Intro to Nursing – Exam 2 Concepts – Modules 5-8

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?

A. A local skin infection requiring antibiotics
B. Sensitive skin that requires special bed linen
C. A stage III pressure ulcer needing the appropriate dressing
D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?

A. Stage I
B. Stage II
C. Stage III
D. Stage IV

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or soft if the blood flow is compromised. The patient may report pain in the area.

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

A. Necrotic tissue
B. Wound drainage
C. Drainage on the dressing
D. Wound after it has first been cleaned with normal saline

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.

After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?

A. Allow the area to be exposed to air until all drainage has stopped
B. Place several cold packs over the area, protecting the skin around the wound
C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration
D. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.

Which description best fits that of serous drainage from a wound?

A. Fresh bleeding
B. Thick and yellow
C. Clear, watery plasma
D. Beige to brown and foul smelling

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Serous fluid generally is serum and presents as light red, almost clear fluid.

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

A. Binder
B. Ice bag
C. Elastic bandage
D. Absorptive diaper

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.

Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?

A. Keeping the buttocks exposed to air at all times
B. Using a large absorbent diaper, changing when saturated
C. Using an incontinence cleaner, followed by application of a moisture-barrier ointment
D. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode.

Which of the following describes a hydrocolloid dressing?

A. A seaweed derivative that is highly absorptive
B. Premoistened gauze placed over a granulating wound
C. A debriding enzyme that is used to remove necrotic tissue
D. A dressing that forms a gel that interacts with the wound surface

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

A. Collection of wound drainage
B. Reduction of abdominal swelling
C. Reduction of stress on the abdominal incision
D. Stimulation of peristalsis (return of bowel function) from direct pressure

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

When is an application of a warm compress indicated? (Select all that apply.)

A. To relieve edema
B. For a patient who is shivering
C. To improve blood flow to an injured part
D. To protect bony prominences from pressure ulcers

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C.
Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.

What is the removal of devitalized tissue from a wound called?

A. Debridement
B. Pressure reduction
C. Negative pressure wound therapy
D. Sanitization

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A.
Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

What does the Braden Scale evaluate?

A. Skin integrity at bony prominences, including any wounds
B. Risk factors that place the patient at risk for skin breakdown
C. The amount of repositioning that the patient can tolerate
D. The factors that place the patient at risk for poor healing

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.

On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient’s pressure ulcer?

A. Stage II
B. Stage IV
C. Unstageable
D. Suspected deep tissue damage

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days.

A. True
B. False

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
A contaminated or traumatic wound may show signs of infection early, within 2 to 3 days. A surgical wound infection usually develops postoperatively within 4 to 5 days.

Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms.

A. True
B. False

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
This is the correct definition of healing by primary intention.

Which of the following may indicate internal hemorrhage? (Select all that apply.)

A. Distention or swelling of the affected body part
B. An elevated white blood cell count
C. A decreased blood pressure and increased pulse
D. A change in the type and amount of drainage from a surgical drain

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D.
The nurse can detect internal bleeding by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock such as a decreased blood pressure, increased pulse, and cool, clammy skin. An elevated white blood cell count would be an indication of infection.

Which of the following patients has the least risk for developing a wound infection?

A. An 80-year-old man who has a burn
B. A 17-year-old patient who has a metal fragment lodged in his thigh
C. A 30-year-old female who had an episiotomy after childbirth
D. A patient receiving chemotherapy who has a surgical incision
E. A patient with peripheral vascular disease and an ulcer on the heel

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
The chances of wound infection are greater when the wound contains dead or necrotic tissue (as with a burn), there are foreign bodies in or near the wound, and the blood supply and local tissue defenses are reduced or the patient is immunocompromised.

When teaching a patient about wound healing, the nurse should tell the patient:

A. Inadequate nutrition delays wound healing and increases risk of infection.
B. Chronic wounds heal more efficiently in a dry, open environment, so leave them open to air when possible.
C. Long-term steroid therapy diminishes the inflammatory response and speeds wound healing.
D. Fat tissue heals more readily because there is less vascularization.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
Inadequate nutrition—including proteins, carbohydrates, lipids, vitamins, and minerals—delays tissue repair and increases risk for infection. Both full-thickness wounds and partial-thickness wounds heal more efficiently in a moist, protected environment. Long-term steroid therapy may diminish the inflammatory response and reduce the healing potential. Steroids slow collagen synthesis. Fat tissue has less blood supply, which decreases transport of nutrients and cellular elements required for healing.

The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient’s knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse has assessed?

A. These are expected findings for this postoperative time period.
B. The patient is becoming dependent upon pain medication.
C. The nurse should observe the patient more closely for wound dehiscence.
D. The patient is demonstrating signs of a postoperative wound infection.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
The risk for infection is greatest 4 to 5 days postoperative. Symptoms of wound infection include fever, tenderness and pain at the wound site, an elevated white blood cell count, and the edges of the wound may appear inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism.

The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence?

A. The nurse should be alert for an increase in serosanguineous drainage from the wound.
B. Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery.
C. The nurse should administer cough suppressant to prevent wound dehiscence.
D. The condition is an emergency that requires surgical repair.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
An increase in drainage is a symptom of a potential dehiscence. Wound dehiscence most commonly occurs before collagen formation (3 to 11 days after injury). To prevent dehiscence, place a folded thin blanket or pillow over an abdominal wound when the patient is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intra-abdominal pressure. Evisceration is an emergency that requires surgical repair. Dehiscence does not necessarily indicate surgery is necessary.

The nurse reports a patient has a wound on his abdomen that is healing by secondary intention. The nurse understands this means the patient:

A. has a drain.
B. is at greater risk for infection.
C. is at greater risk for wound dehiscence.
D. is healing naturally.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
Healing by secondary intention indicates the patient has a wound where there is tissue loss and the wound edges are not well-approximated. There is greater opportunity for development of infection without the protective epidermal barrier and longer healing time.

A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 5 days ago. The patient’s history indicates obesity with a BMI of 32 and smoking 1 pack/day. Based on this information, the nurse understands the patient should be observed for:

A. Developing a blood clot.
B. Developing a fistula.
C. Wound dehiscence.
D. Hemorrhage.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
This patient is at risk for poor wound healing due to the chronic illness of diabetes, being obese (BMI >30), and smoking. Fatty tissue has a poor blood supply for healing and smoking increases the patient’s likelihood of coughing. The nurse should observe for an increase in serosanguineous drainage, an indication of potential dehiscence. The nurse should teach the patient to splint the abdomen with a pillow when coughing as a sudden strain on the incision could lead to dehiscence.

Match the description to the correct term: Thick, yellow, green, tan, or brown.

A. Purulent
B. Serous
C. Serosanguineous
D. Sanguineous

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.

Match the description to the correct term: Clear, watery plasma.

A. Purulent
B. Serous
C. Serosanguineous
D. Sanguineous

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.

Match the description to the correct term: Bright red: indicates active bleeding.

A. Purulent
B. Serous
C. Serosanguineous
D. Sanguineous

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.

Match the description to the correct term: Pale, red, watery.

A. Purulent
B. Serous
C. Serosanguineous
D. Sanguineous

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.

The patient asks the nurse what the purpose is for his Hemovac drain. The nurse’s best response is:

A. “To reduce the need for frequent dressing changes”
B. “To provide constant suction to remove and collect drainage from your wound to help it heal”
C. “To have a more accurate method of determining fluid loss and whether your fluids need to be increased”
D. “To prevent infection and crust formation at the wound site”

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
The correct response would be “To provide constant suction to remove and collect drainage from your wound to help it heal.” Although a Hemovac drain will collect drainage, the Hemovac drain is used to provide constant low-pressure suction to remove and collect drainage from the wound bed to allow the tissues to come together to heal. Measuring the amount of drainage is used to determine when the drain may be removed.

A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if made by the patient, indicates further teaching is required?

A. “I should empty the drain when it is one-half to two-thirds full.”
B. “I should keep a record of how much drainage I empty.”
C. “If drainage suddenly stops, it means the drain is ready to be removed.”
D. “The bulb of the drain should remain compressed.”

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
If drainage suddenly stops, the drainage tubing may have a blockage. Notify the health care provider. The drain reservoir should be emptied every 8 hours or less if the reservoir becomes one-half to two-thirds full. The patient should keep a record of the drain’s output in 24 hours to aid in determining whether the amount is decreasing as expected and when the drain may be removed. The reservoir should remain compressed to provide a constant low suction.

When should wound drainage be cultured?

A. When there is a change in color, amount, or odor of drainage
B. If the patient complains of pain
C. When the drain is removed
D. If the nurse empties the drainage evacuator without applying sterile gloves

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
Wound drainage should be cultured when infection is suspected, as indicated by the drainage appearing to be purulent, a change in the amount or color of the wound drainage, or when a foul odor of the drainage is noted. It is appropriate for the nurse to wear clean gloves to empty the drainage evacuator.

The nurse is teaching a patient how to empty his Hemovac drain. Which action of the patient indicates that further instruction is needed? The patient:

A. opens the plug on the port for emptying the drainage reservoir and drains the contents into the measuring container.
B. presses downward until the bottom and top of the Hemovac are in contact to reestablish the vacuum.
C. holds the surfaces of the Hemovac together with one hand, cleans the opening and plug with an alcohol swab with the other hand, and immediately replaces the plug.
D. empties the Hemovac drain, replaces the plug, and records the amount of drainage.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
The patient must reestablish the vacuum for the Hemovac to be effective. To re-establish the vacuum, the patient needs to press the bottom and the top of the Hemovac together.

Because a patient has a Penrose drain, the nurse inspects the patient’s skin and changes the dressing by placing a drainage sponge around the drain. What is the rationale for doing this?

A. Because drainage can be irritating to the skin and may cause skin breakdown
B. Because a Penrose drain has to be frequently compressed to create a constant low-pressure suction
C. To prevent the tubing from migrating into the wound
D. To advance the tube as the wound heals

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
A Penrose drain does not have a collection device. Therefore, the nurse should inspect the skin and change the dressings as needed to prevent skin breakdown. A Penrose drain does not have a reservoir to compress. A safety pin is inserted through a Penrose drain to prevent the tubing from migrating into the wound. Although a Penrose drain may be advanced as the wound heals, this is not the rationale for the nurse’s inspection and changing of the drainage sponges.

Which of the following is inappropriate to delegate to nursing assistive personnel (NAP)?

A. Emptying a closed drainage container
B. Measuring the amount of drainage
C. Assessment of wound drainage
D. Reporting the amount on the patient’s intake and output record

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Assessment of wound drainage and maintenance of drains and the drainage system require the critical thinking and knowledge application unique to a nurse and therefore are inappropriate to delegate to NAP.***NAPs CANNOT ASSESS***

The patient complains “It feels like the drain is pulling on my surgical site.” What is the nurse’s best action?

A. Secure the drain above the incision to the dressing with tape and a safety pin and instruct the patient to keep the drain above the insertion site when ambulating, sitting, and lying.
B. Make sure there is slack in the tubing from the reservoir to the wound, allowing the patient movement and avoiding pulling at the insertion site.
C. Instruct the patient that this is the normal sensation of having a drain and inquire if the patient would like pain medication.
D. Have the patient lie down and advance the drain further into the patient until the sensation is relieved and drainage is noted in tubing; secure a new dressing over insertion site of drain.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
To avoid pulling at the insertion site, the nurse should be sure there is slack in the tubing from the reservoir to the wound, allowing the patient movement. To facilitate drainage, the nurse should secure the drain below the incision to the dressing with tape and a safety pin and instruct the patient to keep the drain below the insertion site when ambulating, sitting, and lying. An order would be required to administer pain medication. The nurse should not advance the tube into the patient as this would introduce microorganisms.

Which of the following are functions of dressings? (Select all that apply.)

A. To promote hemostasis
B. To keep the wound bed dry
C. Wound debridement
D. To prevent contamination
E. To increase circulation

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D.
Dressings provide several functions, which include debridement, maintaining a moist wound environment, protecting from outside contamination and further injury, preventing the spread of microorganisms, increased patient comfort, and promoting hemostasis by control of bleeding. Dressings are unable to increase circulation.

Which of the following patients would be expected to benefit from a moist-to-dry dressing? (Select all that apply.)

A. A 24-year-old patient with an open and infected wound from a spider bite
B. A 7-year-old with abrasions on the knees
C. A 50-year-old with a postoperative knee-replacement incision
D. A 30-year-old who had a large cyst removed and now has some necrotic tissue present in the crater-type wound

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, D.
Moist-to-dry dressings are best used with necrotic, infected wounds requiring debridement. Moist dressings are often used for helping to heal full-thickness wounds that look like craters. Dry woven gauze dressings are most often used for abrasions and postoperative incisions when minimal drainage is anticipated.

The nurse is observing the patient’s wife perform the moist-to-dry dressing change. Which actions, if made by the patient’s wife, indicate that further instruction is needed? (Select all that apply.)

A. Premedicates for pain
B. Packs wound tightly
C. Leaves contact or primary dressing dripping moist
D. When removing the old dressing the wife leaves the dressing dry, even when it sticks slightly.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: B, C.
Inner gauze should be moist to absorb drainage and adhere to debris. The wound should be loosely packed to facilitate wicking of drainage into the absorbent outer layer of the dressing. The wound should never be over packed because this can cause wound trauma when the dressing is removed. Premedicating for pain will help provide comfort during the dressing change. If dressing sticks on a moist-to-dry dressing, the wife should gently free the dressing and alert the patient of discomfort. The wife was correct in not wetting the dressing as a moist-to-dry dressing should debride the wound.

A patient with a wound vacuum-assisted closure (wound V.A.C.) continues to complain of pain. What measures may be taken? (Select all that apply.)

A. Switch to the white polyvinyl alcohol (PVA) soft foam.
B. Decrease the pressure setting.
C. Administer pain medication.
D. Switch to the black polyurethane (PU) foam.
E. Keep the suction in the “off” position.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, B, C.
Patients may experience more pain with the black foam because of excessive wound contraction. For this reason, they may need to be switched to the PVA soft foam. Administering pain medication can help alleviate pain, and decreasing the pressure setting may also help reduce pain.

During a sterile dressing change, when are the gloves changed?

A. After the old dressing is removed and before creating a sterile field
B. After the old dressing is removed and before cleansing the wound
C. After the old dressing is removed, after cleansing the wound, and before applying a new dressing
D. It is unnecessary to change gloves for chronic wounds.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
Gloves are discarded after removing the old dressing. If required, a sterile field is then prepared, new sterile gloves are applied, and the wound is cleansed. It is unnecessary to change the gloves frequently unless they are accidentally contaminated. Gloves are changed after removing the old dressing and before cleaning the wound to reduce transmission of cross-contamination microorganisms. The same gloves may then be worn for applying a new dressing. Clean gloves may be worn rather than sterile gloves with chronic wounds (check facility policy).

A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient?

A. “If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care facility.”
B. “Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75 cm) around the wound, and that the skin is thoroughly dry before applying the dressing.”
C. “This type of dressing requires frequent changing because they do not stay in place.”
D. “You probably are applying it incorrectly, or perhaps you are just too anxious about having to perform the dressing change.”
E. “There are many options on the market. Why don’t you try to use a non-adhesive-backed transparent dressing instead?”

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
If the transparent dressing does not stay in place, the size of the dressing should be evaluated for adequate (1 to 1.5 inches or 2.5 to 3.75 cm) margin, and the skin should be dried thoroughly before reapplication. The patient requires further instruction, not necessarily a referral, regarding interventions to aid in dressing adherence. The dressing coming off is an unexpected outcome. Blaming the patient is non-therapeutic.

A patient asks the nurse why the Montgomery ties are being used instead of regular tape. The nurse’s best response is:

A. “Because Montgomery ties are nonallergenic.”
B. “Montgomery ties can be tied tighter, providing a more secure dressing and greater support of the wound.”
C. “It allows the wound to breathe.”
D. “Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes.”

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
Frequent removal of tape for dressing changes is irritating to the skin. Montgomery straps are wide tapes with holes to use with ties that secure dressings and facilitate changes without removing the tape each time. Some patients are allergic to adhesive. These patients often benefit from paper or nonallergenic tape. Transparent dressings allow the wound to “breathe.”

How can the nurse determine that negative pressure is being achieved with a wound V.A.C.?

A. The nurse can inquire about the patient’s pain level. If there is a reported decrease in the level of pain, then the wound is constricting and negative pressure is being achieved.
B. The nurse can ensure that there is no whistling noise at the wound site and that the wound V.A.C. has not triggered its alarm.
C. The nurse can check for air leaks by listening with a stethoscope or by moving the hand around the edges of the wound while applying light pressure.
D. The nurse can ensure that the foam is in contact with the entire wound base, margins, and tunneled and undermined areas.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
The nurse should inspect the wound V.A.C. system to verify that negative pressure is being achieved: verify that the display screen reads THERAPY ON; be sure the clamps are open and tubing is patent; identify air leaks by listening with a stethoscope or by moving hand around edges of the wound while applying light pressure; and if a leak is present, use strips of transparent film to patch areas around the edges of the wound. Negative pressure is achieved when an airtight seal is achieved. The wound V.A.C. will sound an alarm if the canister is improperly engaged or if the unit is tilted beyond 45 degrees.

Which of the following is a correct sequence for changing a gauze dressing?

A. Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing.
B. Remove old dressing, discard gloves, apply new gloves, and apply new dressing.
C. Remove old dressing, discard gloves, clean wound, apply loose woven gauze, and cover with thicker woven pad (e.g., ABD pad).
D. Create sterile field, remove old dressing, discard gloves and perform hand hygiene, apply new gloves, clean wound, blot dry, apply new dressing.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
The nurse should remove the old dressing, inspect the wound, dispose of gloves and soiled dressings, and perform hand hygiene. The nurse then creates a sterile field and applies new sterile gloves and cleans the wound from least contaminated (the surgical incision) to the most contaminated (the drain). The nurse dries the area in the same manner and puts on the new dressing.

A patient has a 4-day-old postoperative incision. Which would be a normal finding when changing the dressing?

A. Small amount of serous drainage
B. Moderate amount of sanguineous drainage
C. Small amount of serosanguineous drainage
D. Small amount of purulent drainage

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
A small amount of serous drainage is normal postoperatively. A moderate amount of sanguineous drainage would indicate bleeding. Purulent drainage would indicate infection.

Which of the following are common sites for the development of pressure ulcers? (Select all that apply.)

A. Sternum
B. Heels
C. Sacrum
D. Lateral malleoli
E. Trochanters
F. Ischial tuberosities

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: B, C, D, E, F.
Common sites for the development of pressure ulcers include the sacrum, heels, elbows, lateral malleoli, trochanters, and ischial tuberosities. (Helpful, I know.)

Identify contributing factors to pressure ulcer formation. (Select all that apply.)

A. Malnutrition
B. Middle age
C. Decreased sensory perception/mobility
D. Anemia
E. Excessive sweating
F. Ethnic background

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D, E.
Three pressure-related forces contribute to the development of a pressure ulcer: intensity of pressure (how much pressure is applied), duration of pressure (how long the pressure is applied), and tissue tolerance (the ability of the tissue to redistribute the weight). Having decreased mobility or decreased ability to perceive the need to shift one’s weight or change position places an individual at risk for pressure ulcer development. Three extrinsic factors, shear, friction, and moisture, make the tissues less tolerant of pressure. Other factors important in pressure ulcer development include poor nutrition, advanced age, medical conditions that support poor tissue perfusion (low blood pressure, smoking, elevated temperature, anemia), and psychosocial status, in particular stress-induced cortisol secretion.

Identify prevention strategies for pressure ulcers. (Select all that apply.)

A. Use a moisture barrier ointment, applied after each incontinent episode.
B. Reposition patient at least every 4 hours; use a written schedule.
C. When the patient is in the side-lying position in bed, use the 30-degree lateral position.
D. Place patient on a pressure-reducing support surface.
E. Maintain the head of the bed at 45 degrees.
F. Massage reddened bony prominences.
G. Oral supplements should be instituted if the patient is found to be undernourished.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D, G.
Patients should be repositioned every 2 hours to reduce the duration and intensity of pressure. The 30-degree lateral position avoids direct contact of the trochanter with the support surface. Placing the patient on a pressure-reducing support surface reduces the amount of pressure exerted against the tissues. The head of the bed should be maintained at 30 degrees. If the head is elevated more than this, it can increase the potential of the patient to slide toward the foot of the bed and incur a shear injury. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk of injury to underlying tissue, and therefore it should be avoided. A moisture barrier ointment protects reddened intact skin from incontinence. There is a strong relationship between poor nutrition and pressure ulcer development. Supplements may provide lacking nutrients.

The nurse is observing the patient’s wife perform treatment of her husband’s pressure ulcer. Which action, if made by the patient’s wife, indicates that further instruction is needed?

A. She premedicates the patient for pain before beginning the dressing change.
B. She performs hand hygiene and removes the old dressing and begins to clean the ulcer with soap and water.
C. While wearing gloves, she rinses the ulcer with normal saline, gently wiping around the wound base and surrounding skin with moistened gauze.
D. She applies solution to the gauze and wrings out any excess. She unfolds the gauze and packs the wound with the moistened dressing. She covers the gently packed wound with dry 4 x 4 gauze pads and applies tape to secure the dressing. She removes her gloves and performs hand hygiene.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
To avoid transfer of microorganisms, the caretaker should apply nonsterile gloves to remove the old dressing and discard the gloves and old dressing materials in a plastic bag. She should perform hand hygiene and apply new gloves before beginning to cleanse the wound. She should use the ordered solution, most generally normal saline, because soap can be very drying to tissues and may leave a residue.

A family member calls the nurse to ask for advice regarding their mother who has developed a “bedsore” on her right heel. The family member describes the pressure ulcer as “a blister that has now popped and you can see redness.” Based on this description, at what stage would the nurse classify this pressure ulcer?

A. Stage I
B. Stage II
C. Stage III
D. Stage IV

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
A stage II pressure ulcer can be described as an abrasion, a blister, or shallow crater with skin loss involving the epidermis and/or dermis. A stage I pressure ulcer appears as an area of color change (e.g., persistent redness) on intact skin. A stage III pressure ulcer presents clinically as a deep crater. A stage IV pressure ulcer involves bone, muscle, or supporting structures.

Which of the following is an example of healing by secondary intention? (Select all that apply.)

A. A full-thickness pressure ulcer
B. A surgical incision
C. A dog bite
D. A burn

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D.
Healing by secondary intention often accompanies traumatic open wounds with tissue loss or wounds with a high microorganism count. Examples of wounds that heal by secondary intention are pressure ulcers, a dog bite, a severe laceration, or a burn. Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. Examples of healing by primary intention are a surgical incision, an abrasion, or a skin tear.

It is suspected that a patient is developing a wound infection. Which assessment data would support this conclusion? (Select all that apply.)

A. Yellow-tinged drainage
B. Temperature 100.3°F (37.94°C)
C. Increased complaints of pain at wound site
D. White blood cell count 13,000 mm3 (elevated)
E. Wound edges of pink to normal skin color
F. Foul odor noted from previous dressing

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, B, C, D, F.
The patient has a fever, tenderness, and pain at the wound site and an elevated white blood cell count (normal 5,000 to 10,000 per mm3). Wound edges that appear red and inflamed indicate infection. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism.

Which of the following lab results or measurements indicate a risk for impaired wound healing? (Select all that apply.)

A. A BMI (body mass index) of 35 (elevated)
B. Fasting blood glucose of 215 mg/dl (elevated)
C. A serum albumin of 2.9 g/dl (decreased)
D. A hemoglobin of 10.0 g per dL (decreased)
E. A white blood cell count of 7000 per mm3 (normal)

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, B, C, D.
A BMI over 30 indicates obesity, which is a factor that may impair wound healing because fatty tissue has a poor blood supply. Elevated blood glucose indicates diabetes, which is a chronic disease that leads to poor tissue perfusion. A serum albumin below 3.5 indicates malnutrition. Adequate nutrition plays a significant role in wound healing. Hemoglobin below 12 g per dL indicates anemia and a decreased oxygen-carrying capacity necessary for tissue growth. The normal white blood cell count is 5,000 to 10,000 mm3. If the white blood cell count were elevated, this would indicate infection, which also is a factor that impairs wound healing.

Identify the functions of dressings. (Select all that apply.)

A. Maintaining a moist environment
B. Preventing shear
C. Control of bleeding and drainage
D. Removing surface bacteria
E. Protection from outside contaminants and further tissue injury
F. Increased patient comfort

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, E, F.
Dressings serve several functions, including maintaining a moist environment conducive to wound healing; protecting the wound from outside contaminants, further tissue injury, and transfer of microorganisms; maintaining hemostasis by controlling bleeding with pressure dressings; managing drainage to prevent excoriation of skin; and increased patient comfort. Cleaning the wound removes surface bacteria.

Which of the following regarding removal of the old dressing on a surgical incision are accurate? (Select all that apply.)

A. Tape should be pulled parallel to the skin in a direction away from the incision.
B. If dressing is over a hairy area, remove tape in the direction of hair growth.
C. While wearing clean gloves, remove the dressing layers all at one time and discard.
D. Use caution to avoid tension on any drains that are present.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: B, D.
Tape should be pulled parallel to the skin, in a direction toward the dressing to avoid pulling on the suture line. If the dressing is over a hairy area, remove in the direction of hair growth. With clean gloves, remove dressings one layer at a time, observing appearance and drainage. Use caution to avoid tension on any drains that are present.

Which of the following is a method of wound debridement?

A. Gauze dressing
B. Transparent dressing
C. Moist-to-dry dressing
D. Hemovac drain

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Necrotic tissue may be loosened and possibly removed by the use of moist-to-dry dressings. Transparent dressings are used for partial-thickness wounds with minimal wound exudate. Dry gauze dressings are used for wounds that will heal by primary intention with little drainage such as a closed surgical incision. A Hemovac drain is used to collect drainage, but not for wound debridement.

The nurse is teaching the NAP in a nursing home about daily routine measures to reduce the incidence of pressure ulcers within the facility. Which of the following should the nurse include in the teaching? (Select all that apply.)

A. Turning patients at least every 2 hours
B. Rubbing reddened bony prominences
C. Use of pillow bridging when needed
D. Positioning the patient in the 30-degree lateral position
E. Using a turn sheet to reposition patients
F. Decreasing patients’ fluid intake to decrease the incidence of incontinence

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C, D, E.
There are several strategies to prevent the development of pressure ulcers. Patients should be repositioned at least every 2 hours to reduce the duration and intensity of pressure. The use of pillow bridging will prevent direct contact between bony prominences. Using a turning sheet to reposition patients prevents dragging along the sheets (friction). Maintaining the head of the bed at 30 degrees decreases the potential for the patient to slide toward the foot of the bed and incur a shear injury. The 30-degree lateral position should prevent positioning directly over the bony prominence. Avoid massaging reddened bony prominences because this may cause skin breakdown. Incontinence should be managed by methods other than withholding fluids. Dehydration can also negatively affect tissue integrity.

How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?

A. By turning the suction on
B. By keeping the drain lower than the insertion site
C. By compressing the drain reservoir
D. By “milking” the tubing

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Compressing the surface of the Hemovac drain or the bulb of the Jackson-Pratt drain and quickly reinserting the cap re-establishes the vacuum. Suction is never used with a Jackson-Pratt drain.

A nurse is explaining how to perform a dressing change. Which of the following sequences for changing a surgical wound dressing (wound drain present) indicates that the nurse requires further education regarding this procedure?

A. Dispose of gloves and soiled dressings in waterproof bag. Perform hand hygiene. Create a sterile field with individually wrapped sterile supplies on the over-bed table. Pour necessary prescribed solution into sterile basin. Apply sterile gloves.
B. Cleanse wound. Use a separate swab for each cleansing stroke. Clean incision from top to bottom. Cleanse around drain by using a circular stroke starting near the drain and moving outward.
C. Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top.
D. Use sterile dry gauze to blot dry. Apply prescribed antiseptic ointment by using the same technique as for cleansing. Apply loose, woven gauze as contact layer. Place drain sponge (precut gauze) around drain. Apply additional layers of gauze as needed. Apply thicker woven pad (e.g., ABD or Surgipad).

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
The nurse should clean from the least-contaminated area to the most-contaminated because this avoids introducing microorganisms from surrounding skin into the incision. The nurse should clean the incision first in a direction of top to bottom and then clean the drain site.

A patient is to have frequent dressing changes. What should the nurse use to secure the dressing?

A. Hypoallergenic tape
B. Paper tape
C. Adhesive tape
D. Montgomery ties

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
Frequent removal of tape for dressing changes is irritating to the skin. These dressings should be secured with Montgomery ties . Montgomery ties are wide tapes with holes to use with ties that secure dressings and facilitate changes without removing the tape each time.

Why does a wound bed need to stay moist?

A. To support healing by enabling granulation tissue to grow
B. To prevent excessive fluid loss from the body
C. To determine if the area has reactive hyperemia
D. To decrease patient discomfort

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
Granulation tissue is the healthy, red, fleshy projection of moist tissue that indicates healing. If the wound bed were dry, this process would be impaired. Open wounds frequently have fluid loss as drainage. Replacing this loss is relevant to the patient’s overall hydration.

A nurse is applying a wound V.A.C. dressing independently for the first time. What action, if made by the nurse, indicates that further instruction is needed in performing this procedure?

A. The nurse turns the V.A.C. unit off, applies clean gloves, disconnects the tubes to drain fluids into the canister, and tightens the clamp on the canister tube.
B. With dressing tube unclamped, the nurse instills 10 to 30 mL of normal saline into the tubing to soak the foam underneath. The nurse gently pulls the transparent film horizontally and removes the old V.A.C. dressing, noting drainage. The nurse discards the dressing, removes gloves, and performs hand hygiene.
C. The nurse applies new gloves, irrigates the wound with normal saline, and then gently blots it dry. The nurse measures the wound, removes and discards gloves, and applies a new pair of gloves. The nurse cuts the foam approximately one-half inch smaller than the size of the wound and gently places the foam in the wound, avoiding any tunneled and undermined areas.
D. The nurse applies the tubing to the foam in the wound, applies a skin protectant to skin around the wound, and applies the transparent dressing, covering 3 to 5 cm (1.2 to 2 inches) of surrounding healthy tissue. The nurse secures the tubing to the transparent dressing and connects the tubing from the dressing to the tubing from the canister and V.A.C. unit. The nurse makes sure the tubing clamps are open, turns the wound V.A.C. unit on, and sets the pressure at 125 mm Hg.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
The nurse should use sterile scissors to cut the foam to fit the size and shape of the wound, including tunnels and undermined areas. The nurse should place the foam in the wound, being sure that the foam is in contact with the entire wound base and margins and tunneled and undermined areas. This maintains negative pressure to the entire wound. The edges of the foam dressing must be in direct contact with the patient’s skin.

The nurse may use clean gloves for changing the dressing on which of the following?

A. Chronic pressure ulcer
B. Surgical wound
C. Sterile gloves should always be used for dressing changes performed by nurses.
D. Sterile gloves should always be used for dressing changes performed in the hospital setting.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
Clean gloves and clean technique are acceptable only for the care of chronic wounds. Sterile technique or a no-touch technique with sterile forceps may be used when changing the dressing of a new surgical wound. Sterile gloves or nonsterile gloves may be worn with chronic wounds. Research has noted an absence of difference in wound infection rates when using sterile gloves or clean gloves, and there is a lowered cost for dressing supplies. Gloves should be changed, however, to avoid cross-contamination of microorganisms. The type of wound should determine whether clean or sterile technique is used, not who performs the dressing change or the setting.

The nurse is reading electronic documentation from the emergency room on a patient who is to be admitted to the unit. The documentation states the patient has a hematoma on the right knee. The nurse knows to expect to see:

A. A shallow wound with loss of the epidermis and partial loss of the dermis.
B. A localized collection of blood underneath the tissues that often takes on a bluish discoloration.
C. A deep wound extending into the dermis.
D. An area of skin that has been scraped away.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
A hematoma is a localized collection of blood underneath the tissues that often takes on a bluish discoloration. A shallow wound with loss of the epidermis and partial loss of the dermis is a partial thickness wound. A deep wound extending into the dermis is a full-thickness wound.
An area of skin that has been scraped is an abrasion.

When is a surgical wound at greatest risk for hemorrhage?

A. During the first 24 to 48 hours after surgery.
B. Two to three days after surgery.
C. Four to five days after surgery.
D. Five to seven days after surgery.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
The greatest risk of hemorrhage is during the first 24 to 48 hours after surgery or injury, indicating inadequate hemostasis. The nurse should monitor for decreased blood pressure and increased pulse rate and observe dressing and underneath the patient for any bloody drainage.

The nurse inspects all wounds for signs of infection. A contaminated or traumatic wound may show signs of infection:

A. during the first 24 to 48 hours after injury.
B. two to three days after injury.
C. Up to five days after injury.
D. five to seven days after injury.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: B.
A contaminated or traumatic wound may show signs of infection early, within 2 to 3 days. A surgical wound infection usually develops postoperatively within 4 to 5 days.

A patient with lung cancer received radiation therapy to reduce the size of the tumor prior to a lobectomy (surgical removal of part of the lung). The patient is now being seen on home health services for packing of an abnormal passage between the patient’s chest cavity and an opening on the patient’s back. The nurse is aware the patient is at increased risk for:

A. edema
B. hemorrhage
C. nerve damage with decreased sensation
D. fluid and electrolyte imbalance

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
The patient has a fistula, an abnormal passage between two organs or between an organ and the outside of the body. Most fistulas form as a result of poor wound healing or as a complication of disease, such as in this case cancer and radiation exposure in this case. The patient is at an increased risk for fluid and electrolyte imbalances from fluid loss through the fistula. Chronic drainage of fluids through a fistula can also predispose a person to skin breakdown.

The nurse is instructing a patient on how to change a transparent dressing. Which statement, if made by the nurse, requires correction?

A. “The old dressing may be removed while wearing clean gloves. Remove in direction of hair growth and toward the center. Remove disposable gloves pulling them inside out over the soiled dressing and dispose of properly.”
B. “You will need to apply new gloves after you open your supplies and before you clean the wound. Make sure the area around the wound is dry before applying a new transparent dressing.”
C. “You will want to remove your gloves to prevent the transparent dressing from sticking to them. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling.”
D. “When the dressing change is completed, be sure to wash your hands. A transparent dressing is beneficial because it maintains a moist environment aiding wound healing, allows you to examine the wound without having to remove the dressing, and conforms well to body contours.”

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
Gloves are not discarded until the new dressing has been applied. The transparent film should be placed smoothly over the wound without stretching because wrinkles can provide a tunnel for drainage.

The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse’s best action at this time?

A. Apply sterile gloves and push the intestines back into the wound.
B. Instruct the patient to avoid looking at the wound.
C. Apply sterile saline-soaked towels to the area.
D. Assess the wound to determine the extent of evisceration.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: C.
When evisceration occurs, the nurse places sterile towels soaked in sterile saline over the extruding tissues. The patient should be allowed nothing by mouth (NPO), observed for signs and symptoms of shock, and prepared for emergency surgery.

Which of the following may indicate an increased risk for wound dehiscence?

A. It is within the first 24 to 48 hours after surgery.
B. The patient holds a pillow over the abdomen whenever coughing.
C. There is a small amount of serous drainage noted on the dressing.
D. There is an increase in serosanguineous drainage from the wound.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: D.
When there is an increase in serosanguineous drainage from a wound, the nurse should be alert for the potential for dehiscence. Dehiscence most commonly occurs before collagen formation (3 to 11 days after injury or surgery). Risk for hemorrhage is greatest during the first 24 to 48 hours following surgery. Placing a pillow or folded thin blanket over the abdomen provides a splint to the area, supporting the healing tissue when coughing increases the intra-abdominal pressure. This is done to prevent wound dehiscence.

Which of the following patients is at greatest risk for developing a wound infection?

A. A diabetic obese patient who smokes.
B. An adolescent who takes steroids for asthma.
C. An alcoholic.
D. An elderly patient.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answer: A.
The diabetic patient has the most risk factors for developing a wound infection. Other risk factors include: having a chronic disease, being obese, and smoking. Although taking steroids is one risk factor, this patient has fewer risk factors than the patient who has a chronic disease, is obese, and smokes. The same is true of the other patients.

The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following indicates correct understanding? (Select all that apply.)

A. The nurse instructs the NAP to empty the drain every 8-12 hours or when it is 2/3 full and document the amount as output on the intake and output record.
B. The nurse expects the Jackson-Pratt drain to be used when there is a large amount of drainage (500 mL).
C. The nurse ensures the drainage device appears deflated after it is emptied.
D. The nurse pins the Jackson-Pratt drain above the wound.
E. The nurse instructs the NAP to determine and report what type of drainage is present in the JP drain.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)

Answers: A, C.
The drainage device should be emptied every 8-12 hours or sooner if one-half to two-thirds full. To function properly the drainage device should be compressed. Determining the type of drainage present is the responsibility of the nurse.

The nurse is completing an admission assessment of a new patient to the unit. The nurse notes a long, thin, fading scar on the patient’s abdomen in the right lower quadrant. The nurse knows that scar tissue results from

A. Optimal functioning of the inflammatory process after an injury.
B. Fibrous tissue replacing damaged tissue when injury is extensive.
C. The development of chronic inflammation.
D. A surgical incision.

(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 21)

Answer: B.
Scar tissue, or fibrous repair of damaged tissue, occurs when an area is damaged too extensively for the body to replace damaged tissue with identically functioning tissue after removal of injurious agents and pathogens. Optimal functioning of the inflammatory process will result in regeneration of tissue that functions identically to the damaged and replaced tissue. Chronic inflammation can result in fibrous, or scar, tissue, but that scar tissue production is continuous as the inflammation continues. Fibrous tissue production can result from many different kinds of injuries, not just surgical wounds.

Which of the following patients is at higher risk for inflammatory reactions?

A. 2-year-old girl with a healthy diet.
B. 38-year-old man who is obese.
C. 54-year-old woman in menopause.
D. 79-year-old man with diabetes.

(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 21)

Answer: D.
The 79-year-old man is at highest risk for inflammatory reactions among these patients for two reasons, his age and having diabetes. The risk would be high during the first year of life, but this 2-year-old girl has gotten beyond this risk period and she also has the positive factor of a healthy diet. The 38-year-old man is not in a high-risk category because of age but is because of obesity. Although a 54-year-old woman is getting older, being in menopause does not increase the risk for inflammatory reactions.

A patient admitted to an acute care floor has rubor of an area of injury on the left lower extremity. The nurse understands that this redness is caused by

A. Vasodilation.
B. Extravasation.
C. Neutrophils.
D. Exudate.

(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 21)

Answer: A.
The inflammatory process results in rubor, or redness, of an area of insult. The body responds to injury by increasing the blood flow to an area through vasodilation. This allows increased oxygen and more nutrients and appropriate white blood cells to reach the area, isolating the area and beginning the immune response. Extravasation is the movement of fluid from its confined space into the surrounding tissue. Neutrophils are one of the most common types of white blood cells. Exudate is the fluid filled with proteins and white blood cells that moves out of the vascular spaces through extravasation.

A patient comes to a clinic with a chief complaint of, “My left arm is red and swollen. It hurts badly enough that I couldn’t go to work today.” The physician orders computer-assisted tomography (CT) scanning of the left upper extremity. The nurse knows the patient understands the reason for the procedure when he states

A. “I need to have this done because my arm is broken.”
B. “The doctor wants me to have this so that the pain will stop.”
C. “This will tell you what I did to my elbow because I really don’t know what happened.”
D. “This test will help to better determine where the injury actually is and how severe it is.”

(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 21)

Answer: D.
Radiographic imaging studies such as CT scans help to determine the location and extent of inflammation within the body. The CT scan will help with diagnosis. The diagnosis is not predetermined. CT scanning does not alleviate pain. Radiography does not necessarily determine a cause of an injury.

The nurse is reviewing the erythrocyte sedimentation rate (ESR) for one of her patients. An elevated ESR

A. Determines specific causes of inflammation.
B. Identifies the location of inflammation within the body.
C. Confirms the nonspecific presence of inflammation.
D. Indicates a diagnosis of systemic lupus.

(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 21)

Answer: C.
An elevated ESR is indicative of the presence of inflammation in the body. Proteins produced during the inflammatory process adhere to red blood cells, causing them to be heavier and settle out of blood samples at a faster rate than normal. The ESR does not identify specific causes of inflammation and does not determine a specific location of inflammation. The ESR is a nonspecific indicator of inflammation.

The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (Select all that apply):

A. Applying over-the-counter lotions to skin that is not broken.
B. Assisting the client with frequent turning to prevent pressure ulcers.
C. Covering the client who complains of being cold with more blankets.
D. Placing a sterile gauze pad over broken skin to contain drainage.
E. Assessing a patient complaining of an itching rash.

(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 24)

Answers: A, B, C, D.
All the above options can be delegated to an unlicensed assistive personnel employee except for assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient’s daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? (Select all that apply):

A. Cleansing the wound.
B. Managing pain.
C. Applying a dry sterile dressing.
D. Using cold water in the bath.

(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 24)

Answers: A, B.
Administering pain medications will ensure that the patient is comfortable prior to a dressing change. The nurse should cleanse the wound and then apply the sterile dressing. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.

The nurse would explain to a patient that effective treatments for atopic pruritus include (Select all that apply):

A. Oral steroids.
B. Topical steroids.
C. Oral antihistamines.
D. Topical antihistamines.
E. Topical petroleum ointment.

(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 24)

Answers: A, B.
Oral and topical steroids may be given for acute cases of atopic pruritus. Oral and topical antihistamines are not usually given, because they are ineffective and may cause further irritation. Petroleum is also ineffective.

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to (Select all that apply):

A. Wear sunglasses.
B. Drink plenty of water.
C. Eat plenty of foods high in vitamin K.
D. Apply sunscreen 30 minutes prior to exposure.

(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 24)

Answers: A, D.
Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamin K can cause the blood to clot and has not been indicated.

A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to (Select all that apply):

A. Bathe and dry the skin vigorously to stimulate circulation.
B. Keep the head of the bed elevated 30 degrees.
C. Offer nutritional supplements and frequent snacks.
D. Turn the patient at least every 2 hours.

(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 24)

Answers: C, D.
The patient should be turned at least every 2 hours because permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Use of donut pads, elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not actually encourage, dermal decline.

The nurse is developing a teaching a plan for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse plans to include which instruction in the client’s teaching plan?

A. Take daily tub baths using a mild soap.
B. The infected area should be covered with a clean, dry bandage.
C. Wash the infected areas first, then wash the uninfected areas.
D. Use bath sponges or puffs when bathing.

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: B.
The infected area should be covered with a clean, dry bandage to prevent the spread of infection. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection.

The nursing instructor reviews instructions with the nursing student on caring for the older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client?

A. Massages bony prominences
B. Avoids reddened areas
C. Repositions the client every 1 to 2 hours
D. Uses a moisturizing lotion

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
Massaging bony prominences should be avoided in older adult clients.

The nurse is teaching the client with loss of sensation and movement in the lower extremities secondary to spinal cord injury about protecting skin integrity. Which daily prevention strategy will the nurse include in the client’s teaching plan?

A. Lift hips off the chair at least every 30 minutes.
B. Eat a low-fat diet.
C. Massage reddened areas.
D. Complete a pressure map.

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
Lifting hips off the chair at least every 30 minutes relieves pressure and can prevent pressure ulcers.

During morning rounds, the nurse discovers that the older adult client has been incontinent during the night. To protect the skin, what will the nurse do first?

A. Apply a barrier cream.
B. Assess the area for skin breakdown.
C. Clean the client.
D. Place the client in a side-lying position.

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: C.
Cleaning and drying the client is the first priority for skin protection.

The older adult client who is bedridden has a documented history of protein deficiency. What will the nurse plan to monitor for?

A. Anemia
B. Decreased wound healing
C. Pressure ulcer development
D. Weight gain

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: C. This client is at risk for pressure ulcer if he or she remains bedridden. B is incorrect because there is no indicated wound.

The client has had a melanoma lesion removed. For secondary prevention, what is important for the nurse to teach the client?

A. Ensure that all lesions are reviewed by a dermatologist or a surgeon.
B. Avoid sun exposure.
C. Perform a total skin self-examination monthly.
D. Perform a total skin self-examination monthly with a partner.

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: D.
Performing a monthly total skin self-examination with another person is the best secondary preventive measure. B is incorrect because avoiding sun exposure is a primary prevention.

In teaching the client about skin cancer prevention, which instruction will the nurse include?

A. “Avoid sun exposure between 11 AM and 3 PM.”
B. “Examine skin quarterly for possible cancerous or precancerous lesions.”
C. “Wear transparent clothing to protect the skin from the sun.”
D. “It is safe to use a tanning bed.”

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
The sun’s rays are strongest between 11 AM and 3 PM and can cause more damage during this time.

The young client has been diagnosed with ringworm, but the mother would like the child to return to school. To avoid spreading the infection, what will the nurse suggest to the mother?

A. “Wash your hands frequently.”
B. “Your child may return to school but must be isolated from the rest of the class.”
C. “Keep the site covered with a bandage.”
D. “Keep your child out of school until the infection has cleared.”

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: C.
Keeping the site covered prevents spread of the infection. D is incorrect because keeping the child out of school is not necessary.

The discharged obese client will require frequent dressing changes for a skin condition on the left foot. How will the nurse assess whether the client is able to perform this task at home?

A. Asks the client if he is squeamish
B. Demonstrates how to change the dressing
C. Determines whether the client can reach the affected area
D. Provides all the necessary dressing materials

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: C.
Whether the obese client can access the dressing site is the most important thing to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to perform frequent dressing changes at home. If you chose B, it’s incorrect because demonstration is a good start, but it does not assess the client’s ability to perform the task himself.

The nurse prepares to administer vancomycin (Lyphocin, Vancocin) to a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. How will the nurse administer this medication?

A. Administer by bolus.
B. Give IV push.
C. Infuse over 60 minutes.
D. Mix vancomycin with primary intravenous (IV) bag.

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: C.
Vancomycin (Lyphocin, Vancocin) is irritating to the veins and can trigger thrombophlebitis; it should be given over at least 60 minutes.

The client has an odorous purulent wound. How does the nurse best support this client?

A. Changes the dressing frequently
B. Encourages a diet high in protein
C. Suggests whirlpool therapy
D. Places room deodorizers in the room

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
Frequent dressing changes help the client feel clean.

The client with a foot ulcer says, “I feel helpless.” What is the nurse’s best response?

A. Encourages participation in care of the wound
B. Encourages visitors
C. Says, “I know how you feel”
D. Assures the client that it will be all right

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
Encouraging participation in wound care gives the client a sense of autonomy. If you chose D, it is incorrect because assuring the client that everything will be all right not only fails to address the underlying issue but also may be untrue.

The nurse understands that deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention?

A. First
B. Second
C. Third
D. Mixed

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: B.
Second intention healing is characterized by a cavity-like defect. This requires gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss.

The nurse anticipates that the client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy?

A. Hyperbaric oxygen
B. Nutrition therapy
C. Topical growth factors
D. Vacuum-assisted wound closure

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers.

What is the best way for the nurse to prevent the client’s stage I pressure ulcer from advancing to stage II?

A. Massage the reddened areas.
B. Pad the ulcer.
C. Promote mobility and/or frequent repositioning.
D. Suggest an egg crate mattress.

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: C.
Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client’s pressure ulcer.

The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration?

A. Calcium
B. Hematocrit
C. Numbers of immature white blood cells (WBCs)
D. Serum albumin

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: D.
Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian.

Which statement by the client with psoriasis indicates to the nurse that additional teaching about his condition is required?

A. “A tanning bed will supply the ultraviolet light I need.”
B. “Medicine can prevent the growth of new skin cells.”
C. “I can never be cured.”
D. “Stress can cause my flare-ups.”

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
Ultraviolet (UV) radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these clients. This statement indicates that the client requires further teaching.

Which statement by the client with psoriasis indicates that teaching about the condition has been effective?

A. “I know that I need to avoid warm climates.”
B. “I need to cover up the affected areas to prevent spread to my family.”
C. “I should practice good handwashing technique.”
D. “Psoriasis can be cured with steroids.”

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: C.
Infections such as strep throat can exacerbate psoriatic flare-ups. Handwashing can help prevent infection.

The nurse is teaching the client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include?

A. Avoiding or reducing skin exposure to sunlight
B. Avoiding tanning beds
C. Being aware of skin markings and performing skin self-examination
D. Wearing SPF 40 sunscreen

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
Avoiding or reducing one’s exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats).

The nurse admits a client to the clinic who is reporting severe itching to the arms and legs caused by exposure to poison ivy. The nurse anticipates that the health care provider will prescribe which medication?

A. Anthralin (Anthaforte, Drithocreme, Lasan)
B. Benzyl benzoate (Ascabiol)
C. Calcipotriene (Dovonex)
D. Diphenhydramine (Benadryl)

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: D.
Treatment is aimed at removal of the triggering substance and relief of symptoms. Because the skin reaction is caused by histamine release, antihistamines such as diphenhydramine (Benadryl) are helpful.

The nurse is caring for a client prescribed linezolid (Zyvox) for treatment of methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse plans to monitor the client for which adverse effect of linezolid?

A. Depression
B. Hyperglycemia
C. Hypertension
D. Incontinence

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: C.
Linezolid (Zyvox) constricts blood vessels and may trigger hypertensive crisis.

Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant?

A. Use the Braden scale to determine pressure ulcer risk for a newly admitted client.
B. Complete daily sterile dressing changes for a client with a venous leg ulcer.
C. Reposition every 2 hours a client who has had a stroke and is incontinent.
D. Admit a newly transferred client who had pedicle flap surgery 1 week ago.

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer:C.
The nursing assistant has the education and scope of practice to reposition a client.

The nurse working in the same-day surgery unit has just received report and plans to assess which client first?

A. Adult with a basal cell carcinoma excised who needs discharge teaching about wound care
B. Young adult who has had rhinoplasty and is swallowing frequently
C. Middle-aged adult who reports 7/10 pain after removal of a cyst
D. Older adult ready to be transferred to the long-term care facility after débridement of a pressure ulcer

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: B.
Frequent swallowing after rhinoplasty may indicate bleeding, which requires immediate action by the nurse.

A client with bacteremia associated with a bacterial skin infection is receiving clindamycin (Cleocin) intravenously (IV). Which assessment finding indicates the need for immediate action by the nurse?

A. Blood pressure is 88/40 mm Hg.
B. White blood cell count is 15,000/mm3.
C. Oral temperature is 101° F (38.3° C).
D. Heart rate is 102 beats/min.

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
Too-rapid administration of clindamycin (Cleocin) can cause shock and cardiac arrest; the client’s low blood pressure indicates a need to slow the rate and reassess the client.

A female business professional has extremely dry skin on her legs. In addition to using lotions after bathing, she asks the nurse about other measures to help reduce the dryness. What is the nurse’s best response?

A. “Wear long-legged pajamas to sleep in rather than nightgowns.”
B. “Avoid wearing pantyhose or nylon stockings for more than 2 hours at a time.”
C. “Leave the fat-containing soap on your skin when bathing rather than rinsing it off.”
D. “Bathe in water that is as warm as you can stand to stimulate the release of body oils from your sebaceous glands.”

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: B.
Clothing that fits tightly and rubs can dry the skin. Prolonged contact with nylon stockings or pantyhose causes or exacerbates dry skin on the legs. Avoiding these clothing items can reduce this dryness.
Reference: p. 472, Health Promotion and Maintenance

The newly admitted client has all of the following laboratory test values. Which value suggests to the nurse that the client may be at an increased risk for pressure ulcer formation?

A. International normalized ratio (INR) of 1.5
B. White blood cell (WBC) count of 5200/mm3
C. Serum sodium concentration of 134 mEq/L
D. Serum prealbumin concentration of 15.2 mg/dL

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: C.
Adequate nutrition, especially protein intake, helps promote healthy skin and prevent tissue breakdown. A serum prealbumin concentration less than 19.5 mg/dL indicates inadequate nutrition and a severe protein deficiency. With so little protein, the skin cannot repair itself and is at great risk for injury even with minor trauma.
Reference: p. 477, Safe and Effective Care Environment

Which intervention does the nurse use to promote “take” of a graft placed on the client’s right heel?

A. Elevate the client’s right foot by placing pillows under the leg from the knee to the ankles.
B. Position the client on the abdomen with the right foot hyperextended for at least 4 hours daily.
C. Ensure that the grafted area is pressed tightly to the bed to promote adherence to the wound bed.
D. Assess the circulation distal to the graft every hour and compare the findings with those from the left foot.

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
No pressure should be placed on the graft, and care must be taken to ensure it does not move over the wound so the blood vessels can connect the graft with the wound bed. Elevating the area allows better circulation and no pressure.
Reference: p. 488, Physiological Integrity

Which precaution is most important for the nurse to teach a client prescribed adalimumab (Humira)?

A. Drinking a full glass of water when taking each drug dose
B. Reducing the drug dosage when psoriasis symptoms decrease
C. Reporting symptoms of infection to the prescriber immediately
D. Avoiding sunlight and tanning beds for the duration of drug therapy

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: D.
Humira suppresses inflammatory and immune responses to some degree. This makes the client more susceptible to infection and may suppress some of the usual manifestations of infection. Together, these actions can allow a minor infection to become more severe very quickly. Any potential infection, no matter how minor, should receive immediate medical attention.
Reference: p. 501, Health Promotion and Maintenance

In which position does the nurse place the client immediately after a rhytidectomy to promote venous return and prevent swelling?

A. Fowler’s
B. Lithotomy
C. Lateral Sims’
D. Trendelenburg

(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)

Answer: A.
Only Fowler’s position would make the face less dependent, thus promoting venous return and decreasing swelling.
Reference: p. 507, Safe and Effective Care Environment

A student nurse is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient’s temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient’s temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend?

A. Tell the student that temporary confusion is normal and simply requires reorientation
B. Tell the student to increase the patient’s fluid intake since the urine is concentrated
C. Tell the student that her assessment findings are normal for an older adult
D. Tell the student that he will notify the physician of the findings

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answer: D.
The patient may have subtle symptoms of a urinary tract infection, as evidenced by a slight increase in body temperature, development of confusion, and the dark-colored urine. Temporary confusion is not a normal condition in older adults. Increasing the fluid intake is acceptable but not a recommendation for the set of symptoms the patient presents. The presenting set of symptoms is not normal.

A patient’s family member is considering having her mother placed in a nursing center. You have talked with the family before and know that this is a difficult decision. Which of the following criteria would you recommend in choosing a nursing center? (Select all that apply.)

A.The center should be clean, and rooms should look like a hospital room.
B.There should be adequate staffing on all shifts.
C.Social activities should be available for all residents.
D.Three meals should be served daily with a set menu and serving schedule.
E.Family involvement in care planning and assisting with physical care is necessary.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answers: B, C, E.
Adequate staffing, provision of social activities, and active family involvement are essential. Meals should be high quality with options for what to eat and when it is served. A nursing center should be clean, but it should look like a person’s home.

A nurse has conducted an assessment of a new patient who has come to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the nursing history. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing:

A. Dementia.
B. Depression.
C. Delirium.
D. Disengagement.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answer: B.
Factors that often lead to depression include presence of a chronic disease or a recent change or life event (such as loss). Patients are alert but easily distracted in conversation.

A major life event such as the death of a loved one, a move to a nursing home, or a cancer diagnosis could precipitate:

A. Dementia.
B. Delirium.
C. Depression.
D. Stroke.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answer: C.
The onset of depression could be abrupt or gradual, but the usual cause is a major life-altering event in the life of the person experiencing the depression.

Sexuality is maintained throughout our lives. Which answer below best explains sexuality in an older adult?

A. When the sexual partner passes away, the survivor no longer feels sexual.
B. A decrease in an older adult’s libido occurs.
C. Any outward expression of sexuality suggests that the older adult is having a developmental problem.
D. All older adults, whether healthy or frail, need to express sexual feelings.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answer: D.
Sexuality is normal throughout the life span, and older adults need to be able to express their sexual feelings.Ew.

Older adults experience a change in sexual activity. Which best explains this change?

A. The need to touch and be touched is decreased.
B. The sexual preferences of older adults are not as diverse.
C. Physical changes usually do not affect sexual functioning.
D. Frequency and opportunities for sexual activity may decline.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answer: D.
As a result of loss of a loved one or a chronic illness in themselves or their partner, opportunities for sexual activity may decline.

You see a 76-year-old woman in the outpatient clinic. Her chief complaint is vision. She states she has really noticed glare in the lights at home. Her vision is blurred; and she is unable to play cards with her friends, read, or do her needlework. You suspect that she may have:

A. Presbyopia.
B. Disengagement.
C. Cataract(s).
D. Depression.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answer: C.
Cataracts normally result in blurred vision, sensitivity to glare, and gradual loss of vision. Presbyopia is a common eye condition resulting in a person having difficulty adjusting to near and far vision. The symptoms are not reflective of depression since her vision affects her ability to interact. She has not chosen to avoid her friends. Disengagement is a term referring to aging theory.

A nurse is caring for a patient preparing for discharge from the hospital the next day. The patient does not read and has a hearing loss. His family caregiver will be visiting before discharge. What can you do to facilitate the patient’s understanding of his discharge instructions? (Select all that apply.)

A.Speak loudly so the patient can hear you.
B.Sit facing the patient so he is able to watch your lip movements and facial expressions.
C.Present one idea or concept at a time.
D.Send a written copy of the instructions home with him and tell him to have the family review them.
E.Include the family caregiver in the teaching session.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answers: B, C, E.
Teaching and communication are more effective with older adults when you sit and face the patient and present one idea or concept at a time. This requires planning. Speaking loudly can distort sound. Speak in a normal tone. Sending instructions is helpful but will not directly facilitate the patient’s own understanding. Sharing information with a caregiver provides someone to clarify instructions.

Taste buds atrophy and lose sensitivity, and appetite may decrease. As a result, the older adult is less able to discern:

A. Spicy and bland foods.
B. Salty, sour, and bitter tastes.
C. Hot and cold food temperatures.
D. Moist and dry food preparations.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answer: B.
Often an older adult uses “heavy” spices because of his or her inability to taste the food.

Kyphosis, a change in the musculoskeletal system, leads to:

A. Decreased bone density in the vertebrae and hips.
B. Increased risk for pathological stress fractures in the hips.
C. Changes in the configuration of the spine that affect the lungs and thorax.
D. Calcification of the bony tissues of the long bones such as in the legs and arm.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answer: C.
This can also affect the ability of the patient to deep breath and cough effectively.

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are your major concerns for this patient? (Select all that apply.)

A.The loss of his work role
B.The risk of social isolation
C.A determination if the wife will need to start working
D.How the wife expects household tasks to be divided in the home in retirement
E.The age the patient chose to retire

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answers: A, D.
The psychosocial stresses of retirement are usually related to role changes with a spouse or within the family and to loss of the work role. Often there are new expectations of the retired person. This patient is not likely to become socially isolated because of the size of the family. Whether the wife will have to work is not a major concern at this time, nor is the age of the patient.

During a home health visit a nurse talks with a patient and his family caregiver about the patient’s medications. The patient has hypertension and renal disease. Which of the following findings places him at risk for an adverse drug event? (Select all that apply.)

A.Taking two medications for hypertension
B.Taking a total of eight different medications during the day.
C.Having one physician who reviews all medications
D.Patient’s health history
E.Involvement of the caregiver in assisting with medication administration

Answers: B, D.
The patient is at risk for an adverse drug event (ADE) because of polypharmacy and his history of renal disease, which affects drug excretion. Taking two medications for hypertension is common. Having one physician review all medications and involving a family caregiver are desirable and are safety factors for preventing ADEs.

You are caring for an 80-year-old man who recently lost his wife. He shares with you that he has been drinking more than he ever did in the past and feels hopeless without his wife. He reports that he rarely sees his children and feels isolated and alone. This patient is at risk for:

A. Dementia.
B. Liver failure.
C. Dehydration.
D. Suicide.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answer: D.
The patient is sharing that he is depressed. Key concepts include recent loss of his wife, excessive drinking, hopelessness, and isolation, making him at risk for suicide.

You are working with an older adult after an acute hospitalization. Your goal is to help this person be more in touch with time, place, and person. What might you try?

A. Reminiscence
B. Validation therapy
C. Reality orientation
D. Body image interventions

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answer: C.
Reality orientation is a communication technique that can help restore a sense of reality, improve level of awareness, promote socialization, elevate independent functioning, and minimize confusion.

A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable around 130/70. The patient does not exercise regularly and complains of weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.)

A.Presence of a chronic disease
B.Impaired vision
C.Residence design
D.Blood pressure
E.Leg weakness
F.Exercise history

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 14)

Answers: B, E, F.
Risk factors for falling include sensory changes such as visual loss, musculoskeletal conditions affecting mobility (in this case weakness), and deconditioning (from lack of exercise). The mere presence of a chronic disease is not a risk factor unless it is a condition such as a neurological disorder that alters mobility or cognitive function. The patient’s blood pressure is stable, and there is no report of orthostatic hypotension. A one-floor residence should not pose risks.

Instruments such as the Functional Activities Questionnaire (FAQ) for postoperative patients who are at home, the Minimum Data Set for Nursing Facility Resident Assessment and Care Screening (MDS) for nursing home patients, the Functional Status Scale (FSS) for children, and the Edmonton Functional Assessment Tool for cancer patients are used to assess activities of daily living (ADLs). The nurse needs to remember that a disadvantage of these instruments includes

A. The efficacy and reliability of the instruments.
B. The variations in assessments and responses may be subjective because of self-reporting of functional activities.
C. The instruments do not show a true measure of ability because of a lack of interactivity during the assessments.
D. The information contained in the instruments is insufficient to make a determination about functional status in these populations.

(Giddens: Concepts for Nursing Practice, 1st Edition, Concept 2 – Functional Ability)

Answer: B.
A disadvantage of many of the ADLs and instrumental activities of daily living (IADLs) scales is the self-reporting of functional activities. Efficacy and reliability are not measured when assessing ADLs and IADLs. Interaction with the patient is necessary to complete the ADL and IADL assessments. The FAQ and FSS are comprehensive tools that can help the nurse determine functional status.

The nurse is assessing a patient’s ability to perform instrumental activities of daily living (IADLs). Which of the following activities are considered in the IADLs assessment? (Select all that apply):

A. Feeding oneself.
B. Preparing a meal.
C. Balancing a checkbook.
D. Walking.
E. Toileting.
F. Grocery shopping.

(Giddens: Concepts for Nursing Practice, 1st Edition, Concept 2 – Functional Ability)

Answers: B, C, F.
IADLs include shopping, meal preparation, housekeeping, doing laundry, managing finances, taking medications, and using transportation. The other activities listed are activities of daily living (ADLs) related to self-care.

The nurse is assessing a patient’s ability to perform basic activities of daily living (BADLs). Which of the following activities are considered in the BADLs assessment? (Select all that apply):

A. Feeding oneself.
B. Preparing a meal.
C. Balancing a checkbook.
D. Walking.
E. Toileting.
F. Grocery shopping.

(Giddens: Concepts for Nursing Practice, 1st Edition, Concept 2 – Functional Ability)

Answers: A, D, E.
BADLs include feeding oneself, ambulation, and toileting. Instrumental activities of daily living (IADLs) include shopping, meal preparation, housekeeping, doing laundry, managing finances, taking medications, and using transportation.

Which of the following interventions should be included in a plan of care for a patient who had a stroke 30 days ago and is now in home care rehabilitation? (Select all that apply).

A. Promoting independence and encouraging patient participation in activities of daily living (ADLs).
B. Promoting rest and sleep.
C. Promoting a diet rich in protein.
D. Promoting exercise and ambulation.
E. Assisting the patient with ADLs.
F. Limiting visitors and social contacts.

(Giddens: Concepts for Nursing Practice, 1st Edition, Concept 2 – Functional Ability)

Answers: A, B, D.
It is important to promote independence in ADLs early in the plan of care to increase independence in general. Promoting rest and sleep will promote well-being. Ambulation and exercise promote well-being and increase healing by circulating oxygen to the brain. Protein promotes healing in postsurgical patients but is not a main focus in stroke patients. Assisting the patient does not promote independence. Limiting visitors will isolate the patient, which can lead to depression.

The nurse is caring for an 85-year-old woman 6 weeks following a hysterectomy secondary to ovarian cancer. The patient will need chemotherapy and irradiation on an outpatient basis. Which of the following priorities would be seen as a barrier to healing and need to be considered when planning care for this patient? (Select all that apply):

A. Can feed herself and prepare meals but cannot drive to the store.
B. Lives on a fixed income and can balance her checkbook.
C. Has stress incontinence.
D. Was active at the senior center and now cannot participate in activities.
E. Lives alone and has no nearby relatives.
F. Has no transportation to the oncology clinic.

(Giddens: Concepts for Nursing Practice, 1st Edition, Concept 2 – Functional Ability)

Answers: C, E, F.
The patient will not be able to get treatment if she has no transportation or no relatives that live nearby who can help her with recovery. Stress incontinence increases the risk of falls because of urgency and rushing to get to the bathroom. Income and social abilities are lower priorities during this phase of recovery.

The nurse is having difficulty reading a physician’s order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take?

A. Call a pharmacist to interpret the order
B. Call the physician to have the order clarified
C. Consult the unit manager to help interpret the order
D. Ask the unit secretary to interpret the physician’s handwriting

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: B.
You must have the right documentation and clarify all orders with the prescriber before administering medications.

The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her?

A. 2 mL
B. 5 mL
C. 16 mL
D. 30 mL

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: D.
1 tablespoon = 15 mL; 2 tablespoons = 30 mL.

A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient’s ear when administering the medication?

A. Outward
B. Back
C. Upward and back
D. Upward and outward

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: D.
Eardrops are administered with the ear positioned upward and outward for patients greater than 3 years of age.

A patient is to receive cephalexin (Kefl ex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer?

A. ½ tablet
B. 1 tablet
C. 1 ½ tablets
D. 2 tablets

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: D.
Using dimensional analysis:
Tablets = 1tablet/250 mg× 500 mg = 500/250 = 2 tablets.

A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, “I don’t remember my child having that medication before.” What is the nurse’s next action?

A. Give the medications
B. Identify the patient using two patient identifiers
C. Withhold the medications and verify the medication orders
D. Provide medication education to the mother to help her better understand her child’s medications

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: C.
Do not ignore patient or caregiver concerns; always verify orders whenever a medication is questioned before administering it.

A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse?

A. Set up the follow-up appointments with the physician for the patient.
B. Ensure that someone will provide housekeeping for the patient at home.
C. Ensure that the home care agency is aware of medication and health teaching needs.
D. Make sure that the patient’s family knows how to safely bathe him or her and provide mouth care.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: C.
A nursing responsibility is to collaborate with community resources when patients have home care needs or difficulty understanding their medications.

A nursing student takes a patient’s antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient?

A. Only the patient’s physician can give this information.
B. The student provides the name of the medication and a description of its desired effect.
C. Information about medications is confidential and cannot be shared.
D. He has to speak with his assigned nurse about this.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: B.
Patients need to know information about their medications so they can take them correctly and safely.

The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse’s next best course of action?

A. Ask the prescriber to change the order
B. Crush the pill with a mortar and pestle
C. Hide the capsule in a piece of solid food (lol!)
D. Open the capsule and sprinkle it over pudding

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: A.
Enteric-coated or sustained-release capsules should not be crushed; the nurse needs to contact the prescriber to change the medication to a form that is liquid or can be crushed.

The nurse takes a medication to a patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurse’s next action?

A. Ask the patient’s reason for refusal
B. Explain that she must take the medication
C. Take the medication away and chart the patient’s refusal
D. Tell the patient that her physician knows what is best for her

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: A.
When patients refuse a medication, first ask why they are refusing it.

The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines the appropriate route for administering the diuretic according to:

A. Hospital policy.
B. The prescriber’s orders.
C. The type of medication ordered.
D. The patient’s size and muscle mass.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: B.
The order from the prescriber needs to indicate the route of administration.

A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse:

A. Continues to let the IV run.
B. Applies a warm compress to the infiltrated site.
C. Stops the administration of the medication and follows agency policy.
D. Should not worry about this because vesicant filtration is not a problem.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: C.
When an IV medication infiltrates, stop giving the medication and follow agency policy.

If a patient who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects:

A. Sepsis.
B. Phlebitis.
C. Infiltration.
D. Fluid overload.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: B.
Redness, warmth, and tenderness at the IV site are signs of phlebitis.

After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to:

A. Follow ISMP guidelines for safe medication abbreviations.
B. Explain to the physician that the order needs to be given to a registered nurse.
C. Write down the order on the patient’s order sheet and read it back to the physician.
D. Ensure that the six rights of medication administration are followed when giving the medication.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: B.
Nursing students cannot take orders.

A nurse accidently gives a patient a medication at the wrong time. The nurse’s first priority is to:

A. Complete an occurrence report.
B. Notify the health care provider.
C. Inform the charge nurse of the error.
D. Assess the patient for adverse effects.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)

Answer: D.
Patient safety and assessing the patient are priorities when a medication error occurs.
A patient is taking albuterol through a pressurized metered dose inhaler (pMDI) that contains a total of 200 puffs. The patient takes 2 puffs every 4 hours. How many days will the
pMDI last?
__________ days(Potter: Fundamentals of Nursing, 8th Edition, Chapter 31)
Correct Responses: “16, Two puffs × 6 times a day = 12 puffs per day; 200 puffs/12 puffs per day = 16.67 days, or about 16 days. This cannot be rounded up since the inhaler will not last a total of 17 days., 16, Two puffs × 6 times a day = 12 puffs per day; 200 puffs/12 puffs per day = 16.67 days, or about 16 days. This cannot be rounded up since the inhaler will not last a total of 17 days.”

Which components of pharmacokinetics does the nurse need to understand before administering a drug? (Select all that apply.)

a.Drugs with a smaller volume of drug distribution have a longer half-life.
b.Oral drugs are dissolved through the process of pinocytosis.
c.Patients with kidney disease may have fewer protein-binding sites and are at risk for drug toxicity.
d.Rapid absorption decreases the bioavailability of the drug.
e.When the drug metabolism rate is decreased, excess drug accumulation can occur, which can cause toxicity.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)

Answer: C, E.

The nurse will question the health care provider if a drug with a half-life (t1/2) of more than 24 hours is ordered to be given more than how often?

a.Once daily
b.Every other day
c.Twice weekly
d.Once weekly

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)

Answer: A.

The nurse is explaining drug action to a nursing student. Which statement made by the nurse is correct?

a.”Water-soluble and ionized drugs are quickly absorbed.”
b.”A drug not bound to protein is an active drug.”
c.”Most receptors are found under the cell membrane.”
d.”Toxic effects can result if the trough level is low.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)

Answer: B.

The nurse is caring for a patient with congestive heart failure who is receiving digoxin (Digitek, Lanoxicaps, Lanoxin). The nurse plans to take which action when administering digoxin?

a. Check the peak levels of digoxin.
b. Check the trough levels digoxin.
c. Monitor for tachyphylaxis.
d. Monitor the therapeutic range of digoxin.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)

Answer: D.
The nurse anticipates that the health care provider will order which laboratory test for an older adult with renal dysfunction?
a.Creatinine clearance
b.Glomerular filtration rate
c.Urine specific gravity
d.Urine pH(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)
Answer: A.

When reviewing the patient’s medication regimen, the nurse understands that the interval of drug dosage is related to what?

a.Half-life
b.Stimulation of receptors
c.Therapeutic index
d.Trough level

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)

Answer: A.

Which nursing assessment(s) will the nurse include when developing a patient medication plan? (Select all that apply.)

a. Check peak and trough levels of drugs.
b. Check the drug literature for the protein-binding percentage of a drug.
c. Identify side effects of drugs that are nonspecific.
d. Evaluate the patient’s reaction to a drug.
e. To enhance absorption, advise the patient to crush an enteric-coated tablet before taking.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)

Answers: A, B, C.

A student nurse is studying the phases of drug action. Which statement by the student indicates to the nursing instructor that the student understands the pharmaceutic phase?

a.”To achieve drug action, drugs are moved by four processes.”
b.”For the drug to cross the biologic membrane, the drug becomes a solution.”
c.”In this phase, drugs are concentrated and a biologic or physiologic response occurs.”
d.”The pharmaceutic phase is the process by which the drug becomes available to body fluids and tissue.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)

Answer: B.

The nurse plans to advise the patient to avoid which food(s) before ingesting an enteric-coated medication? (Select all that apply.)

a.Bananas
b.Baked lamb chops
c.Broiled fish
d.Ice cream
e.Fried chicken

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 1)

Answers: D, E.

The nurse is having a health teaching session with a patient who has many questions about the history of drug labels. What is the nurse’s best legislation reference for drug labels and increased control on drug safety?

a.Kefauver-Harris Amendment to the 1938 Act
b.Controlled Substances Act
c.Food, Drug, and Cosmetic Act
d.Durham-Humphrey Amendment to the 1938 Act

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 2)

Answer: A.

The nurse is reviewing a patient’s list of medications and notes that several have the highest abuse potential. According to U.S. standards, the highest potential for abuse of drugs with accepted medical use is found in drugs included in which schedule?

a. II
b. III
c. IV
d. V

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 2)

Answer: A.

The nurse is reviewing the drug-approval process in the United States and learns that the Food and Drug Administration Modernization Act of 1997 contains which provisions? (Select all that apply.)

a.Review of new drugs is accelerated.
b.Drug companies must provide information on “off-label” drugs.
c.Privacy of individually identifiable health information must be protected.
d.Drug companies must offer advanced notice of plans to discontinue drugs.
e.Drug labels must describe side effects and adverse effects.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 2)

Answers: A, B, D.

The patient has questions about counterfeit drugs. Which factors alert the patient or nurse that a drug is counterfeit or adulterated? (Select all that apply.)

a.Variations in packaging
b.Unexpected side effects
c.Different taste
d.Different chemical components
e.Different odor

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 2)

Answers: A, B, C.

The nurse must be knowledgeable about the Nurse Practice Act. In the event the nurse gives the correct drug via the wrong route, resulting in the death of the patient, what may the nurse be charged with in a civil court?

a. Misfeasance
b. Nonfeasance
c. Malfeasance
d. Negligence

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 2)

Answer: C.

The nurse knows the importance of administering the right medication to the patient and that drugs have many names. It is therefore most important that drugs be ordered by which name?

a.Generic
b.Brand
c.Trade
d.Chemical

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 2)

Answer: A.

A drug label has “t/c” on it. The nurse knows that which statement is true about this designation? (Select all that apply.)

a.It is on all schedule F prescription drugs.
b.It is on targeted substances, such as benzodiazepines.
c.It is a designation of the Canadian Controlled Drugs and Substances Act.
d.It is on all narcotics.
e.It is on over-the-counter drugs.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 2)

Answers: B, C.

What provisions from the Controlled Substances Act of 1970 were designed to remedy drug abuse?

a. The act established treatment and rehabilitation facilities.
b. The act tightened controls on experimental drugs.
c. The act required clinical trial data on drugs.
d. The act required drug companies to give information on off-label drugs.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 2)

Answer: A.

The nurse is performing a health assessment on a newly admitted patient of Asian descent. The patient looks at the floor whenever the nurse asks a question. Communication is enhanced when the nurse does which action?

a. Frequently touches the patient
b. Asks questions that require only “yes” or “no” for answers
c. Discontinues the health assessment
d. Uses eye contact sparingly

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 3)

Answer: D.

The nurse has been measuring the blood pressure of an African-American patient every 4 hours for the past 3 days in a hospital setting. The blood pressure is consistently above 140/90. The patient has been compliant with the antihypertensive drug therapy while hospitalized. The nurse will initially perform which action?

a.Question the patient about the types of food consumed in the last 3 to 4 days.
b.Inform the prescriber that the antihypertensive drug therapy is not working.
c.Increase blood pressure measurements to every 2 hours.
d.Place the patient on a restricted fluid intake.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 3)

Answer: B.

A nurse who is male is caring for a young, married woman who is an observant Muslim. It is important that the nurse perform which action?

a.Touch no part of the patient’s body.
b.Identify the patient’s preference regarding touch.
c.Touch the patient only when her spouse is present.
d.Tell the nurse manager he cannot care for female patients who practice Islam.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 3)

Answer: B.

A nurse is teaching a 16-year-old female patient about a newly prescribed medication. The patient is bilingual in Spanish and English. Which behavior best indicates the patient’s understanding of the instructions?

a. The patient frequently nods her head while listening to the nurse’s instructions.
b. The patient states that she understands the instructions.
c. The patient repeats the nurse’s instructions to her parents.
d. The patient does not ask the nurse for clarification of the instructions.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 3)

Answer: C.

A Native American patient is newly diagnosed with diabetes mellitus type 2 and is prescribed the antidiabetic drug metformin (Glucophage) 500 mg PO with morning and evening meals. Which statement best indicates to the nurse that the patient will adhere to the pharmacotherapy?

a.”I will no longer put sugar on my cereal because that will help me be healthier.”
b.”If I take this medicine, I will feel better soon and won’t have to take it anymore.”
c.”To reduce the possibility of damage to my body, I must take the medicine as scheduled.”
d.”I have diabetes because of my ancestry, so there’s not much I can do about it.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 3)

Answer: C.

The rate of absorption of drugs can change when two drugs are taken at the same time. The nurse is aware that the rate of absorption can be changed by which actions? (Select all that apply.)

a.Modifying gastric emptying time
b.Changing gastric pH
c.Decreasing inflammation
d.Forming drug complexes
e.Eating too slowly

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answers: A, B, D.

The nurse is reviewing a patient’s medications as part of patient teaching. The nurse is aware that which drug is least likely to cause photosensitivity?

a. Penicillins
b. Sulfonamides
c. Sulfonylureas
d. Thiazides

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answer: A.

A patient asks the nurse about the drug qualities that determine the category in which a drug is placed. What is the nurse’s best response? (Select all that apply.)

a.”Drugs that are in clinical trials”
b.”Drugs judged to be both safe and effective”
c.”Drugs judged to be either unsafe or ineffective”
d.”Drugs with insufficient data to judge safety or efficacy”
e.”Herbal products”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answers: B, C, D.

The nurse is meeting with a community group about medication safety. The nurse must emphasize that patients at high risk for drug interactions include which groups? (Select all that apply.)

a.Older patients
b.Patients with chronic health conditions
c.Patients taking three or more drugs
d.Patients dealing with only one pharmacy
e.Patients covered by Medicare or Medicaid

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answer: A, B, C.

The nurse recognizes that when a patient takes a hepatic enzyme inducer, the dose of the warfarin (Coumadin) is usually modified in which way?

a. It is increased.
b. It is decreased.
c. It remains the same.
d. It is unpredictable.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answer: A.

The nurse is conducting a patient assessment and notes that the patient has alkaline urine, which promotes excretion of drugs that are weak acids. Which drug is a weak acid?

a.phenytoin (Dilantin)
b.acetylsalicylic acid (aspirin)
c.quinidine (Apo-Quinidine)
d.warfarin (Coumadin)

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answer: B.

The nurse is describing to a patient the synergistic effects of two of his medications. Which statement by the nurse is correct about synergistic drug effects?

a.”Two drugs have antagonistic effects on each other.”
b.”The action of a drug is nullified by another drug.”
c.”One drug acts as an antidote to the side effects of another drug.”
d.”A greater effect is achieved when two drugs are combined.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answer: D.

A patient asks the nurse about cautions related to use of OTC medications. What is the nurse’s best response? (Select all that apply.)

a. “Over-the-counter drugs may delay professional diagnosis.”
b. “They may mask symptoms.”
c. “They may make diagnosis easier.”
d. “Their inactive ingredients may cause adverse reactions.”
e. “They may be more expensive.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answers: A, B, D.

Patients on long-term digoxin (Lanoxin) therapy need regular digoxin-level monitoring to detect early toxicity manifested by which symptoms? (Select all that apply.)

a.Visual problems
b.Nausea and vomiting
c.Skin eruptions
d.Urinary retention
e.Dizziness

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answers: A, B, D.

The nurse is reviewing a teaching plan with a patient who was recently diagnosed with asthma. What cautions about the use of aspirin are important for the nurse to advise the patient? (Select all that apply.)

a.It may trigger an acute asthma attack.
b.It may trigger a heart attack.
c.There is an increased risk for bleeding if also taking an anticoagulant.
d.It may decrease renal function.
e.It may decrease hepatic function.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answers: A, C, D.

A patient asks the nurse about drug interactions with OTC preparations. What is the nurse’s best response?

a. “Discuss this with the health care provider.”
b. “There are not many interactions, so don’t worry about it.”
c. “Read the labels carefully, and check with your health care provider.”
d. “Avoid over-the-counter preparations.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 4)

Answer: C.

When caring for a patient recovering from an episode of opioid toxicity, the nurse determines that the patient has an addiction to the drug based on which finding?

a.Physical withdrawal signs
b.A history of daily use
c.Craving that results in drug-seeking behaviors
d.Intravenous rather than oral use of the drug

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 5)

Answer: C.

While teaching the parents of an adolescent who has been using marijuana, the nurse explains that the euphoria that results from the use of abused psychoactive substances is believed to be caused by which factor?

a.Blockade of opioid receptors in the mesolimbic system of the brain
b.Stimulation of the dopamine pathways in the pleasure areas of the brain
c.Increased release of serotonin in all areas of the brain
d.Reduction in the responsiveness of brain receptors

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 5)

Answer: B.

A patient hospitalized with a fractured femur following an automobile accident develops diarrhea and vomiting with abdominal cramps, chills with goose bumps, and dilated pupils. The nurse suspects that the patient is experiencing which reaction?

a. Opioid withdrawal
b. Alcohol toxicity
c. Flashbacks from psychedelic abuse
d. Barbiturate withdrawal

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 5)

Answer: A.

Which agent(s) will the nurse anticipate administering to a patient who has been admitted with acute alcohol intoxication? (Select all that apply.)

a.naloxone (Narcan)
b.thiamine
c.lorazepam (Ativan)
d.naltrexone (ReVia)
e.intravenous glucose solution
f.flumazenil (Romazicon)

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 5)

Answers: B, C, E.

A patient is admitted to the emergency department with acute cocaine toxicity. Which is the most important intervention by the nurse?

a.Institute cardiac monitoring, and obtain frequent blood pressures.
b.Monitor the patient for decreasing respiratory function and level of consciousness.
c.Provide reality orientation with a calm, quiet approach.
d.Administer oral fluids with caffeine to prevent withdrawal symptoms.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 5)

Answer: A.

A nurse observes another nurse taking oral opioids from the medication room at the hospital. Which is the best action by the nurse?

a. Report the finding to the nursing supervisor to enable the nurse’s participation in a diversion program.
b. Ignore the situation to protect the nurse from dismissal and possible loss of licensure.
c. Confront the nurse and demand that the drugs be returned before someone notices their absence.
d. Ask the nurse to request pain medications from a physician rather than stealing them from the hospital.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 5)

Answer: A.

A patient is to start disulfiram (Antabuse) to help with alcohol abuse. The nurse providing medication education about the drug will include which topics in the education plan? (Select all that apply.)

a.Importance of taking this medication every day
b.That better results are experienced when a support group helps with adhering to treatment
c.Common food and hygiene products containing alcohol
d.That disulfiram treatment should be stopped 1 day before alcohol consumption
e.That disulfiram works by disrupting the metabolism of alcohol
f.That use of alcohol with disulfiram may cause nausea and vomiting and may even be fatal

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 5)

Answers: A, B, C, E, F.

A patient in the hospital is experiencing methamphetamine withdrawal. What does the nurse expect the symptoms and treatment to be?

a. Hypertension, tachycardia, and autonomic overactivity; treated by benzodiazepines
b. Hypersomnia, irritability; treated by supportive care including pushing food and fluids
c. Minimal notable symptoms; no treatment needed
d. Anxiety, insomnia, hyperactivity, and rapid, pressured speech; treated by symptom management

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 5)

Answer: B.

What provisions of the Dietary Supplement Health and Education Act of 1994 are most important for the nurse to know related to patient health teaching? (Select all that apply.)

a. Clarified marketing regulations
b. Reclassified herbs as dietary supplements
c. Stated that herbal products can be marketed with suggested dosages
d. Required that package labels give quality and strength of all contents
e. Stated that herbs can be used as drug

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 6)

Answer: A, B, C.

The nurse discovers that a patient has recently decided to take four herbal preparations. Which action will the nurse take first?

a.Discuss the cost of herbal products.
b.Instruct the patient to inform the health care provider of all products taken.
c.Instruct the patient to stop taking all herbal products immediately.
d.Suggest that the patient taper off use of herbal products over the next 2 weeks.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 6)

Answer: B.

Labeling of herbal products is important. Which is an appropriate claim for an herbal product?

a.”Prevents diabetes”
b.”Helps increase blood flow to the extremities”
c.”Cures Alzheimer’s disease”
d.”Is safe for all”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 6)

Answer: B.

The nurse is reviewing a patient’s current medications. Which herbal products interfere with the action of anticoagulants? (Select all that apply.)

a. aloe
b. feverfew
c. ginger
d. licorice
e. cranberry

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 6)

Answers: B, C, D.

A patient has multiple prescription medications and is not able to recall which herbal product he uses for relief of migraine headaches. He notes that it is a serum antagonist and asks the nurse to assist him. What is the best response by the nurse?

a.”Valerian”
b.”Feverfew”
c.”Milk thistle”
d.”Ginkgo”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 6)

Answer: B.

A patient is being followed by a cardiovascular clinic and takes garlic, which is reported to decrease cholesterol, triglycerides, blood pressure, and blood-clotting capability. Which patient statement indicates a need for further teaching? (Select all that apply.)

a.”I can just take garlic for my heart problems.”
b.”Garlic may provide some decrease in blood pressure.”
c.”Garlic is very effective in preventing depression.”
d.”Garlic may promote healing of my incision.”
e.”Garlic will not cure impotence.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 6)

Answers: A, C.

The nurse notes that many patients are taking herbal remedies for relief of depression and anxiety. Which herbal preparation has at least 10 pharmacologically active components for relief of depression and anxiety?

a. St. John’s wort
b. licorice
c. saw palmetto
d. goldenseal

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 6)

Answer: A.

A patient who is pregnant asks the nurse, “What herbal products can I take?” What is the best response by the nurse?

a.”What are you taking now?”
b.”Taking a product at bedtime is usually not a problem.”
c.”How long have you been taking herbal products?”
d.”Discuss this with your health care provider.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 6)

Answer: D.

A patient reports taking aloe, ginkgo, and licorice on a regular basis. Which patient statement indicates a need for health teaching about potential drug interactions?

a.”Aloe decreases the effect of my digoxin.”
b.”Ginkgo decreases the effects of my antiepileptics.”
c.”Licorice increases the effect of my digoxin.”
d.”Licorice decreases the effect of my antihypertensives.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 6)

Answer: A.

A patient has nine medications prescribed to take daily. Which are common reasons for nonadherence to the drug regimen in the older adult? (Select all that apply.)

a.Taking multiple drugs at one time
b.Impaired memory
c.Decreased dexterity
d.Increased mobility
e.Increased visual acuity

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)

Answers: A, B, C.

The nurse is reviewing a patient’s list of medications with the patient. The nurse understands that the older adult’s slower absorption of oral medications is primarily because of which phenomenon?

a. Decreased cardiac output
b. Increased blood flow
c. Decreased enzyme function
d. Increased pH of gastric secretions

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)

Answer: D.

The older adult patient has questions about oral drug metabolism. What is the most important information to include in this patient’s teaching plan?

a.First-pass effect
b.Enzyme function
c.Glomerular filtration rate
d.Motility

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)

Answer: A.

A 97-year-old patient asks why a protein supplement has been prescribed. What is the nurse’s best response?

a.”You have increased circulation of free drug.”
b.”You have decreased hepatic size.”
c.”You have decreased calcium absorption.”
d.”You have increased motility.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)

Answer: A.

An 80-year-old patient complains of recent onset of insomnia, saying, “If only I could get to sleep!” If a drug is prescribed, which drug characteristics would be best for this situation? (Select all that apply.)

a. Short-intermediate acting
b. Rapidly eliminated
c. Slowly eliminated
d. Multiple metabolites
e. Few metabolites

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)

Answers: A, B, E.

An older patient has just started on hydrochlorothiazide (HydroDiuril) and is advised by the health care provider to eat foods rich in potassium. What is the nurse’s best recommendation of foods?

a.Cabbage and corn
b.Pineapple and orange juice
c.Bran cereal and raisins
d.Brown rice and fish

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)

Answer: C.

Insomnia is a frequent complaint voiced by the patient. What are the most important elements for the nurse to include in the teaching plan? (Select all that apply.)

a.There are a limited number of FDA-approved medications to treat insomnia.
b.Benzodiazepines with long half-lives are preferred.
c.17% of the older adult population take hypnotics.
d.Temazepam is to be taken 1 to 2 hours before bedtime.
e.Triazolam should be tapered rather than abruptly stopped.

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 8)

Answer: A, D, E.

1. The nurse in the clinical research setting is knowledgeable about ethical principles and protection of human subjects. What principle is demonstrated when ensuring the patient’s right to self-determination?

a.Beneficence
b.Autonomy
c.Justice
d.Informed consent

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 10)

Answer: B.

2. The research nurse is meeting with a patient and, based on the assessment, determines that the patient meets the criteria. The patient agrees to participate in the clinical trial. The nurse advises the patient that which member of the health care team has the responsibility to explain the study and respond to questions?

a.Registered nurse
b.Pharmacist
c.Research associate
d.Health care provider

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 10)

Answer: D.

3. The clinical research nurse knows that only a small proportion of drugs survives the research and development process. An appreciation of the process and associated costs grows when the nurse is aware that approximately one in how many potential drugs is actually used in clinical situations?

a.100
b.1000
c.10,000
d.100,000

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 10)

Answer: C.

4. The nurse is interviewing a patient in a Phase I clinical trial. Which patient statement indicates an understanding of this trial phase?

a. “I am doing this to be sure this drug is safe.”
b. “I am doing this to be sure this drug is efficacious.”
c. “I hope this drug has no side effects.”
d. “I can be part of demonstrating a cure.”

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 10)

Answer: A.

5. The nurse is reviewing the protocols associated with a triple-blind study. The nurse understands that this technique is preferred in clinical trials because it removes which factor?

a.Knowledge
b.Conflicts
c.Prejudice
d.Bias

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 10)

Answer: D.

6. The foundation of clinical trials, Good Clinical Practice (GCP) is a helpful resource for nurses. The nurse is correct in choosing GPC as a reference for standards in which areas? (Select all that apply.)

a.Design and performance
b.Monitoring and auditing
c.Analyses
d.Reporting
e.Outcomes evaluation

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 10)

Answers: A, B, C, D.

7. The nurse has an important role in working with patients on aspects of care that require informed consent. The patient and the nurse must be aware of the dimensions of informed consent. Which dimensions are included? (Select all that apply.)

a. Protection of subjects from harm
b. Promotion of finding cure of disease
c. Protection of patient’s self-determination
d. Promotion of patient’s educated decision making
e. Promotion of individual autonomy

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 10)

Answers: A, C, D, E.

8. The nurse researcher reviews the proposed informed consent form for a future clinical trial. The nurse expects to find which in the document? (Select all that apply.)

a.Description of benefits and risks
b.Identification of related drugs, treatments, and techniques
c.Description of outcomes
d.Statement of compensation for participants, if any
e.Description of serious risks

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 10)

Answers: A, B, D, E.

9. The nurse knows that the patient should be informed about available alternatives and consequences. What ethical principle does this describe?

a.Respect for persons
b.Veracity
c.Justice
d.Beneficence

(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Chapter 10)

Answer: A.

A patient needs to learn to use a walker. Which domain is required for learning this skill?

A. Affective domain
B. Cognitive domain
C. Attentional domain
D. Psychomotor domain

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)

Answer: D.
Using a walker requires the integration of mental and muscular activity.

The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? (Select all that apply.)

A. When there are visitors in the room
B. When the patient’s pain medications are working
C. Just before lunch, when the patient is most awake and alert
D. When the patient is talking about current stressors in his or her life

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)

Answer: B, C.
Plan teaching when the patient is most attentive, receptive, alert, and comfortable.

A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse’s best plan in teaching this patient?

A. Teach the patient’s spouse
B. Focus on knowledge the patient will need in a few weeks
C. Provide only the information that the patient needs to go home
D. Convince the patient that learning about her health is necessary

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)

Answer: C.
This patient is in denial; thus it is appropriate to only give her information that is needed immediately.

The school nurse is about to teach a freshman-level high school health class about nutrition. What is the best instructional approach to ensure that the students meet the learning outcomes?

A. Provide information using a lecture
B. Use simple words to promote understanding
C. Develop topics for discussion that require problem solving
D. Complete an extensive literature search focusing on eating disorders

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)

Answer: C.
Adolescents learn best when they are able to use problem solving to help them make choices.

A nurse is going to teach a patient how to perform breast self-examination. Which behavioral objective does the nurse set to best measure the patient’s ability to perform the examination?

A. The patient will verbalize the steps involved in breast self-examination within 1 week.
B. The nurse will explain the importance of performing breast self-examination once a month.
C. The patient will perform breast self-examination correctly on herself before the end of the teaching session.
D. The nurse will demonstrate breast self-examination on a breast model provided by the American Cancer Society.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)

Answer: C.
Return demonstration provides an excellent source of feedback and reinforcement to evaluate learning.

A patient with chest pain is having an emergency cardiac catheterization. Which teaching approach does the nurse use in this situation?

A. Telling approach
B. Selling approach
C. Entrusting approach
D. Participating approach

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)

Answer: A.
The telling approach is most appropriate when preparing a patient for an emergency procedure.
The nurse is teaching a parenting class to a group of pregnant adolescents. The nurse pretends to be the baby’s father, and the adolescent mother is asked to show how she would respond to the father if he gave her a can of beer. Which teaching approach did the nurse use?
A. Role play
B. Discovery
C. An analogy
D. A demonstration(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)
Answer: A.
In role play people are asked to play themselves or someone else in a situation to enhance their confidence in handling that situation in the future.
An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse:
A. Speaks loudly.
B. Presents the information once.
C. Expects the patient to understand the information quickly.
D. Allows the patient time to express himself or herself and ask questions.(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)
Answer: D.
When teaching older adults, it is important to establish rapport, involve them in their care, and allow them to progress at their own pace.
A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn?
A. Describing difficulties a family member has had in taking insulin
B. Expressing the importance of learning the skill correctly
C. Being able to see and understand the markings on the syringe
D. Having the dexterity needed to prepare and inject the medication(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)
Answer: B.
Patients are ready to learn when they understand the importance of learning and are motivated to learn.
A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use?
A. Simulation
B. Demonstration
C. Group instruction
D. One-on-one discussion(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)
Answer: B.
Demonstration is used to help patients learn psychomotor skills.
When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, he or she tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use?
A. Telling
B. Analogy
C. Demonstration
D. Simulation(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)
Answer: B.
Analogies use familiar images when teaching to help explain complex information.
A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first?
A. How to use an inhaler during an asthma attack
B. The need to avoid people who smoke to prevent asthma attacks
C. Where to purchase a medical alert bracelet that says she has asthma
D. The importance of maintaining a healthy diet and exercising regularly(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)
Answer: A.
It is important to start with essential life-saving information when teaching people because they usually remember what you tell them first.
A nurse is teaching a group of young college-age women the importance of using sunscreen when going out in the sun. What type of content is the nurse providing?
A. Simulation
B. Restoring health
C. Coping with impaired function
D. Health promotion and illness prevention(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)
Answer: D.
Health promotion and illness prevention are the focus when nurses provide information to help patients improve their health and avoid illness.
A nurse is planning a teaching session about healthy nutrition with a group of children who are in first grade. The nurse determines that after the teaching session the children will be able to name three examples of foods that are fruits. This is an example of:
A. A teaching plan.
B. A learning objective.
C. Reinforcement of content.
D. Enhancing the children’s self-efficacy.(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)
Answer: B.
A learning objective describes what the learner will do after the teaching session.
A nurse is teaching a 27-year-old gentleman how to adjust his insulin dosages based on his blood sugar results. What type of learning is this?
A. Cognitive
B. Affective
C. Adaptation
D. Psychomotor(Potter: Fundamentals of Nursing, 8th Edition, Chapter 25)
Answer: A.
Cognitive learning requires thinking; learning how to adjust insulin requires analysis, synthesis, and evaluation, which are all types of cognitive learning.

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone [21%] 2. Client admitted 2 days ago with congestive …

A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention would be appropriate? 1. Administering digestive enzymes before meals as prescribed 2. Providing small, frequent meals 3. …

A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome? Glucose level After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion …

1. Which item below correctly describes the U.S. Bureau of Labor Statistics predictions by 2020? a. Positions that historically required registered nurses will be filled by unlicensed personnel. b. The job growth rate for RNs will surpass job growth in …

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