TEST BANK
Medical Surgical Nursing 11th Edition
By Ignatavicius Workman
MULTIPLE CHOICES
The nurse receives all of the following stat orders for Mr. Palmer. Which one should the nurse question?
1) Oxygen per nasal cannula at 4 L per minute.
2) Enoxaparin (Lovenox) 40 mg subcutaneously.
3) Troponin level.
4) Computed tomography (CT) angiogram. - Correct Ans✓✓ Rationale: The nurse should questions the order
for Lovenox because the patient is receiving a heparin drip.
Christine Warren, 45 years old, has a long history of ulcerative colitis, and non-surgical treatment no longer
relieved her symptoms. She underwent a total proctocolectomy and a permanent ileostomy 12 hours ago.
The nurse should contact the physician immediately if Mrs. Warren has which of these findings?
1) The stoma appears pale and dry.
2) The stoma appears red and shiny.
3) There is 200 mL of dark green output from the stoma.
4) There is 50 mL of serosanguinous drainage from the stoma. - Correct Ans✓✓ 1) The stoma appears pale and
dry.
1|Page
,Rationale: If there is an adequate blood supply to the stoma, the color is pink or red, and the stoma is moist as a
result of mucous production. A pale dry color suggests ischemia of the stoma or bowel and must be reported
immediately to the physician. With an ileostomy initially after surgery, the output is a loose, dark green liquid
that may contain some blood. The ileostomy usually begins to drain within 24 of surgery at more than one liter
per day.
When changing Mrs. Warren's ileostomy bag, the nurse notices that the peristomal skin is irritated.
Which of these actions by the nurse would be appropriate before reapplying the appliance?
1) Wash the area with antiseptic soap and water.
2) Clean the site with Dakin's solution.
3) Use a solid skin barrier.
4) Obtain an order for a topical antibiotic. - Correct Ans✓✓ 3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly irritate the surrounding tissue. Therefore, a solid skin
barrier, with a pectin base or karaya wafer that has a measurable thickness and hydrocolloid adhesive properties,
should be applied.
Which of these comments, if made by Mrs. Warren before her surgery, would indicate that she had concerns
about her body image?
1) "I will have to stop my aerobics classes."
2) "I'm so afraid I may not survive the surgery."
3) "I need to go shopping for some loose, baggy clothes."
4) "I'm concerned that this may be only the first of many surgeries." - Correct Ans✓✓ 3) "I need to go shopping
for some loose, baggy clothes."
Rationale: Body image refers to a person's perception of self and determines how the person interacts with
others. One does not need to purchase special clothing after ileostomy surgery, although some minor
adjustments may be needed for comfort, e.g., stretch underwear or pantyhose for support.
2|Page
,Lewis Palmer, 45 years old, has a history of multiple myocardial infarctions and is a heavy smoker. He takes
warfarin sodium (Coumadin) daily. Two weeks ago, he had a right femoral-popliteal bypass, which became
occluded 24 hours ago. He is admitted following an angioplasty of the femoral-popliteal bypass graft. Mr.
Palmer is receiving continuous IV heparin.
Because Mr. Palmer is receiving heparin, it is essential for the nurse to
1) monitor his prothrombin time.
2) observe him for signs of pulmonary embolism.
3) limit his intake of foods high in vitamin K.
4) check the femoral puncture site at frequent intervals. - Correct Ans✓✓ 4) check the femoral puncture site at
frequent intervals.
Rationale: Since bleeding is a common side effect of heparin, it is vital to check the operative site, the femoral
puncture area, for signs of bleeding.
Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr. Palmer has a below-knee amputation
(BKA) of his right extremity and is returned to the medical-surgical unit with an intravenous infusion in place.
His orders include: heparin drip, morphine sulfate 10 mg IV push q4h prn for pain, and ampicillin sodium g 1 IV
q6h.
Twelve hours postoperatively, Mr. Palmer is found to be short of breath and diaphoretic. He says, "My chest
hurts." His pulse is 140/min, compared to a baseline of 80/min. His blood pressure is105/60 mm Hg, compared
to a baseline of 138/70 mm Hg. His respirations are 32/min, compared to a baseline of 16/min. His O2
saturation is 85%. The nurse immediately calls for help. Which of the following questions is most important for
the nurse to ask?
1) "Have you ever had this type of chest pain before?"
2) "How long have you had this pain?"
3) "What pain medication do you usually take?"
4) "What - Correct Ans✓✓ 1) "Have you ever had this type of chest pain before?"
Rationale: Because of the patient's symptoms and his history of myocardial infarctions, the nurse should find out
if the patient has had this time of pain previously.
3|Page
, Maggie Clark, a 42-year-old female, was admitted with newly diagnosed type 2 diabetes mellitus. Her blood
glucose has been stabilized, and the nurse is preparing her for discharge. Her discharge orders will include
metformin (Glucophage). Mrs. Clark is also being treated for hypertension.
Because Mrs. Clark is to take Glucophage on a regular basis it is important to
1) monitor her glomerular filtration rate.
2) check her serum amylase routinely.
3) obtain her red blood cell count periodically.
4) examine her urine for casts. - Correct Ans✓✓ 1) monitor her glomerular filtration rate.
Rationale: The estimated glomerular filtration rate (eGFR) is one way to measure the adequacy of kidney
function. Glucophage is excreted by the kidney and the risk of lactic acidosis increases in patients with impaired
kidney function. The drug may be used if the eGFR is between 45 and 60 mL/min/1.73 m2, i.e., in mild chronic
kidney disease. Glucophage is absolutely contraindicated if the eGFR is below 30 mL/min/1.73 m2.
Mrs. Clark is prescribed metoprolol tartrate (Lopressor) for hypertension. Which symptom of hypoglycemia
would be masked by Lopressor?
1) Diaphoresis.
2) Tingling.
3) Diplopia.
4) Tachycardia. - Correct Ans✓✓ 4) Tachycardia.
Rationale: A side effect of Lopressor, a beta blocker, is bradycardia. The Lopressor-induced bradycardia can
mask tachycardia, a symptom of hypoglycemia.
Charles Haverford is diagnosed with prostate cancer and is to have a radical prostatectomy.
Mr. Haverford has been researching his diagnosis and now asks the nurse to recommend a reliable web source
for accurate prostate cancer information. The nurse should identify which of these websites as most reliable?
1) www.wikipedia.org.
4|Page
Medical Surgical Nursing 11th Edition
By Ignatavicius Workman
MULTIPLE CHOICES
The nurse receives all of the following stat orders for Mr. Palmer. Which one should the nurse question?
1) Oxygen per nasal cannula at 4 L per minute.
2) Enoxaparin (Lovenox) 40 mg subcutaneously.
3) Troponin level.
4) Computed tomography (CT) angiogram. - Correct Ans✓✓ Rationale: The nurse should questions the order
for Lovenox because the patient is receiving a heparin drip.
Christine Warren, 45 years old, has a long history of ulcerative colitis, and non-surgical treatment no longer
relieved her symptoms. She underwent a total proctocolectomy and a permanent ileostomy 12 hours ago.
The nurse should contact the physician immediately if Mrs. Warren has which of these findings?
1) The stoma appears pale and dry.
2) The stoma appears red and shiny.
3) There is 200 mL of dark green output from the stoma.
4) There is 50 mL of serosanguinous drainage from the stoma. - Correct Ans✓✓ 1) The stoma appears pale and
dry.
1|Page
,Rationale: If there is an adequate blood supply to the stoma, the color is pink or red, and the stoma is moist as a
result of mucous production. A pale dry color suggests ischemia of the stoma or bowel and must be reported
immediately to the physician. With an ileostomy initially after surgery, the output is a loose, dark green liquid
that may contain some blood. The ileostomy usually begins to drain within 24 of surgery at more than one liter
per day.
When changing Mrs. Warren's ileostomy bag, the nurse notices that the peristomal skin is irritated.
Which of these actions by the nurse would be appropriate before reapplying the appliance?
1) Wash the area with antiseptic soap and water.
2) Clean the site with Dakin's solution.
3) Use a solid skin barrier.
4) Obtain an order for a topical antibiotic. - Correct Ans✓✓ 3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly irritate the surrounding tissue. Therefore, a solid skin
barrier, with a pectin base or karaya wafer that has a measurable thickness and hydrocolloid adhesive properties,
should be applied.
Which of these comments, if made by Mrs. Warren before her surgery, would indicate that she had concerns
about her body image?
1) "I will have to stop my aerobics classes."
2) "I'm so afraid I may not survive the surgery."
3) "I need to go shopping for some loose, baggy clothes."
4) "I'm concerned that this may be only the first of many surgeries." - Correct Ans✓✓ 3) "I need to go shopping
for some loose, baggy clothes."
Rationale: Body image refers to a person's perception of self and determines how the person interacts with
others. One does not need to purchase special clothing after ileostomy surgery, although some minor
adjustments may be needed for comfort, e.g., stretch underwear or pantyhose for support.
2|Page
,Lewis Palmer, 45 years old, has a history of multiple myocardial infarctions and is a heavy smoker. He takes
warfarin sodium (Coumadin) daily. Two weeks ago, he had a right femoral-popliteal bypass, which became
occluded 24 hours ago. He is admitted following an angioplasty of the femoral-popliteal bypass graft. Mr.
Palmer is receiving continuous IV heparin.
Because Mr. Palmer is receiving heparin, it is essential for the nurse to
1) monitor his prothrombin time.
2) observe him for signs of pulmonary embolism.
3) limit his intake of foods high in vitamin K.
4) check the femoral puncture site at frequent intervals. - Correct Ans✓✓ 4) check the femoral puncture site at
frequent intervals.
Rationale: Since bleeding is a common side effect of heparin, it is vital to check the operative site, the femoral
puncture area, for signs of bleeding.
Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr. Palmer has a below-knee amputation
(BKA) of his right extremity and is returned to the medical-surgical unit with an intravenous infusion in place.
His orders include: heparin drip, morphine sulfate 10 mg IV push q4h prn for pain, and ampicillin sodium g 1 IV
q6h.
Twelve hours postoperatively, Mr. Palmer is found to be short of breath and diaphoretic. He says, "My chest
hurts." His pulse is 140/min, compared to a baseline of 80/min. His blood pressure is105/60 mm Hg, compared
to a baseline of 138/70 mm Hg. His respirations are 32/min, compared to a baseline of 16/min. His O2
saturation is 85%. The nurse immediately calls for help. Which of the following questions is most important for
the nurse to ask?
1) "Have you ever had this type of chest pain before?"
2) "How long have you had this pain?"
3) "What pain medication do you usually take?"
4) "What - Correct Ans✓✓ 1) "Have you ever had this type of chest pain before?"
Rationale: Because of the patient's symptoms and his history of myocardial infarctions, the nurse should find out
if the patient has had this time of pain previously.
3|Page
, Maggie Clark, a 42-year-old female, was admitted with newly diagnosed type 2 diabetes mellitus. Her blood
glucose has been stabilized, and the nurse is preparing her for discharge. Her discharge orders will include
metformin (Glucophage). Mrs. Clark is also being treated for hypertension.
Because Mrs. Clark is to take Glucophage on a regular basis it is important to
1) monitor her glomerular filtration rate.
2) check her serum amylase routinely.
3) obtain her red blood cell count periodically.
4) examine her urine for casts. - Correct Ans✓✓ 1) monitor her glomerular filtration rate.
Rationale: The estimated glomerular filtration rate (eGFR) is one way to measure the adequacy of kidney
function. Glucophage is excreted by the kidney and the risk of lactic acidosis increases in patients with impaired
kidney function. The drug may be used if the eGFR is between 45 and 60 mL/min/1.73 m2, i.e., in mild chronic
kidney disease. Glucophage is absolutely contraindicated if the eGFR is below 30 mL/min/1.73 m2.
Mrs. Clark is prescribed metoprolol tartrate (Lopressor) for hypertension. Which symptom of hypoglycemia
would be masked by Lopressor?
1) Diaphoresis.
2) Tingling.
3) Diplopia.
4) Tachycardia. - Correct Ans✓✓ 4) Tachycardia.
Rationale: A side effect of Lopressor, a beta blocker, is bradycardia. The Lopressor-induced bradycardia can
mask tachycardia, a symptom of hypoglycemia.
Charles Haverford is diagnosed with prostate cancer and is to have a radical prostatectomy.
Mr. Haverford has been researching his diagnosis and now asks the nurse to recommend a reliable web source
for accurate prostate cancer information. The nurse should identify which of these websites as most reliable?
1) www.wikipedia.org.
4|Page
