Test Bank For Medical Surgical Nursing 5th Edition By Holly K. Stromberg Chapter 1-49 Newest Version 2023

a. Activity Intolerance b. Impaired Gas Exchange c. Ineffective Cardiopulmonary Tissue Perfusion d. Self-Care Deficit: Bathing and Hygiene ANS: B While all nursing diagnoses may apply to this patient, impaired gas exchange is the highest priority because this is the underlyingproblem for the other nursing diagnoses, as well as physiologically the highest priority. PTS: 1 DIF: Cognitive Level: Analysis REF: 23 OBJ: 11 (clinical) TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Management of Care MULTIPLE RESPONSE The nurse explains to the nursing student that the application of critical thinking to patient care involves whichfactor(s)? (Select all that apply.) a. Identification of a patient problem b. Setting priorities c. Concentrating on the patient rather than family needs d. Use of logic and intuition e. Expansion of thought beyond the obvious ANS: A, B, D, E Critical thinking as applied to nursing care requires setting priorities of patient problems and needs by using logic and intuition. Inclusion of the family in the care makes the approach family oriented. Critical thinking should go beyond the obvious. PTS: 1 DIF : Cognitive Level: Comprehension REF: 15 OBJ: 7 (clinica l) TOP: Critical Thinking KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care Which statement(s) demonstrates application of the nursing process? (Select all that apply.) a. Performing a head-to-toe assessment. b. Updating the patient care plan on a weekly basis. c. Evaluating if patient goals have been met. d. Determining if nursing interventions need to be changed based on lack of patient progress toward meeting goals. e. Ensuring that all personnel caring for the patient are implementing the care plan and working toward the same goal. ANS: A, C, D, E The nursing care plan should be updated as necessary, not just on a weekly basis. Concepts of the nursing process are demonstrated by performing orderly, logical head- to-toe assessments, as well as ongoing evaluation of patient goals and interventions to meet those goals. PTS: 1 DIF : Cognitive Level: Comprehension REF: 17 OBJ: 8 (clinica l) TOP: Nursing Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care Which example(s) demonstrate patient care that reflects knowledge of the National Patient Safety Goals? (Select allthat apply.) a. Identifying the patient prior to medication administration by asking the patient to state his or her name. b. Reporting any sentinel event to the facility’s quality assurance team. c. Assessing the patient’s heartrate prior to administration of digoxin. d. Performing hand hygiene prior to performing a patient assessment. e. Documenting the appropriate time of medication administration. ANS: C, D, E Assessing the patient’s heart rate prior to administration of digoxin demonstrates knowledge of medication actions and prevention of adverse effects; hand hygiene is required before any patient care, including assessment; and documentation of the time of medicationadministration is necessary to prevent medication errors. To meet National Patient Safety Goals, the nurse must use at least two methods of patient identification prior to medication administration. Reporting a sentinel event is required but demonstrates that National Patient Safety Goals were not met. PTS: 1 DIF: Cognitive Level: Application REF: 4, 23 OBJ: 4 (theory ) TOP : National Patient Safety Goals KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control COMPLETION The nursing student demonstrates knowledge of the proper use of the when determining that it is safe to administer meperidine (Demerol) and promethazine (Phenergan) together. ANS: Medication Reconciliation Form The Medication Reconciliation Form tracks all medications the patient is taking as prescribed by different physicians and canidentify overdoses or drugs that are not compatible. PTS: 1 DIF : Cognitive Level: Application REF: 20 OBJ : 8 (clinica l) TOP: Medication Reconciliation Form KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care Shortness of breath due to emphysema would be a major component of the care plan. ANS: interdisciplinary An interdisciplinary care plan involves all members of the health care team and is based on the medical diagnosis rather than aproblem statement/nursing diagnosis. PTS: 1 DIF : Cognitive Level: Application REF: 26 OBJ: 8 (clinica l) TOP: Interdisciplinary Care Plan KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance MATCHING Place the steps of the nursing process in their proper sequence. a. Evaluation b. Assessment c. Implementation d. Planning e. Problem statement/nursing diagnosis 28. Step 1 29. Step 2 30. Step 3 31. Step 4 32. Step 5 28. ANS: B PTS: 1 DIF: Cognitive Level: Comprehension REF : 17 OBJ: 4 (theory ) TOP : Applyi ng the Nursing Process KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance 29. ANS: E PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory ) TOP : Applyi ng the Nursing Process KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance 30. ANS: D PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory ) TOP : Applyi ng the Nursing Process KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance 31. ANS: C PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory ) TOP : Applyi ng the Nursing Process KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance ANS: A PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing Process KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance Chapter 03: Fluid, Electrolytes, Acid-Base Balance, and Intravenous TherapydeWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition MULTIPLE CHOICE The nurse uses a diagram to demonstrate how in dehydration the water is drawn into the plasma from the cells bywhich process? a. Distilla tion b. Diffusi on c. Filtrati on d. Osmosi s ANS: D The process of osmosis accomplishes the movement of water from the cells into the plasma, causing dehydration. PTS: 1 DIF: Cognitive Level: Knowledge REF: 32 OBJ: 3 (theory ) TOP : Dehydration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation The nurse assessing a patient with vomiting and diarrhea observes that the urine is scant and concentrated. Whichcontrolling factor is responsible for compensatory reabsorption of water? a. Osmoreceptors in the hypothalamus b. Antidiuretic hormone in the posterior pituitary c. Baroreceptors in the carotid sinus d. Insulin from the pancreas ANS: B The antidiuretic hormone controls how much water leaves the body by reabsorbing water in the renal tubules. PTS: 1 DIF: Cognitive Level: Comprehension REF: 30 OBJ: 2 (theory ) TOP : Regulation of Body Fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation The nurse uses a picture to show how ions equalize their concentration by which passive transport process? a. Osmos is b. Filtrati on c. Titrati on d. Diffus ion ANS: D Diffusion is the process by which substances move back and forth across compartment membranes until they are equally divided. PTS: 1 DIF: Cognitive Level: Knowledge REF: 31 OBJ: 2 (theory ) TOP : Diffusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation Which term describes the active transport process that moves sodium and potassium into or out of cells? a. Filtration b. Sodium pump c. Diffusion d. Osmosis ANS: B The sodium pump is the mechanism by which sodium and potassium are moved into or out of cells regardless of the concentration. PTS: 1 DIF: Cognitive Level: Knowledge REF: 32 OBJ: 2 (theory ) TOP : Active Transport KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation The patient taking furosemide (Lasix) to correct excess edema shows a weight loss of 5.5 pounds in 24 hours. Thenurse calculates that this weight loss is equivalent to how many liters (L) of fluid? a. 1 L b. 1.5 L c. 2.0 L d. 2.5 L ANS: D Each kilogram (2.2 pounds) of weight loss is equivalent to 1 liter of fluid. Therefore, 5.5 pounds ÷ 2.2 pounds = 2.5 liters. PTS: 1 DIF : Cognitive Level: Application REF: 33, Clinical Cues OBJ: 1 (clinica l) TOP: Fluid Loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation The nurse is caring for a patient with a potassium level of 2.9 mEq/L. The nurse should carefully monitor the patient for which potential problem? a. Excessive urinary output b. Abdominal distention c. Increased reflexes d. Hyperactive bowel sounds ANS: B A potassium level lower than 3.5 mEq/L results in reduced urine output, cardiac dysrhythmia, muscle weakness, abdominal pain and distention, paralytic ileus, lethargy, and confusion. PTS: 1 DIF: Cognitive Level: Application REF: 41, Table 3-4 OBJ: 15 (clinical) TOP: Hypokalemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort While the nurse is washing the face of a patient in renal failure, the patient demonstrates a spasm of the lips and face. Which laboratory value corresponds with the nurse’s assessment findings? a. Potassium of 3.4 mEq/L b. Calcium of 7.9 mg/dL c. Sodium of 140 mEq/L d. Phosphorus of 2.8 mg/dL ANS: B Chvostek sign is a signal of hypocalcemia. It occurs when the facial nerve is tapped or stroked about an inch in front of the earlobe and results in unilateral twitching of the face. Hypocalcemia occurs when the calcium level drops below 8.4. A potassium level of 3.4 mEq/Land a sodium level of 140 mEq/L are findings within normal limits. A patient in renal failure is most likely to have a high phosphorus level rather than a low phosphorus level, and 2.8 mg/dL is within the range consistent with hypophosphatemia. PTS: 1 DIF: Cognitive Level: Analysis REF: 43, Table 3-4 OBJ: 4 (theory ) TOP : Chvostek Sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease Which finding is most important for the nurse to confirm prior to hanging an intravenous (IV) bag containingpotassium? a. Verify a blood pressure of at least 60 mm Hg diastolic. b. Check for urine output of at least 30 mL/hr. c. Ensure filter placement on the IV line. d. Verify a pulse of at least 50 beats/min. ANS: B An adequate urine output must be present prior to the administration of potassium to ensure adequate excretion of potassium, preventing hyperkalemia. PTS: 1 DIF: Cognitive Level: Application REF: 43, Safety Alert OBJ: 10 (theory) TOP: Administration of IV Potassium KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential Which statement demonstrates that the patient accurately understands the nurse’s teaching related to a low-sodiumdiet? a. “I can have all the dried fruits I want.” b. “I’m looking forward to a tall glass of tomato juice.” c. “I’m going to eat my favorite avocado and orange salad.” d. “I’m going to eat a cheeseburger with extra ketchup.” ANS: C Avocado and oranges have no significant sodium content. Dried fruits, tomato juice, cheese, and ketchup are foods with high sodium content that should be limited or avoided. PTS: 1 DIF : Cognitive Level: Application REF: 43, Nutrition Considerations OBJ: 4 (clinica l) TOP: Low-Sodium Diet KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort The nurse is caring for an 80-year-old patient. Which finding is the best early indicator of dehydration in this patient? a. Reduced skin turgor b. Constipation c. Increased temperature d. Thirst ANS: B The nurse understands that this patient’s age places him at greater risk for dehydration. Constipation is the best early indicator of dehydration in the older adult. Older adults have age-related poor skin turgor. Increasedtemperature and thirst are later signs of dehydration. PTS: 1 DIF: Cognitive Level: REF 33- Analysis : 34 OBJ: 5 (theory ) TOP : Dehydration in the Older Adult KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease The patient with long-term obstructive pulmonary disease ha3s a pH of 7, HCO2 – of 18 mEq/L, and a PaCO of 40 mm Hg. These laboratory values are consistent with which acid-base imbalance? a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis ANS: D These results are indicative of metabolic acidosis. PTS: 1 DIF: Cognitive Level: Application REF: 46 OBJ: 15 (clinical) TOP: Respiratory Acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance The nurse is caring for a young patient with asthma. Which activity should the nurse encourage in order to help preventrespiratory acidosis? a. Engage in deep-breathing exercises every 2 hours. b. Drink 8 ounces of fluid every 4 hours. c. Ambulate for 15 minutes twice a day. d. Sleep with the head of the bed elevated 45 degrees. ANS: A Deep breathing blows off CO2, which reduces the acid ions, thus preventing respiratory acidosis. Drinking fluids prevents dehydration and keeps secretions moist and thin, and sleeping with the head of the bed elevated will ease breathing and improve gas exchange. Ambulating 15 minutes twice a day does not have an impact on respiratory acidosis. PTS: 1 DIF: Cognitive Level: Analysis REF: 46 OBJ: 8 (theory) TOP: Respiratory Acidosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease of 36 The patient who has had diarrhea for the last 3 days has blood gase3 s of pH of 7.1, HCO - of 20 mEq/L, and PCO2 mm Hg. These laboratory values are consistent with which acid-base imbalance? a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis ANS: D - Metabolic acidosis shows a low pH, low HCO , and normal CO . 3 2 PTS: 1 DIF: Cognitive Level: Application REF: 46 OBJ: 8 (theory) TOP: Metabolic Acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance The nurse is caring for a patient with metabolic acidosis. Which assessment finding reveals that the compensatory mechanism to correct this imbalance is in effect? a. Increased urinary output b. Reduced abdominal distention c. Kussmaul respirations d. Decreased blood pressure ANS: C Kussmaul respirations, or deep and rapid respirations, are blowing off carbon dioxide to reduce an acidotic state. PTS: 1 DIF: Cognitive Level: Application REF: 47 OBJ: 7 (theory ) TOP : Metabolic Acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation The nurse assesses the patient’s IV insertion site and observes that the vein is hard, the skin is red and tender, and a blood return in the IV line. After removing the IV catheter, which action should the nurse take next? a. Obtain an arm board to properly secure the IV. b. Elevate the arm above the level of the heart. c. Clean the site with alcohol and apply cool compresses. d. Apply a warm moist pack. ANS: D These are signs and symptoms of phlebitis and should be treated with a warm moist pack to increase blood flow to the area. The IV has been discontinued, so an arm board for stabilization is unnecessary. Elevation of the arm would be helpful to reduce swelling. A cool compress would be indicated for other issues related to IV infusion problems, such as extravasation. PTS: 1 DIF: Cognitive Level: Application REF: 51 OBJ: 18 (clinical) TOP: Phlebitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort Because there are no IV pumps available for the immediate infusion of an IV medication, the nurse must calculate theflow rate for 500 mL to run for 4 hours, using a set that delivers 15 gtt/mL. Which flow rate is correct? a. 30 gtt/min b. 35 gtt/min c. 40 gtt/min d. 45 gtt/min ANS: A 500 mL to be given in 4 hours equals 125 mL/hr. 125 mL ÷ 60 minutes = 2 mL/min 15 gtt/mL = 30 gtt/min. PTS: 1 DIF: Cognitive Level: Application REF: 53 OBJ: 12 (theory) TOP: Calculation of IV Flow Rate KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort The count of the solution in the IV container at the beginning of the shift is 800 mL. A new 1000-mL bag was hung during the shift and has 650-mL left at the end of the shift. What amount should the nurse record as the IV fluid intake for the shift? a. 1000 mL b. 1050 mL c. 1100 mL d. 1150 mL ANS: D 800 mL + 350 mL from second bag = 1150 mL. PTS: 1 DIF: Cognitive Level: Application REF: 53-54 OBJ: 12 (theory) TOP: Calculating IV Fluid Intake KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort After selecting an appropriate fluid, which action should the nurse take to correctly flush a PRN lock? a. Flush forcefully to clear the lumen. b. Use slow, gentle pressure to clear the lumen. c. Flush hard enough to clear resistance. d. Aspirate for blood return prior to flushing. ANS: B The standard of care utilizes slow, gentle pressure. The nurse should stop the flush if resistance is met. Resistance may indicate a clot and force would break the clot loose. Aspiration is not necessary. PTS: 1 DIF: Cognitive Level: Application REF: 54 OBJ: 18 (clinical) TOP: Flushing PRN Lock KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort The nurse is caring for a patient who has been on total parenteral nutrition (TPN) for 48 hours. Which actiondemonstrates effective nursing care? a. Checking the patient’s blood glucose level according to facility protocol. b. Increasing the infusion rate if the prescribed intake falls behind. c. Informing the patient that TPN can only be administered via a central line for 1 week. d. Monitoring the peripheral IV site of TPN infusion for signs of infiltration at least every 8 hours. ANS: A The hypertonic solution causes difficulty with glucose tolerance, so monitoring of blood glucose level is imperative. The infusion rate should never be increased to “catch up” because of the likelihood of fluid overload caused by the hypertonicity of the TPN. TPN can beadministered for more than 1 week and it is almost always administered via a central line rather than a peripheral line. PTS: 1 DIF: Cognitive Level: Application REF: 55 OBJ: 19 (clinical) TOP: TPN KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance The nurse is assessing a patient with renal failure and notes fatigue, muscle cramps, confusion, and headache. Whichlaboratory abnormality corresponds with these findings? a. Potassium of 3.3 mEq/L b. Sodium of 129 mEq/L c. Calcium of 8.2 mg/dL d. Chloride of 105 mEq/L ANS: B The patient is demonstrating signs and symptoms of hyponatremia; therefore, the nurse should assess the patient’s sodium level. PTS: 1 DIF: Cognitive Level: Application REF: 40, Table 3-4 OBJ: 15 (clinical) TOP: Hyponatremia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Management of Care MULTIPLE RESPONSE The nurse is assessing the hydration status of the patient. Which action(s) demonstrates knowledge of proper assessment? (Select all that apply.) a. Monitoring the patient’s daily weight. b. Assessing the patient’s skin turgor on the back of the hand. c. Checking the patient’s blood glucose level four times a day. d. Assessing for skin tenting on the patient’s forehead. e. Asking the patient if he is experiencing thirst. ANS: A, D, E The skin of the abdomen, forearm, sternum, forehead, and thigh can be “tented” as a test for skin turgor by gently pinching up a fold of skin and observing the delay in return to normal. Assessment of skin turgor is not reliable on the back of the hand. Weight and experiencing thirst can be indicators of hydration status, along with further assessment. The patient’s blood glucose level is not an assessment parameter for hydration status. PTS: 1 DIF: Cognitive Level: Application REF: 33 OBJ: 13 (clinical) TOP: Assessment Data: Skin Turgor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort