FOUNDATIONS AND ADULT HEALTH NURSING 8TH EDITIONCOOPER TEST BANKTEST BANK

Foundations and Adult Health Nursing 8th Edition Cooper Test Bankc. Replace the dressing with sterile fluffy pads.d. Apply a warm, moist normal saline sterile dressing.ANS: D Cover the wound with a sterile towel moistened with sterile physiologic saline (warm).DIF: Cognitive Level: Application REF: 46 OBJ: 13 TOP: Evisceration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity When should the nurse offer prescribed analgesics to a patient who is 24 hours postoperative? 18. a. Only when the patient asks.b. When the onset of pain is assessed.c. Sparingly to avoid drug dependence.d. Only when severe pain is assessed.ANS: B The nurse should assess for pain frequently to medicate at the onset of pain. DIF: Cognitive Level: Application REF: 48 OBJ: 14 TOP: Medication administration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity What should the nurse do to minimize the potential for venous stasis? 19. a. Place pillows under the knee in a position of comfort.b. Assist patient to sit with feet flat on the floor.c. Assist with early ambulation.d. Perform gentle leg massage.ANS: C Early ambulation has been a significant factor in hastening postoperative recovery and preventing postoperative complications.NRIGB.CMUSNTO DIF: Cognitive Level: Application REF: 49 OBJ: 13 TOP: Venous stasis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity The nurse clarifies that serum potassium levels are determined before surgery to: 20. a. assess kidney function.b. determine respiratory insufficiency.c. prevent arrhythmias related to anesthesia.d. measure functional liver capability.ANS: C Serum electrolytes are evaluated if extensive surgery is planned or the patient has extenuating problems. One of the essential electrolytes examined is potassium; if potassium is not available in adequate amounts, arrhythmias can occur during anesthesia. DIF: Cognitive Level: Analysis REF: 23 OBJ: 4 TOP: Preoperative assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IntegrityNURSINGTB.COM Foundations and Adult Health Nursing 8th Edition Cooper Test Bank In performing the preoperative assessment, the nurse discovers that the patient is allergic to 21. latex. What should the nurse do initially? a. Notify the diet kitchen to omit peaches from diet tray.b. Apply a medical alert band to patient's wrist.c. Tag chart with allergy alert.d. Place patient in an isolation room.ANS: B The initial intervention would be to place a medical alert band on the patient, then tag the chart. The charge nurse and the surgeon should be notified in the event the surgeon wants to order a preoperative prophylactic treatment. DIF: Cognitive Level: Knowledge REF: 25 OBJ: 13 TOP: Latex allergy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment Which of the following early postoperative observations should be reported immediately? 22. a. "Coffeeground" emesisb. Shiveringc. Scanty urine outputd. Evidence of painANS: A Any emesis that is red or coffee ground should be reported immediately as it indicates GI bleeding. Shivering, scanty urine output, and evidence of pain are within normal expectation of a postsurgical patient.NRIGB.CMUSNTODIF: Cognitive Level: Application REF: 44-45 OBJ: 10 TOP: Postoperative assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity When the postoperative patient complains of sudden chest pain combined with dyspnea, 23. cyanosis, and tachycardia, the nurse recognizes the signs of: a. hypovolemic shock.b. dehiscence.c. atelectasis.d. pulmonary embolus.ANS: D Sudden chest pain combined with dyspnea, tachycardia, cyanosis, diaphoresis, and hypotension is a sign of pulmonary embolism. DIF: Cognitive Level: Analysis REF: 47 OBJ: 13 TOP: Assessment and postoperative complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity The removal of a nondiseased appendix during a hysterectomy is classified as: 24. a. major, emergency, diagnostic.b. major, urgent, palliative.c. minor, elective, ablative.d. minor, urgent, reconstructive. NURSINGTB.COM Foundations and Adult Health Nursing 8th Edition Cooper Test Bank ANS: C Surgery is classified as elective, urgent, or emergency. Surgery is performed for various purposes, which include diagnostic studies, ablation (an amputation or excision of any part of the body or removal of a growth or harmful substance), and palliative (therapy to relieve or reduce intensity of uncomfortable symptoms without cure), reconstructive, transplant, and constructive purposes. DIF: Cognitive Level: Comprehension REF: 15 OBJ: 2 TOP: Types of surgeries KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity Which medication would cause surgery to be delayed if it had not been discontinued several 25. days before surgery? a. Analgesic agentb. Antihypertensive agentc. Anticoagulant agentd. Antibiotic agentANS: C Anticoagulants alter normal clotting factors and thus increase risk of hemorrhaging. They should be discontinued for 48 hours before surgery. DIF: Cognitive Level: Analysis REF: 36 OBJ: 4 TOP: Individual's ability to tolerate surgery KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity The most appropriate intervention by the nurse to decrease the pain of an abdominal incision 26. while coughing would be to: NRIGB.CMUSNTO a. support the surgical site with a pillow. b. position patient in a side-lying position.c. medicate with prescribed narcotic before coughing.d. ask the patient to cross arms over the chest to increase force of cough.ANS: A To ease the pressure on the incision, the nurse helps the patient support the surgical site with a pillow or rolled bath blanket. The heel of the hand can be used as well, but it is not the ideal method.DIF: Cognitive Level: Application REF: 47 OBJ: 8 TOP: Postoperative nursing interventions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity The nurse would include the patient problem of deficient knowledge, postoperative, when the 27. patient scheduled for a bowel resection tomorrow remarks: a. "I am going to have adequate pain medication after surgery."b. "I know you all are going to make me cough and walk soon after surgery."c. "I am glad I will get to go home tomorrow evening."d. "I will have to put up with dressing changes."ANS: C The patient's lack of understanding about the length of time in the hospital following such a serious surgery indicates a knowledge deficit that needs to be addressed. NURSINGTB.COM Foundations and Adult Health Nursing 8th Edition Cooper Test BankDIF: Cognitive Level: Analysis REF: 19 OBJ: 16 TOP: Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment What instruction should a nurse give when teaching the patient to cough effectively after 28. surgery? a. Breathe through the nose, hold breath, and exhale slowly.b. Take three deep breaths and cough from the chest.c. Inhale while contracting the abdominal muscles and exhale while contracting the diaphragm.d. Take short, frequent panting breaths and cough from the throat to clear accumulated mucus.ANS: B Because lung ventilation is vital, the nurse assists the patient to turn, cough, and breathe deeply every 1 to 2 hours until the chest is clear. Having practiced this combination preoperatively, the patient is usually adequately able to remove trapped mucus and surgical gases. DIF: Cognitive Level: Application REF: 47 OBJ: 8 TOP: Prevention of postoperative complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity What is the responsibility of the nurse as a witness to informed consent? 29. a. Explain the surgical options.NRIGB.CMb. Explain the operative risks.USNTOc. Verify/obtain the patient's signature.d. Verify the patient's understanding of the procedure.ANS: C A witness is only verifying that this is the person who signed the consent and that it was a voluntary consent. The witness (often a nurse) is not verifying that the patient understands the procedure. DIF: Cognitive Level: Knowledge REF: 23 OBJ: 7 TOP: Informed consent KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment On the patient's return to the medical-surgical unit, the nurse performing an abdominal 30. assessment can affirm an absence of bowel sounds after listening in each quadrant for at least: a. 30 seconds.b. 1 minute.c. 2 minutes.d. 3 minutes.ANS: D Normal peristalsis is gauged by hearing 5 to 30 gurgles per minute. Absence of bowel sounds may be recorded if the nurse has listened to each quadrant 3 to 5 minutes. DIF: Cognitive Level: Knowledge REF: 50 OBJ: 12 NURSINGTB.COM Foundations and Adult Health Nursing 8th Edition Cooper Test BankTOP: Bowel sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity When the patient asks the nurse to make sure no one sees her with her dentures out, the nurse 31. recognizes the common preoperative fear of: a. anesthesia.b. loss of control.c. fear of separation from family.d. mutilation.ANS: B Fear of loss of control may be partially related to concerns about anesthesia, but this patient's concern is about self-image. Preoperative anxiety from any cause may affect the amount of anesthesia and postoperative analgesia needed. DIF: Cognitive Level: Assessment REF: 19 OBJ: 4 TOP: Nursing process KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance What is the ideal time for preoperative teaching? 32. a. Immediately before surgery to eliminate fearb. 2 months in advance so the patient can preparec. 1 to 2 days before the surgery when anxiety is not as highd. In the surgical holding areaANS: C Preoperative teaching is provided when the surgery is scheduled if the patient is being seen in NRIGB.CMthe surgeon's office, when anxiety is not as high.USNTO DIF: Cognitive Level: Implementation REF: 21 OBJ: 4 TOP: Preoperative teaching KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance In preparation for the return of the surgical patient, the patient's bed and equipment should be 33. in what position? a. Lowest position with side rails elevated with oxygen and suction equipment availableb. Highest position with side rails elevated with IV pole and pump at bedsidec. Lowest position with side rails down on the receiving sided. Highest position with the side rails down on receiving side and up on opposite sideANS: D In preparation for the return of the surgical patient, the patient's bed should be in the highest position to be level with the surgical gurney and should have the side rail down on the receiving side, with the opposite side rail up to prevent the patient from falling out of bed during transfer. DIF: Cognitive Level: Implementation REF: 40 OBJ: 12 TOP: Postoperative preparation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and MaintenanceNURSINGTB.COM Foundations and Adult Health Nursing 8th Edition Cooper Test Bank A patient is transferred from the operating room to the recovery room after undergoing an 34. amputation of his left foot. Which intervention is the last step for immediate assessment once the patient enters the PACU? a. System reviewb. Breathingc. Circulationd. Airwaye. Level of consciousnessANS: A The assessment of an adequate airway is primary in the postanesthesia assessment, followed by breathing assessment, level of consciousness, circulation, and finally system review. DIF: Cognitive Level: Application REF: 43 OBJ: 12 TOP: Nursing assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance Which is the first step a patient should take to control coughing? 35. a. Inhale deeply and hold breath for a count of three.b. Document exercise and patient reaction.c. Cough two or three times without inhaling then relax.d. Take several deep breaths.e. Inhale through nose.f. Exhale through pursed lips.ANS: D The patient should be instructed to take several deep breaths, inhale through the nose, exhale through pursed lips, inhale deeply and hold for a count of three, cough two or three times without exhaling, relax. The procedure may be repeated before documentation.NRIGB.CMUSNTO DIF: Cognitive Level: Application REF: 29 OBJ: 13 TOP: Controlled coughing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IntegrityMULTIPLE RESPONSE A postoperative patient who had a left inguinal hernia repair is ready for his discharge 1. instructions. Which information should the nurse provide? (Select all that apply.) a. Care of the wound site and any dressingsb. When he may operate a motor vehiclec. Signs and symptoms to report to the physiciand. Call the physician's office once he arrives homee. Report bowel movements to the physicianf. Actions and side effects of any medicationsANS: A, B, C, F As the day of discharge approaches, the nurse should be certain that the patient has vital information. DIF: Cognitive Level: Analysis REF: 53 OBJ: 15 TOP: Discharge instructions KEY: Nursing Process Step: Planning NURSINGTB.COM Foundations and Adult Health Nursing 8th Edition Cooper Test BankCOMPLETION ______________ therapy is performed to alleviate or decrease uncomfortable symptoms 1. without curing the problem. ANS: Palliative Palliative therapy is designed to relieve or reduce intensity of uncomfortable symptoms without cure. Need the answer? 4629 tutors online. Answers in as fast as 15 minutes. DIF: Cognitive Level: Knowledge REF: 16 OBJ: 1 TOP: Palliative therapy KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment Discharge planning for a surgical procedure begins in the preoperative period and continues 2. through the _____________ period. ANS: recuperative When discharge planning is begun in the preoperative period and all through the postoperative period, the patient can assume greater responsibility for self-care and will experience less stress about going home.NRIGB.CMUSNTODIF: Cognitive Level: Comprehension REF: 53 OBJ: 15 Need the answer? 4629 tutors online. Answers in as fast as 15 minutes. TOP: Discharge planning KEY: Nursing Process Step: Planning Need the answer? 4629 tutors online. Answers in as fast as 15 minutes. MSC: NCLEX: Health Promotion and Maintenance The type of anesthesia that uses a combination of drugs to reduce the level of consciousness 3. and provides amnesia is conscious (or moderate) ____________________. ANS: sedation Conscious/moderate sedation uses a combination of drugs to produce a reduced level of consciousness and amnesia, as well as pain control, but allows the patient to control his or her own breathing. The recovery is more rapid than with general anesthesia. Need the answer? 4629 tutors online. Answers in as fast as 15 minutes. DIF: Cognitive Level: Comprehension REF: 38 OBJ: 10 TOP: Conscious sedation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity The nurse is aware that there is a loss of _________ during catabolism after severe tissue 4. injury. ANS: potassium The injured cells loose potassium as catabolism (tissue breakdown) occurs. Need the answer? 4629 tutors online. Answers in as fast as 15 minutes. NURSINGTB.COM Foundations and Adult Health Nursing 8th Edition Cooper Test BankDIF: Cognitive Level: Knowledge REF: 50 OBJ: 13 TOP: Catabolism KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity The nurse explains that to promote deep breathing and improve lung expansion and 5. oxygenation the patient should use the _____________ ______________ at regular intervals during the day. ANS: incentive spirometer The incentive spirometer is a device to encourage deep breathing and lung expansion. The usual rate of usage is 10 breaths hourly during waking hours. Need the answer? 4629 tutors online. Answers in as fast as 15 minutes. DIF: Cognitive Level: Comprehension REF: 47 OBJ: 13 TOP: Incentive spirometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity The nurse caring for a postsurgical patient is aware that the patient should void ____ to 8 6. hours postsurgery. ANS: 6 Urinary output should be obvious 6 to 8 hours postsurgery. If urinary output has not begun, a catheter may be inserted.NRIGB.CMUSNTO