which of the following traits is she
demonstrating that is linked to health and healing?
1) Invincibility
2) Hardiness
3) Baseline strength
4) Vulnerability
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. The World Health Organizations definition of health includes which of the following?
Choose all that apply.
1) Absence of disease
2) Physical well-being
3) Mental well-being
4) Social well-being
2. According to Penders health promotion model, which variables must be considered when
planning a health promotion program for a client? Choose all that apply.
1) Individual characteristics and experiences
2) Levels of prevention
3) Behavioral outcomes
4) Behavior-specific cognitions and affect
3. Goals for Healthy People 2020 include which of the following? Choose all that apply.
1) Eliminate health disparities among various groups.
2) Decrease the cost of healthcare related to tobacco use.
3) Increase the quality and years of healthy life.
4) Decrease the number of inpatient days annually.
4. The nurse is implementing a wellness program based on data gathered from a group of
low-income seniors living in a housing project. He is using the Wheels of Wellness as a model for his
planned interventions. Which of the following interventions would be appropriate based on
this model? Choose all that apply.
1) Creating a weekly discussion group focused on contemporary news
2) Facilitating a relationship between local pastors and residents of subsidized housing
3) Coordinating a senior tutorial program for local children at the housing center
4) Establishing an on-site healthcare clinic operating one day per week
5. The nurse working in an ambulatory care program asks questions about the clients locus
of control as a part of his assessment because of which of the following? Choose all that apply.
1) People who feel in charge of their own health are the easiest to motivate toward change.

13. People who feel powerless about preventing illness are least likely to engage in health
2) promotion activities.
People who respond to direction from respected authorities often prefer a health
3) promotion program that is supervised by a health provider.
People who feel in charge of their own health are less motivated by health promotion
4) activities.
6. Health promotion programs assist a person to advance toward optimal health. Which of
the following activities might such programs include? Choose all that apply.
1) Disseminating information
2) Changing lifestyle and behavior
3) Prescribing medications to treat underlying disorders
4) Environmental control programs
7 Which of the following actions demonstrate how nurses promote health?
1) Role modeling
2) Educating patients and families
3) Counseling
4) Providing support
Completion
Complete each statement.
1. A middle-aged woman performs breast self-examination monthly. This intervention is
considered to be prevention.
2. refers to nursing actions performed to help clients to achieve an
optimal state of health.
3. What is the name of the nursing theorist who defines health as having three elements: a high
level of overall physical, mental, and social functioning; a general adaptive-maintenance level of
daily functioning; and the absence of illness (or the presence of efforts that lead to its absence)?
Chapter 1. Health Promotion (Part 2) Answer
Section
MULTIPLE CHOICE
1. ANSWER: 4
Although health promotion and health protection may involve the same activities, their difference
lies in the motivation for action. Health protection is motivated by a desire to avoid illness. Health
promotion is motivated by the desire to increase wellness. Smoking cessation may also be a wellness
behavior and may be considered a step toward healthy living; however, neither of these addresses
motivation for action.
Comprehension
2. ANSWER: 3
Prochaska and Diclemente identified four stages of change: the contemplation stage, the
determination stage, the action stage, and the maintenance stage. This patient demonstrates
behaviors typical of the action stage. If a participant exits a program before the end of the
maintenance stage, relapse is likely to occur as the individual resumes his previous life style.

14. 3. ANSWER: 3
Field tests for running are good for children and can be utilized when assessing cardiorespiratory
fitness. The step test is appropriate for adults. The 12-inch bench height is too high for young
children. The sit-and-reach test as well as range-of-motion exercises would be appropriate when
assessing flexibility.
4. ANSWER: 1
Leavell and Clark identified three levels of activities for health protection: primary, secondary, and
tertiary. Interventions are classified according to the point in the disease process in which they
occur.
5. ANSWER: 3
Muscle strength measures the amount of weight a muscle (or group of muscles) can move at one
time. This is recorded as a ratio of weight pushed (or lifted) divided by body weight. A woman
weighing 132 pounds who is able to lift 72 pounds has a ratio of 72 divided by 132, or 0.55.
6. ANSWER: 2
Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and injuries and
intentional death (suicide and homicide). Although alcohol as a depressant slows metabolism,
chronic alcohol use is more likely associated with poor nutrition, which may or may not lead to
obesity. Chronic alcohol use causes damage to liver cells over time in the later years. Alcohol intake
is often associated with tobacco and recreational drug use; however, the risk of unintentional injury,
such as car accident, suicide, or violence, is more concerning than smoking.
7. ANSWER: 3
Primary prevention activities are designed to prevent or slow the onset of disease. Activities such as
eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting
immunizations are examples of primary level interventions. Secondary prevention activities detect
illness so it can be treated in the early stages. Tertiary prevention focuses on stopping the disease
from progressing and returning the individual to the pre-illness phase. The patient has an
established disease and is receiving care to stop the disease from progressing.
8. ANSWER: 1
Health screening activities are designed to detect disease at an early stage so that treatment can begin
before there is an opportunity for disease to spread or become debilitating.
9. ANSWER: 1
The American Academy of Pediatrics take a targeted approach, recommending that overweight
children receive cholesterol screening, regardless of family history or other risk factors for
cardiovascular disease. The American Heart Association recommends that all adults age 20 years or
older have a fasting lipid panel at least once every 5 years. If total cholesterol is 200 mg/dL or
greateror HDL is less than 40 mg/dLfrequent monitoring is required.
10. ANSWER: 2
Research has also demonstrated that in the face of difficult life events, some people develop
hardiness rather than vulnerability. Hardiness is a quality in which an individual experiences high
levels of stress yet does not fall ill. There are three general characteristics of the hardy person:
control (belief in the ability to control the experience), commitment (feeling deeply involved in the
activity producing stress), and challenge (the ability to view the change as a challenge to grow).
These traits are associated with a strong resistance to negative feelings that occur under adverse
circumstances.
MULTIPLE RESPONSE
1. ANSWER: 2, 3, 4

15. The World Health Organization defines health as a state of complete physical, mental, and social
well-being, not merely the absence of disease of infirmity.
2. ANSWER: 1, 3, 4
Pender identified three variables that affect health promotion: individual characteristics and
experiences, behavior-specific cognitions and affect, and behavioral outcomes. Levels of prevention
were identified by Leavell and Clark; three levels relate to health protection. The levels differ based
on their timing in the illness cycle.
3. ANSWER: 1, 3
The four overarching goals of Healthy People 2020 are to 1) increase the quality and years of healthy
life, free of disease, injury, and premature death, 2) eliminate health disparities and improve health
for all groups of people, 3) create physical and social environments for people to live a healthy life,
and 4) promote healthy development for people in all stages of life.
4. ANSWER: 1, 2, 3, 4
The Wheels of Wellness model identifies the following dimensions of health: emotional, intellectual,
physical, spiritual, social/family, and occupational. A weekly discussion group stimulates intellectual
health. A relationship between local pastors and those living in subsidized housing creates a climate
for spiritual health. A tutorial program offered by seniors to local children will facilitate
occupational health. An on-site healthcare clinic addresses physical health.
5. ANSWER: 1, 2, 3
Identifying a persons locus of control helps the nurse determine how to approach a client about
health promotion. People who feel powerless about preventing illness are least likely to engage in
health promotion activities. People who respond to direction from respected authorities often
prefer a health promotion program that is supervised by a health provider. Clients who feel in
charge of their own health are the easiest to motivate toward positive change.
6. ANSWER: 1, 2, 4
Health promotion programs may be categorized into four types: disseminating information;
programs for changing lifestyle and behavior; environmental control programs; and wellness
appraisal and health risk assessment programs. Prescribing medications to treat underlying
disorders is an activity that fosters health focused at an individual level rather than at a group
program level.
7. ANSWER: 1, 2, 3, 4
Nurses promote health byacting as role models, counseling, providing health education, and
providing and facilitating support.
1. ANSWER: secondary
Secondary prevention activities detect illness so that it can be treated in the early stages. Health activities
such as mammograms, testicular examinations, regular physical examinations, blood pressure and
diabetes screenings, and tuberculosis skin tests are examples of secondary interventions. Primary
prevention activities are designed to prevent or slow the onset of disease and promote health.
Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and
getting immunizations are examples of primary level interventions. Tertiary prevention focuses on
stopping the disease from progressing and returning the individual to the pre-illness phase.
Chapter 2. Common Symptoms

16. 1. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through
narrowed bronchioles would produce which of these adventitious sounds?
a. Wheezes
b. Bronchial sounds
c. Bronchophony
d. Whispered pectoriloquy
ANSWER: A
Wheezes are caused by air squeezed or compressed through passageways narrowed almost to
closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic
emphysema.
2. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse
that he has had a runny nose for a week. When performing the physical assessment, the nurse
notes that the child has nasal flaring and sternal and intercostal retractions. The nurses next
action should be to:
a. Assure the mother that these signs are normal symptoms of a cold.
b. Recognize that these are serious signs, and contact the physician.
c. Ask the mother if the infant has had trouble with feedings.
Perform a complete cardiac assessment because these signs are probably indicative of early heart
d.
ANSW
ER: B
failure.
The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the
nostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternum and
intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute
airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is
warranted. These signs do not indicate heart failure, and an assessment of the infants feeding is not a
priority at this time.
3. A teenage patient comes to the emergency department with complaints of an inability to
breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis,
tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on
the left, and decreased breath sounds on the left. The nurse interprets that these assessment
findings are consistent with:
a. Bronchitis.
b. Pneumothorax.
c. Acute pneumonia.
d. Asthmatic attack.
ANSWER: B
With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the
pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased
or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest

17. expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with
the presence of pneumothorax.
4. The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. This
test is used to confirm a(n):
a. Inflamed liver.
b. Perforated spleen.
c. Perforated appendix.
d. Enlarged gallbladder.
ANSWER: C
An inflamed or perforated appendix irritates the iliopsoas muscle, producing pain in the RLQ.
5.Which statement indicates that the nurse understands the pain experienced by an older adult?
a. Older adults must learn to tolerate pain.
b. Pain is a normal process of aging and is to be expected.
c. Pain indicates a pathologic condition or an injury and is not a normal process of aging.
d. Older individuals perceive pain to a lesser degree than do younger individuals.
ANSWER: C
Pain indicates a pathologic condition or an injury and should never be considered something that
an older adult should expect or tolerate. Pain is not a normal process of aging, and no evidence
suggests that pain perception is reduced with aging.
6. In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in
appearance, and appear to have deep crypts. What is correct response to these findings?
a. Refer the patient to a throat specialist.
b. No response is needed; this appearance is normal for the tonsils.
c. Continue with the assessment, looking for any other abnormal findings.
d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.
ANSWER: B
The tonsils are the same color as the surrounding mucous membrane, although they look more
granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until
puberty and then involutes.
7. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the
mother states, I think she is getting her first tooth because she has started drooling a lot. The
nurses best response would be:
a. Youre right, drooling is usually a sign of the first tooth.
b. It would be unusual for a 3 month old to be getting her first tooth.
c. This could be the sign of a problem with the salivary glands.
d. She is just starting to salivate and hasnt learned to swallow the saliva.

18. ANSWER: D
In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to
swallow the saliva. This drooling does not herald the eruption of the first tooth, although many
parents think it does.
8. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for
this patient?
a. Hypertrophy of the gums
b. Increased production of saliva
c. Decreased ability to identify odors
d. Finer and less prominent nasal hair
ANSWER: C
The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers.
Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy,
and saliva production decreases.
9. The nurse is palpating the sinus areas. If the findings are normal, then the patient should report
which sensation?
a. No sensation
b. Firm pressure
c. Pain during palpation
d. Pain sensation behind eyes
ANSWER: B The person should feel firm pressure but no pain. Sinus areas are tender to
palpation in persons with chronic allergies or an acute infection (sinusitis).
10. A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a
friend who just died from cancer of the prostate. He is concerned this will happen to him.
Howshould the nurse respond?
a. The swelling in your prostate is only temporary and will go away.
b. We will treat you with chemotherapy so we can control the cancer.
c. It would be very unusual for a man your age to have cancer of the prostate.
d. The enlargement of your prostate is caused by hormonal changes, and not cancer.
ANSWER: D The prostate gland commonly starts to enlarge during the middle adult years. BPH is
present in 1 in 10 men at the age of 40 years and increases with age. It is believed that the
hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas.
The other responses are not appropriate.
11. A patient reports excruciating headache pain on one side of his head, especially around his
eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each
day. The nurse should suspect:
a. Hypertension.

19. b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches.
ANSWER: B Cluster headaches produce pain around the eye, temple, forehead, and cheek
and are unilateral and always on the same side of the head. They are excruciating and occur
once or twice per day and last to 2 hours each.
12. A patient says that she has recently noticed a lump in the front of her neck below her Adams
apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to
suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):
a. Is tender.
b. Is mobile and not hard.
c. Disappears when the patient smiles.
d. Is hard and fixed to the surrounding structures.
ANSWER: BPainless, rapidly growing nodules may be cancerous, especially the appearance of a
single nodule in a young person. However, cancerous nodules tend to be hard and fixed to
surrounding structures, not mobile.
Chapter 3. Preoperative Evaluation & Perioperative Management
MULTIPLE CHOICE
1. The nurse is identifying diagnoses appropriate for a client scheduled for a surgical procedure.
Which of the following is a diagnosis commonly used for preoperative client?

20. 1. Anxiety
2. Sleep deprivation
3. Excess fluid volume
4. Disturbed body image
The preoperative experience may be one of the most tension-producing periods of
hospitalization. The nursing diagnosis anxiety is commonly used for preoperative clients. The
other diagnoses are not commonly used as preoperative diagnoses.
2. The preoperative nurse cares for the client until the client progresses into the intraoperative
phase of care which begins when the client:
1. signs the surgical consent form.
2. arrives at the surgical suite doors.
3. is transferred to the postanesthesia care unit.
4. accepts that surgery is pending.
ANSWER: 2
The preoperative period ends and the intraoperative period begins when the patient and family are
at the door to the surgical suites. Intraoperative care does not begin when the client signs the
surgical consent form, is transferred to the postanesthesia care unit, or accepts that surgery is
pending.
3. The nurse is ensuring that a client is able to make knowledgeable decisions regarding an
upcoming surgery and can provide informed consent. What is the responsibility of the nurse
regarding informed consent?
1. Explain the surgical options
2. Explain the operative risks
ANSWER: 1

21. 3. Describe the operative procedure to be done
4. Witness a patients signature
ANSWER: 4
The nurse may concurrently sign that he has witnessed a patients signature. It is the physicians
responsibility to explain the other answer choices.
PTS: 1 DIF: Apply REF: Decision Strategies and Informed Consent
4.A client being prepared for surgery has a pulse oximeter placed on one digit of his hand. The
nurse is applying this device to monitor the clients:
1. oxygen level.
2. heart rate.
3. blood pressure.
4. urine output.
ANSWER: 1
Pulse oximeters are used to precisely identify the clients peripheral tissue oxygenation. Pulse
oximeters are not to measure heart rate, blood pressure, or urine output.
PTS: 1 DIF: Analyze REF: Trends
5.A client is scheduled for surgery in 2 weeks. Which of the following should the nurse instruct
the client regarding healthy lifestyle behaviors?
1. Eat nutritious meals.
2. If obese, cut calories before the surgery.
3. If sedentary, exercise more before the surgery.
4. Stop all prescribed medications.

22. ANS: 1
The client should be encouraged to adopt healthy dietary, rest, and exercise habits before the
surgery. A client who has not followed healthy lifestyle habits should not suddenly make these
changes before a surgical procedure. The nurse should encourage the client to eat nutritious
meals. A client who is obese should not be encouraged to cut calories before the surgery. The
client who is sedentary should not be encouraged to suddenly exercise before the surgery. The
client should not be instructed to stop prescribed medications unless a physician has prescribed
this action.
PTS: 1 DIF: Apply REF: Time Frames and Tasks
6. The nurse wants to reduce the stress level for a preoperative client. Which of the following
communication techniques can the nurse use to achieve this result?
1. Allow the client to be alone before the surgery.
Observe and ask the client if there is anything that can be done to help reduce her
2. anxiety.
3. Refer to the client by her first name.
4. Make tasteful jokes or comments to help the client laugh.
ANSWER: 2
Strategies to reduce preoperative stress include observing and asking the client if there is anything
that can be done to help reduce her anxiety. Leaving the client alone before the surgery will not help
reduce stress. Referring to the client by her first name might be considered unprofessional and
should not be done. Making jokes is also not a professional behavior and should not be done by the
nurse.
PTS: 1 DIF: Apply REF: Nurse/Patient Communication
7. Which of the following can the nurse do to help an elderly client scheduled for a surgical
procedure?
1. Work at a slower pace.
2. Speed up the pace so the client has time to rest.
3. Talk to family members and leave the client alone.

23. 4. Send them to the surgical holding area in advance.
ANSWER: 1
When caring for elderly clients, pace is important. Nurses should slow the pace. The nurse should
not ignore the client. The nurse should also not send the client to the surgical holding area in
advance since this could prove to be uncomfortable for the elderly client.
PTS:1DIF:ApplyREF:Age-Related Issues
8. The nurse is concerned that a client scheduled for surgery will be at risk for hypothermia.
Which of the following did the nurse assess in this client to determine the risk?
1. Client is a vegetarian.
2. Client exercises 5 days a week for 30 minutes.
3. Client has a history of congestive heart failure.
4. Clint is 48 years old.
ANSWER: 3
Clients at risk for hypothermia include the very young, the very old, those with a history of heart
disease, those with a bleeding tendency, having complex surgery, and having surgery on a large
body area that will be exposed. Being a vegetarian or exercising does not predispose a client to
developing hypothermia during surgery.
PTS:1DIF:AnalyzeREF:Environmental Safety
9. The nurse is concerned that a client may have an undocumented allergy to latex when which of
the following is assessed?
1. Recent episode of appendicitis
2. Recovered from bronchitis 3 months ago
3. Allergy to specific foods
4. Does not like to wear wool clothing

24. ANS: 3
Risk factors for latex allergy include a history of allergies, for example, food allergies or contact
dermatitis (eczema). Appendicitis and bronchitis do not increase the clients risk of a latex allergy.
The clients not wearing wool clothing does not increase the clients risk of a latex allergy.
PTS: 1 DIF: Analyze REF: Personal Patient Safety
10. The nurse is providing a medication to reduce the preoperative clients anxiety. Which of the
following medications is the nurse most likely providing to the client?
1. Hydrogen ion antagonist
2. Anticholinergic
3. Calcium channel blocker
4. Opioid
ANSWER: 4
Opioids provide analgesia, decrease anxiety, and provide sedation. Calcium channel blockers
treat specific heart problems. Hydrogen ion antagonists are used to reduce gastric secretions.
Anticholinergics are used to reduce oral and respiratory tract secretions.
PTS:1DIF:ApplyREFharmacology
11. An elderly client scheduled for surgery is concerned that his wife is not going to be able to
manage at home alone. Which of the following can the nurse do to help this client and spouse?
1. Encourage the client to not worry about his spouse.
2. Ask the client if the spouse would agree to having some help while he is hospitalized.
3. Encourage the spouse to come and stay with the client in the hospital.
4. Suggest the spouse stay in a hotel until the client is discharged.
ANSWER: 2
When the frail elderly and spouse live together, they depend on each other for daily existence.
When one is hospitalized, it places both at risk. The nurse should ask the client if the spouse would
agree to having some help while the client is hospitalized. Encouraging the client not to

25. worry does not take into consideration the risk to the spouse. Having the spouse stay with the
client in the hospital could cause additional health problems for both the client and spouse. The
clients finances might not support the spouse staying in a hotel until the client is discharged.
PTS:1DIF:Apply
12. A client needs emergency surgery after sustaining injuries from a natural gas explosion. The
client is not attended by any family member and the surgery cannot wait. Which of the following
can be done to ensure the best and safest care is provided to the client?
1. Hold the surgery until a family member arrives to the hospital to provide consent.
2. Contact a pastor to pray with the client before the surgery.
3. Instruct the client in postoperative exercises while waiting for anesthesia to take effect.
Have a member of the nursing staff try to reach the family at home to provide consent
4. for the surgery.
ANSWER: 4
In the case of an unaccompanied trauma client, the team should make every effort to reach the
family; however, preservation of life and function is a priority. A member of the nursing staff can
attempt to reach the family for consent, but the surgery should not be delayed until a family
member arrives to provide consent. Since the surgery takes precedence, the clients instruction,
psychosocial, and spiritual needs will need to be addressed afterwards.
PTS: 1 DIF: Apply REF: Urgent and Emergent Care
13. A client who smokes one pack of cigarettes per day tells the nurse that she will need to be
taken outside to have a cigarette while recovering from surgery. Which of the following can the
nurse respond to this client?
1. That can be arranged.
2. You really should stop smoking before the surgery.
3. Your physician will prescribe medication to help reduce the nicotine cravings.
I can assign someone who will be responsible for transporting you to the smoking
4. section.

26. ANS: 3
The client who smokes will have concerns about nicotine withdrawal. The nurse should respond
that medications are available and can be prescribed to help the client through this difficult time.
The nurse should not support the clients smoking by saying that being taken out of doors can be
arranged or that someone will be assigned to transport the client to the smoking section. The
response you really should stop smoking before the surgery does not address the clients concern.
PTS: 1 DIF: Apply REF: Population-Based Care
MULTIPLE RESPONSE
1.A client tells the nurse that he has been told that he needs surgery but does not know who to
select as his surgeon. Which of the following should the nurse instruct the client regarding
important attributes to consider when choosing a surgeon? (Select all that apply.)
1. Board certification
2. Graduation from a reputable school
3. Personality or bedside manner
4. Location of office
5. Word of mouth from trusted others
6. The car he or she drives
ANSWER: 1, 2, 3, 5
When choosing a surgeon, a client should consider board certification, graduation from a reputable
school of medicine, personality and bedside manner, and the opinion of others through word of
mouth. Where the office is located and the car the physician drives are not signs of the surgeons
talent.
2.A client tells the nurse that the surgeon has provided the client with a choice of several
hospitals in which to have a surgical procedure performed, but the client does not know which
one to choose. Which of the following can the nurse instruct the client to consider when
choosing a hospital or surgical center? (Select all that apply.)
1. Does the facility have a national reputation?

27. 2. Is there an ICU in the hospital?
3. Is it close to family?
4. Will insurance pay for the stay?
5. Does the hospital have magnet status?
6. Does it have good food?
ANSWER: 1, 2, 4, 5
The client should consider the facilitys reputation, the presence of an intensive care unit, if the
facility accepts the clients health insurance coverage, and if the facility has magnet status.
Proximity to family and the food served are not good reasons to choose a place to have surgery.
3.A client scheduled for surgery is instructed on the use of a patient-controlled analgesic device
that she will use after the procedure. What are the advantages this device for pain control? (Select
all that apply.)
1. The client controls the timing of medication delivery.
2. The client does not have to wait for a nurse to provide pain medication.
3. The nurse does not have to check on the client as frequently.
4. The physician does not need to prescribe various pain medication after the surgery.
5. The medication is delivered intravenously.
6. Pain control improves client comfort after surgery.
ANSWER: 1, 2, 5, 6
Advantages to the use of a patient-controlled analgesic device for a client include client paces the
timing of medication delivery, client has control and immediate relief from medications,
medications are delivered instantly, medications are delivered intravenously, client has improved
comfort. The nurse not needing to check on the client as frequently is not an advantage for this

28. type of analgesic device. The physician not needing to prescribe various pain medications is not an
advantage for this type of device.
PTS: 1 DIF: Analyze REF: Trends
4.A client is scheduled for a same-day surgical procedure in which he will be discharged
afterwards, and he tells the nurse that he does not know what to bring to the hospital. Which of
the following should the nurse instruct the client? (Select all that apply.)
1. Bring identification, but send it home after it is used.
2. Bring personal sleepwear to put on after the surgery.
3. Bring work-related items.
4. Leave important jewelry at home.
5. Make a list of all medications and bring the list to the hospital.
6. Books and puzzles to be entertained while waiting for the surgery.
ANSWER: 1, 4, 5
On the day of the surgery, the nurse should instruct the client to bring identification, but to send it
home after it is used; and a list of medications. Important jewelry should be left at home to
reduce the risk of its being lost. Personal sleepwear is most likely not going to be used since the
client will be wearing a hospital gown. Work-related items are not recreational and could be
anxiety producing. Books and puzzles would be appropriate if the client is expecting to be
admitted, but they are not necessary for a same-day surgical procedure and discharge.
PTS:1DIF:Apply
REFatient Playbook: What to Bring to the Hospital or Surgicenter
5. The preoperative nurse has a variety of activities to complete when preparing a client for
surgery. Which of the following are activities of this nurse? (Select all that apply.)
1. Awareness of safety considerations
2. Assessment of vital signs during the surgery

29. 3. Physical assessment of the client
4. Assessment of the environment
5. Postoperative care in the recovery room
6. Awareness of best practices
ANSWER: 1, 3, 4, 6
The nurses role in preparing a client for surgery includes the following activities: awareness of
safety considerations, physical assessment of the client, assessment of the environment, and
awareness of best practices. The preoperative nurse will not assess vital signs during the surgery nor
provide postoperative care in the recovery room.
1.A nurse is considering additional training to become a perioperative nurse. Which of the
following skills are implemented by the perioperative nurse?
1. Conducts telephone interviews with the preoperative client
2. Applies principles of aseptic technique
3. Instructs the preoperative client on exercises to use while recovering from surgery
4. Plans for the postoperative clients discharge to home
Skills of the perioperative nurse include applying principles of aseptic technique and explaining how
this knowledge applies to other areas within the operating suite. The perioperative nurse does not
conduct telephone interviews with the preoperative client, instruct the preoperative client in
postoperative exercises, nor plan for the postoperative clients discharge to home.
PTS: 1 DIF: Apply REF: The Role of the Perioperative Nurse
2. Even though the nurse realizes that the ideal time period to plan for postoperative pain
management for a pediatric client begins in the operating room, the nurse will begin the
assessment process:
ANSWER: 2

30. 1. at the time the decision is made that the client needs surgery.
2. in the familys home.
3. during the admission process.
4. in the operating room after anesthesia wears off.
ANSWER: 3
Pain management cannot begin before the patient is admitted, and starting after the surgery is too
late. It begins at the admission when the type of surgery indicates which type of medication will be
needed, and medication skills will be taught to the client and the family. Planning for pain
management cannot begin in the clients home nor at the time the decision is made that the client
needs surgery.
PTS: 1 DIF: Apply REF: Pain Management in Pediatric Patients
3. The perioperative nurse realizes that the surgical environment is designed to ensure which of
the following?
1. Calming effect on the client
2. Ease of use by personnel
3. Control surgical asepsis
4. Reduce postoperative pain
The design of the intraoperative environment is to maintain surgical asepsis. The design is not to
have a calming effect on clients. Intraoperative environments are not designs for ease of use by
personnel or to reduce postoperative pain.
PTS: 1 DIF: Analyze REF: The Surgical Environment
4. The scrub nurse is preparing the sterile field by opening an instrument package that was
sterilized in an autoclave with direct exposure to steam. This type of sterilization is considered to be:
ANSWER: 3

31. 1. high-pressure/high-temperature steam.
2. cold chemical.
3. dry heat.
4. alcohol.
ANSWER: 1
High-pressure/high-temperature steam sterilization is the use of an autoclave to directly expose
the instruments to steam for a specified period of time. Cold chemical sterilization is the
submersion of instruments in a sterilizing solution for a predetermined period of time. Dry heat
utilizes static air or forced air to sterilize items. Alcohol is a commonly used disinfectant. It is not
an effective sterilant and, therefore, is not acceptable.
5. Prior to the surgeons making an incision into a client, the clients skin is bathed with a
bacteriostatic solution. The nurse realizes that this solution will:
1. sterilize the clients skin.
2. disinfect the clients skin.
3. sanitize the clients skin.
4. inhibit the number of bacteria on the clients skin.
ANSWER: 4
A bacteriostatic solution is one that will inhibit the increase in the number of bacteria.
Sterilization, disinfection, and sanitization are all methods to reduce or destroy microorganisms on
objects. These methods cannot be used on skin.
6. The operating room personnel are applying masks and either goggles or face shields prior to
beginning a surgical procedure. The purpose of these items is to:
1. facilitate vision.
2. protect against splashes or sprays of blood.

32. 3. facilitate breathing.
4. facilitate communication.
ANSWER: 2
These pieces of personal protective equipment (PPEs) are used to protect personnel from
splashes and sprays of blood and body fluids. Masks, goggles, and face shields do not facilitate
vision, breathing, or communication.
PTS: 1 DIF: Analyze REF: Personal Protective Equipment
7. The nurse is preparing to participate in a surgical procedure and has completed the surgical
scrub. Which of the following should the nurse do now in preparation for the surgery?
1. Don a surgical gown.
2. Apply sterile gloves.
3. Adjust the surgical mask.
4. Apply covering over the hair.
ANSWER: 1
Gowns should be put on after completing a surgical scrub and before gloving. The surgical mask
should be adjusted before applying sterile gloves. Head covering should be applied before
conducting the surgical scrub.
PTS: 1 DIF: Apply REF: Personal Protective Equipment
8. A client with a suspected degenerative brain disease is having surgery to place an intracerebral
shunt. Which of the following should be done with the instruments after this surgical procedure?
1. Sterilize with high-pressure steam.
2. Sterilize with the special treatment to eliminate prions.
3. Wash with bacteriostatic solution and submerge in an appropriate chemical bath.

33. 4. Rinse with disinfectant and place in a gas sterilizer.
ANSWER: 2
Prion diseases are rare, but they can survive some sterilization processes, and chemical
disinfectants are not strong enough to eliminate them. These instruments will need to be
sterilized with a special treatment to eliminate the prions. High-pressure steam, bacteriostatic
solutions, chemicals, disinfectants, and gas sterilizers are not known sterilization methods to
eliminate prions.
PTS: 1 DIF: Apply REF: Personal Protective Equipment
9. A client received general anesthesia for a surgical procedure. Which of the following
assessments will the nurse complete first for this client?
1. Surgical dressing
2. Intravenous sites
3. Airway
4. Pain
ANSWER: 3
Clients often require assistance in maintaining a patent airway after use of general anesthesia.
The first assessment the nurse should make is that of the clients airway. The surgical dressing,
intravenous sites, and pain can be assessed after the clients airway has been established.
10. The student nurse observing a surgical procedure begins to feel lightheaded and nauseated.
Which of the following should the student do at this time?
1. Tell someone she does not feel well.
2. Leave the operating room immediately.
3. Nothing since this feeling will pass.
4. Immediately sit down on the floor.
ANSWER: 2

34. If feelings of lightheadedness or nausea occur during an observation of a surgical procedure, the
first thing to do is head for the door or at least to a wall away from the surgical field. The student
should not tell someone that she is not feeling well. The student should not ignore these feelings
since they are signs of fainting. The student should not immediately sit on the floor since this could
be in the area of the sterile field and could compromise the surgical procedure.
PTS:1DIF:Apply
REF: Box 21-2 Tips for the Student When Observing in Operating Room
11. A nurse is filling the role of circulator during a surgical procedure. Which of the following
will this nurse do to provide care to the client during the case?
1. Maintain the sterile field.
2. Assist the surgeon.
3. Serve as the client advocate.
4. Assist with the administration of anesthesia.
ANSWER: 3
The circulating nurse serves as the client advocate while the client is least able to care for himself.
Maintaining the sterile field is a responsibility of the scrub nurse. Assisting the surgeon is an activity
of the registered nurse first assistant. Assisting with the administration of anesthesia is an activity of
the nurse anesthetist.
PTS: 1 DIF: Apply REF: Circulator/Circulating Nurse
12. An elderly client is scheduled for a surgical procedure. The nurse realizes that the outcome of
the clients operation will depend upon the clients:
1. age.
2. severity of illnesses.
3. nutritional status.
4. activity status.
ANSWER: 2

35. Severity of illness is a much better predictor of outcome of surgery when compared to age.
Nutritional status and activity status would be characteristics that are associated with severity of
illness.
PTS: 1 DIF: Analyze REF: Geriatric Considerations
13. During a surgical procedure, the clients bodytemperature spikes to a dangerous level. Which of
the following will be done to help this client?
1. Reduce the flow of the anesthetic agent.
2. Provide 50% oxygen.
3. Stop the surgery for cardiac dysrhythmias.
4. Administer a Dantrolene infusion.
ANSWER: 4
Malignant hyperthermia is a medical emergency. The anesthetic agent should be stopped
immediately and the client should be hyperventilated with 100% oxygen. The surgery should be
stopped if it is an elective case. Dantrolene should be provided.
PTS: 1 DIF: Apply REF: Malignant Hyperthermia
MULTIPLE RESPONSE
1.A perioperative nurse is identified as being the scrub nurse for a surgical procedure. Which of
the following is this nurses responsibilities during the surgery? (Select all that apply.)
1. Don surgical attire and personal protective equipment.
2. Maintain the sterile field.
3. Pass instruments and supplies to the surgeon.
4. Prepare medication.
5. Remove used instruments.
6. Organize the sterile field for use.

36. ANSWER: 2, 3, 4
Responsibilities of the scrub nurse during a surgical procedure include maintaining the sterile field,
passing instruments and supplies to the surgeon, and preparing medication. Donning surgical attire
and organizing the sterile field are responsibilities done before the surgery begins. Removing used
instruments are done after the surgery has concluded.
2. The perioperative nurse is identifying nursing diagnoses appropriate for a client currently
having surgery. Which of the following would be appropriate for the client at this time?
1. Risk for infection
2. Risk for impaired skin integrity
3. Risk for injury
4. Risk for inadequate nutrition
5. Risk for hypothermia
6. Risk for fluid volume overload
ANSWER: 1, 2, 3, 5
Nursing diagnoses for the perioperative client include risk for infection, risk for impaired skin
integrity, risk of injury, and risk of hypothermia. Risk for inadequate nutrition and risk for fluid
volume overload would be more appropriate during the postoperative period of client care.
PTS: 1 DIF: Analyze REF: NANDA and the Nursing Process
3. Which of the strategies can a perioperative nurse use to make a child feel less anxious prior to a
surgical procedure? (Select all that apply.)
1. Take the client on a tour of the operating room.
2. Allow the client to bring a toy or stuffed animal.
3. Allow the parents to stay with the child as much as possible.
4. Have the chaplain say a prayer with the child.

37. 5. Use age-appropriate explanations.
6. Respond to questions in a straightforward manner.
ANSWER: 1, 2, 3, 5, 6
Strategies to help a preoperative pediatric client feel less anxious prior to a surgical procedure
include taking the client on a tour of the operating room, allowing the client to bring a toy or
stuffed animal, allowing the parents to stay with the client as much as possible, using age-
appropriate explanations, and responding to questions in a straightforward manner. Having a
chaplain say a prayer with the child is good, but it may not be age appropriate.
PTS: 1 DIF: Apply REF: Pediatric Considerations
4. The circulating nurse is performing a time out prior to the beginning of a surgical procedure.
Which of the following will be assessed during this time out? (Select all that apply.)
1. Correct client
2. Correct procedure
3. Correct site and side
4. Correct surgeon
5. Correct day
6. Correct time
ANSWER: 1, 2, 3, 4
A correctly performed time out includes verifying the right client; the correct procedure; the
correct site and side; the correct surgeon; the correct position; the correct equipment, instruments,
and implants if necessary. The correct day and time are not parts of the surgical time out.
PTS: 1 DIF: Apply REF: Time Out
5. The nurse determines that a client is experiencing a risk associated with the use of anesthesia for
a surgical procedure. Which of the following are considered risks of anesthesia? (Select all that
apply.)

38. 1. Nausea and vomiting
2. Sore throat
3. Seizure
4. Postoperative myocardial infarction
5. Surgical wound infection
6. Hypothermia
ANSWER: 1, 2, 3, 4, 6
Risks of anesthesia include adverse reaction to the anesthetic, nausea and vomiting, sore throat,
seizure, myocardial infarction, hypothermia, malignant hyperthermia, numbness or loss of
function of a bodypart, and disseminated intravascular coagulation. Surgical wound infection is
not a risk associated with anesthesia.
1. The nurse in the postanesthesia recovery room documents a clients vital signs and current
status and then covers the clipboard with a blank sheet of paper. The nurses actions are to
support which of the following?
1. HIPAA laws
2. Postsurgical care expectations
3. The surgeons expectations
4. The anesthesiologists expectations
In order to protect client privacy and confidentiality with HIPAA laws, written information is to be
covered so that casual observers cannot violate the law. Blank sheets should be placed over
clipboards to obstruct viewing. The nurse is not covering the clipboard because of postsurgical
care expectations. This action is not a surgeon or anesthesiologists expectation.
PTS:1DIF:Analyze
ANSWER: 1

39. REF:Ethics in Practice: HIPAA: Implications for Perioperative Care
2. The nurse, caring for a postoperative client, will assess vital signs:
1. every15 minutes for the first hour.
2. every20 minutes for the first hour.
3. every30 minutes for the first hour.
4. not important at this point.
ANSWER: 1
Vital signs are performed every 15 minutes for the first hour and may be done more often if the
client is less stable. Vital sign assessment is extremely important and should be done more
frequently than every 20 or 30 minutes.
PTS: 1 DIF: Apply REF: Postoperative Physiological Stabilization
3. The nurse, caring for a postoperative client, will apply supplemental oxygen because:
1. the client needs it.
2. of anesthetic gasses in the lungs.
3. it helps control blood pressure.
4. it helps with wound healing.
ANSWER: 2
Postoperative clients require supplemental oxygen because they may still be retaining anesthetic
gasses in the lungs. The client will not be able to state that they need oxygen. Oxygen will not
control blood pressure nor will it help with wound healing.
PTS: 1 DIF: Analyze REF: Postoperative Physiological Stabilization
4. A client recovering from anesthesia in the care unit has an artificial airway. The nurse knows the
purpose of an artificial airway is to:

40. 1. keep the mouth open.
2. keep the tongue from blocking the airway.
3. keep the client from vomiting.
4. allow the client to talk.
ANSWER: 2
The artificial airway ensures that the tongue does not block the upper airway. An artificial airway
may or may not keep the mouth open. An artificial airway will not prevent the client from vomiting
and is not used to facilitate client communication.
PTS: 1 DIF: Analyze REF: Postoperative Physiological Stabilization
5. The nurse, caring for a client recovering from surgery, is monitoring the urine output and will
notify the surgeon if the output falls below:
1. 10 mL/hr.
2. 20 mL/hr.
3. 30 mL/hr.
4. 50 mL/hr.
ANSWER: 3
With proper renal function, the kidneys will produce a minimum of 30 mL of urine per hour. A
urine output of 10 or 20 mL/hr should be reported to the physician. A urine output of 50 mL/hr
does not need to be reported.
PTS: 1 DIF: Apply REF: Postoperative Physiological Stabilization
6. The nurse assesses an area of drainage on the dressing of a postanesthesia care clients surgical
wound. Which of the following should the nurse do?
1. Call the surgeon right away.

41. 2. Cover the dressing with a new dressing.
3. Circle the area and mark it with the date and time.
4. Pass it off to the next shift.
ANSWER: 3
If any drainage is showing on the dressing, the nurse is to circle the area and mark it with the date
and time. The surgeon does not need to be phoned unless excessive bleeding or hematoma
formation has occurred. The dressing does not need to be covered with a new dressing. The nurse
should not pass this finding off to the next shift.
PTS:1DIF:ApplyREF:Wound Stabilization
7. The nurse coaches a postoperative client to utilize a breathing device that prevents the
complication of atelectasis. This device would be a(n):
1. IPPB.
2. blow bottles.
3. incentive spirometer.
4. postural drainage.
ANSWER: 3
An incentive spirometer assists the patient with deep breathing exercises that can help prevent
atelectasis. A client would not use an intermittent positive pressure breathing device without the
presence of a nurse and/or respiratory therapist. Blow bottles are not a medical device used to
prevent atelectasis. Postural drainage is a technique used to drain secretions from the lung lobes.
PTS: 1 DIF: Apply REF: Nursing Care Beyond Transfer
8. Which of the following nursing interventions would be appropriate after a wound evisceration?
1. Place the client in high-Fowlers position.
2. Give the client fluids to prevent shock.

42. 3. Push the organs back inside and tape up the wound.
4. Apply a sterile saline-soaked dressing and cover.
ANSWER: 4
The nurse is to cover the wound with a sterile saline-soaked dressing and maintain it until the client
is taken to surgery. High-Fowlers position will not help with wound evisceration.
Providing fluids would be contraindicated since the client will be returning to surgery. The nurse
should not manipulate the exposed organs.
PTS: 1 DIF: Apply REF: Anticipating Complications
9. The nurse should instruct the postoperative client that antiembolic stockings are used to:
1. keep the legs warm.
2. serve as a nonslip slipper.
3. promote venous return.
4. make it easier to ambulate after surgery.
ANSWER: 3
Surgery may result in swelling that could impede blood return. Antiembolic stockings will aid in
blood return and reduce lower extremity edema postoperatively. These stockings are not used to
keep the legs warm, serve as a nonslip slipper, nor make it easier to ambulate after surgery.
PTS: 1 DIF: Apply REF: Recovery Milestones Beyond the Day of Surgery
10. The nurse is planning to teach a postoperative client about discharge medication. Which of
these nursing interventions would best assist the client in learning?
1. Withhold anypain medication so that the client can concentrate better.
2. Schedule the teaching after physical therapy so the client will be relaxed.
3. Place the client in a comfortable position and have the patient use the bathroom.

43. Plan the teaching at night right before bed so that the client can sleep on the new
4. information given.
ANSWER: 3
Placing the client in a comfortable position and having him use the bathroom will allow him to
concentrate on the learning to take place. The client will not be able to concentrate on the
instructions if he is in pain. The client may be tired after physical therapy and would not want to
engage in instruction at this time. Waiting until night to conduct instruction is also not a good time
considering the client may be fatigued from activities throughout the day and needs to rest.
11. The nurse is instructing a family member on how to change a clients postoperative wound
dressing at home. Which of the following should be included in these instructions?
1. Wear gloves to remove the old dressing.
2. Wear sterile gloves to apply the new dressing.
3. Clean hands prior to applying the new dressing.
4. Reposition the new dressing after application.
ANSWER: 3
If the client is to change the dressing at home, there is no need to wear gloves when the old
dressing is removed. Clean hands are sufficient to apply the new dressing. Sterile gloves are not
needed to apply the new dressing. Once the new dressing has been placed over the wound, it
should be left alone and not repositioned.
PTS: 1 DIF: Apply REF: Patient and Family Teaching
12. Which of the following should the nurse do when caring for an elderly postoperative client?
1. Allow rest periods between activities.
2. Address the client by the first name.
3. Assess for confusion if the client takes a long time to complete a task.
4. Avoid eye contact.

44. ANSWER: 1
Caring for an elderlypostoperative client, the nurse should allow rest periods between activities,
avoid using the clients first name, not mistake slow activity for confusion, and maintain eye contact
and full attention.
PTS:1DIF:Apply
REF: Respecting Our Differences: Postoperative Considerations for the Older Adult
13. The nurse is instructing a postoperative client regarding signs of complications. Which of the
following should be included in these instructions?
1. Notify the physician with a body temperature greater than 99F.
2. Expect the pain level to increase.
3. Report a change in drainage or increase in bleeding.
4. Dizziness and fainting is an expected side effect of anesthesia.
ANSWER: 3
Signs and symptoms of postoperative complications include fever, usually greater than 100 or
101F; sudden change in pain; change in drainage or bleeding; dizziness and fainting. The client
should not be instructed to notify the physician with a body temperature of 99F. Pain level
should not increase once discharged. Dizziness and fainting should be reported immediately.
PTS: 1 DIF: Apply REF: Patient and Family Teaching
MULTIPLE RESPONSE
1. When a client is brought from the surgical suite to the postanesthesia care unit, the nurse will
conduct a rapid head-to-toe visual assessment. Which of the following statuses will be assessed
during the initial assessment? (Select all that apply.)
1. Surgical site
2. Vital signs
3. Respiratory stability
4. Circulatory stability

45. 5. Range of motion of lower extremities
6. Bowel sounds
ANSWER: 1, 2, 3, 4
When a client is admitted to the postanesthesia care unit, the initial head-to-toe assessment includes
surgical site, vital signs, respiratory stability, and circulatory stability. Range of motion of the lower
extremities and bowel sounds are not a part of the initial head-to-toe assessment.
PTS: 1 DIF: Apply REF: Postoperative Physiological Stabilization
2. The postanesthesia care unit nurse is caring for clients with different types of wound drains.
Which are the most common types of drains? (Select all that apply.)
1. Plantar drain
2. Penrose drain
3. Davol
4. Hemovac
5. Ostomy appliance
6. Chest tube collection device
ANSWER: 2, 3, 4
The most common types of wound drains include the Penrose, Davol, and Hemovac. An ostomy
appliance is not a postoperative wound drain. A chest tube collection device is not a postoperative
wound drain.
3. The nurse, determining if a client is ready to be discharged from the postanesthesia care unit,
utilizes the Aldrete System which assesses which of the following? (Select all that apply.)
1. Activity
2. Respiration

46. 3. Circulation
4. Consciousness
5. Oxygen saturation
6. Appetite
ANSWER: 1, 2, 3, 4, 5
The Aldrete System is used to assess readiness for discharge from the postanesthesia care unit
and uses a numeric scoring system that measures stability with activity, respiration, circulation,
consciousness, and oxygen saturation. Appetite is not assessed with the Aldrete System.
PTS:1DIF:Apply
REF:Assessment Needs and Criteria for Discharge from PACU
4. A postoperative client is being transferred from the stretcher to the bed. Which of the following
transfer techniques will be used to safety relocate this client? (Select all that apply.)
1. Use a padded transfer board.
2. Locate an extra transfer person on the side of the stretcher.
3. Lock the wheels on both the stretcher and the bed.
4. Keep the bed anchored against the back wall.
5. Slide the client first to the edge of the stretcher.
6. Use the count of five to move the client.
ANSWER: 1, 3, 5
Techniques to safely transfer a client from a stretcher to a bed include: use a padded transfer board;
lock the wheels on both the stretcher and the bed; slide the client first to the edge of the stretcher.
An extra transfer person should be located on the side of the bed and not on the side of the
stretcher. The head of the bed should be placed about a foot from the wall. The transfer will usually
commence on the count of three.

47. 5. The nurse is preparing instructions for a postoperative client. When planning these instructions,
the nurse needs to take into consideration which three types of learning? (Select all that apply.)
1. Individual
2. Affective
3. Computerized
4. Psychomotor
5. Group
6. Cognitive
ANSWER: 2, 4, 6
There are three types of learning: 1) cognitive, 2) affective, and 3) psychomotor. Individual, computerized,
and group are strategies or approaches to providing instruction.
Chapter 4. Geriatric Disorders
MULTIPLE CHOICE
1. W
hen discussing aging, to whom does the term older adulthood apply?
a. Age 55 and above
b. Age 65 and above
c. Age 70 and above
d. Age 75 and above
ANSWER: B

48. Older adulthood begins at about age 65.
2.When the nurse discusses prevention of cardiac disease, falls, and depression with a group of
older adults, the benefits of what are important to stress?
a. Nutrition
b. Medications
c. Exercise
d. Sleep
ANSWER: C
Primary prevention stresses exercise for the prevention of cardiac disease, falls, and depression.
3.When was the Social Security Act, which was the first major legislation providing financial
security for older adults, passed?
a. 1930
b. 1935
c. 1940
d. 1945
ANSWER: B
The first major legislation to provide financial security for older adults was the Social Security Act
of 1935.
4.When assessing the skin of an older adult patient who is complaining of pruritus, what should
the nurse advise the patient to avoid to reduce further drying of her skin?
a. Perfumed soap
b. Hard-milled soap
c. Antibacterial soap
d. Lotion soap
ANSWER: C
Antibacterial soap is very drying.
5.Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure ulcers,
the nurse alters the care plan to include turning the bedfast patient how often?
a. Once every shift
b. Every 4 hours
c. Each evening

49. d. Every 2 hours
ANSWER: D
Pressure ulcers can be avoided by repositioning the patient every 2 hours.
6.At mealtime, the older adult seems to be eating less food than would be adequate. Compared to
the younger adult, what is a requirement for the older adult?
a. More fluids
b. Less calcium
c. Fewer calories
d. More vitamins
ANSWER: C
The older adult requires 30 calories per kilogram of body weight, whereas the younger adult
requires 40 calories.
7.The older patient informs the nurse that food has no taste and therefore the patient has no
appetite. What is this most likely caused by?
a. Tasteless food
b. Overuse of salt
c. Lack of variety
d. Loss of taste buds
ANSWER: D
Older adults mayexperience a loss of appetite. Change in taste as a result of decreased saliva
production and a decreased number of taste buds may make food unappealing.
8.An older adult is having difficulty swallowing. What position should the nurse recommend to
aid in swallowing?
a. Chin parallel
b. Chin upward
c. Chin down
d. Chin to the side
ANSWER: C
The upright position, leaning slightly forward with the chin down, improves swallowing with the
assistance of gravity.

50. 9.The patient complains to the nurse about a newly developed intolerance to milk. What should
the nurse suggest to fulfill calcium needs?
a. Rye bread
b. Yogurt
c. Apples
d. Raisins
ANSWER: B
Lactose, primarily found in milk, is a common source of food intolerance. Dairy products are an
important source of calcium, which is needed to prevent osteoporosis. Lactose-intolerant
individuals need to replace milk with cheese and yogurt, which are processed and digested more
easily.
10.The older adult patient complains to the nurse about nocturia. This problem is most likely
related to:
a. loss of bladder tone.
b. decrease in testosterone.
c. decrease in bladder capacity.
d. intake of caffeine.
ANSWER: C
At least 50% of older men and 70% of older women must get up two or more times during the
night to empty their bladders, a condition known as nocturia (excessive urination at night). The
most significant age-related change is the decrease in bladder capacity.
11.The older adult female patient is concerned about incontinence when she sneezes. What is the
correct terminology for this type of incontinence?
a. Urge incontinence
b. Stress incontinence
c. Overflow incontinence
d. Functional incontinence
ANSWER: B
Stress incontinence results from increased abdominal pressure, which occurs with coughing or
sneezing. Urge incontinence occurs after a sudden urge to void and is associated with cystitis,
tumors, stones, and CNS disorders. Overflow incontinence is associated with diabetic neuropathy
and spinal cord injuries. Functional incontinence results from unwillingness or inability to get to
the toilet.

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IF YOU WANT THIS TEST BANK OR
SOLUTION MANUAL EMAIL ME
kevinkariuki227@gmail.com TO RECEIVE ALL
CHAPTERS IN PDF FORMAT