AIIH MED-SURG 1 TEST 2

AIIH MED-SURG 1 TEST 2 1. The client undergoing preoperative assessment before an elective procedure tells the nurse that she has been taking 10 mg of prednisone daily for rheumatoid arthritis. What is the nurse’s best action? A. Notify the surgeon and anesthesiologist. B. Document the information as the only action. C. Reschedule the surgery in 2 weeks when the client has cleared the drug from her system. D. Suggest that the client switch to a nonsteroidal anti-inflammatory agent for pain relief. ANS: A The surgery does not need to be delayed; however, corticosteroids have many adverse effects and will have an impact on the client’s responses. In addition, clients who have been taking corticosteroids on a daily basis need to continue this therapy through the perioperative period to prevent adrenal insufficiency from abrupt withdrawal. 2. How does palliative surgery differ from any other type of surgery? A. The main purpose is cosmetic in nature rather than functional repair or comfort. B. There are fewer risks associated with palliative surgery than with any other type of surgery. C. The outcomes of palliative surgery cannot be ensured to produce the desired effect or restoration of functional ability. D. Palliative surgery is performed to provide temporary relief of distressing symptoms rather than to cure a problem or condition. ANS: D The purpose of palliative surgery is to improve the client's quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and, often, does not prolong life. Although the exact outcomes of palliative surgery cannot be ensured, neither can the outcomes of any other type of surgery. 3. While examining the 82-year-old client's preoperative laboratory blood tests, the nurse finds the client's serum sodium level to be 139 mEq/mL. What is the nurse’s best action? A. Increase the IV flow rate. B. Initiate oxygen therapy by mask. C. Document the finding as the only action. D. Notify the surgeon and anesthesiologist. ANS: C The normal range for serum sodium in clients of this age is 135 to 145 mEq/L. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 4. The client who is scheduled to have surgery cannot read or write. The surgeon obtaining the consent wants to have the client's spouse sign the consent instead. What is the nurse’s best action? A. Nothing; a signed informed consent statement does not need to be obtained from this client. B. Locate the spouse, because the informed consent statement must be signed by the client's closest relative. C. Inform the surgeon that the client may sign the informed consent statement with an X in front of two witnesses. D. Notify the administration because the court must appoint a legal guardian to represent the client's best interests and give consent for all surgical procedures. ANS: C The lack of ability to read or write does not constitute incapacity to give legal consent. If the client meets all other legal and clinical aspects of competence, he or she may use an X to demonstrate consent if the act is witnessed by two persons. 5. When asked about allergies, the preoperative client tells the nurse she has allergies to all of the following substances. Which allergy alerts the nurse to potential problems in relation to the scheduled surgery? A. Pollens B. Bee stings C. Shellfish D. Peanuts ANS: C Many people who have hypersensitivities or allergies to shellfish will have allergies to povidone-iodine, a substance commonly used to cleanse surgical sites. 6. The client is NPO for surgery scheduled to occur in 4 hours. It is now 9 AM and the client's normal oral medications (consisting of digoxin, 0.125 mg, Colace, 300 mg, and Feostat, 325 mg) are due to be administered. The physician will not be available until the time of surgery. What is the nurse’s best action? A. Hold all medications. B. Administer all medications orally. C. Administer all medications parenterally. D. Administer digoxin with minimal water and hold the other drugs. ANS: D Regularly scheduled cardiac medications should be administered on schedule. If taken with a few small sips of water at least 2 hours before surgery, this medication should not increase the risk of intraoperative or postoperative aspiration. 7. Twenty minutes after the client has received a preoperative injection of atropine and midazolam (Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. What is the nurse’s best first action? A. Document the findings as the only action. B. Check the client's pulse and blood pressure. C. Prepare to administer epinephrine and diphenhydramine (Benadryl). D. Explain to the client that these symptoms are normal responses to the medication. ANS: B Although these are the expected physiologic responses to the preoperative medication, any time the client states that he or she can feel a change in normal cardiac function, the system should be assessed. If the client's pulse and blood pressure are within normal limits, the nurse should then explain the responses to the client and document the change. 8. The client scheduled to have surgery within the next 2 hours tells the nurse during the admission interview the following information. Which piece of information should the nurse be certain to communicate on the outside of the chart for the entire surgical team to know? A. The client is allergic to cats. B. The client is hard of hearing. C. The client had a glass of wine 12 hours ago. D. The client takes 2000 mg of vitamin C each day. ANS: B The team will need to communicate with the client in the surgical holding area, the operating room, and the postanesthesia recovery unit. Any problem with communication, such as a hearing impairment, should be stressed so that team members can use alternative means to assure accurate communication with the client. 9. Which statement made by the client indicates a need for further teaching? A. “These exercises help prevent blood clots.” B. “Once I am up and walking around, I won't need to do these as often.” C. “Keeping my knees bent will prevent my arthritis from making me so stiff.” D. “If I feel pain in my calf when I bend my ankles up and down, I should tell my nurse.” ANS: C The major purpose of the leg exercises is to promote venous return and prevent the formation of blood clots. Keeping the knees bent inhibits venous return and may promote blood clot formation. 10. The client’s surgery has been delayed because of hyperkalemia. The client doesn’t understand why. What is the nurse’s best response? A. “Potassium affects how the heart works and you could have a heart attack if this is not corrected.” B. “Your kidneys could quit working during surgery and the surgery would have to be cancelled.” C. “We want you to have the best recovery after surgery. Sometimes, if this problem is not corrected before surgery, you may be too sleepy after surgery to talk to your family.” D. “By making sure your potassium is normal before surgery, it will keep your heart functioning at its best during your surgery.” ANS: D Hyperkalemia may cause cardiac dysrhythmias, especially during anesthesia. Explaining to the client that correcting this problem helps his heart function at its best is consistent with providing open, honest communication to the client. Telling the client that he may have a heart attack would cause unnecessary anxiety, and may in fact create problems during surgery. 11. Which nursing action or statement is most likely to reduce anxiety in a client being brought to the surgical suite? A. Asking the client if he or she has talked with the hospital chaplain B. Asking the client what specific surgery he or she is having done today C. Asking the client if he or she wants family members to be with them in the holding area D. Explaining to the client that the surgical area is the most technologically advanced in the city ANS: C Most anxious clients would feel some relief by having one or more familiar persons waiting with them until surgery begins. In addition, asking the client what he or she wants allows the client to have more control over the situation. Asking the client if he or she has visited with the hospital chaplain and telling the client about the advanced technology can imply to the client that the procedure is dangerous. Although the client must be asked what procedure he or she is having (to ascertain that the client does know what is to be done), this question may make the client worry about the competency of the staff. 12. Which task or function during a surgical procedure is designated as being within the scope of practice for the scrub nurse? A. Closing the surgical wound B. Setting up the sterile field C. Administering blood products D. Monitoring the client's cardiopulmonary function ANS: B The tasks or functions of the scrub nurse are those that can be performed under sterile conditions. These functions include setting up the sterile field, assisting with the draping of the client, managing sterile supplies and equipment, and maintaining an accurate account of sponges, sharps, instruments, and amounts of irrigation fluid and medication used. Scrub nurses do not suture or cut tissue. Nurses who are certified as registered nurse first assistants can perform these functions. 13. Which is the best technique to use when rinsing hands and forearms after a surgical scrub? A. Rinsing is not performed after a surgical scrub because it will reduce the antimicrobial activity of the cleansing solution. B. Rinsing should start at the hand, with water running up the forearm. C. Rinsing should start at the elbow, with water running down to the hand. D. Rinsing should start with the hand positioned so that water runs off the extremity rather than up or down. ANS: D The object of a surgical scrub and rinse is to remove as many microorganisms and as much skin debris as possible. Rinsing so that water runs off rather than up or down the extremity limits the chance for loose debris and contaminants to move onto scrubbed surfaces. 14. In the operating room, the client tells the circulating nurse that he is going to have the cataract in his left eye removed. The nurse notes that the consent form indicates that surgery is to be performed on the right eye. What is the nurse’s best first action? A. Assume that the client is a little confused because he is older and has received midazolam intramuscularly. B. Check to see if the client has received any preoperative medications. C. Notify the surgeon and anesthesiologist. D. Ask the client his name. ANS: D Ensuring proper identification of the client is a responsibility of all members of the surgical team. Especially in a specialty surgical setting, where many people undergo the same type of surgery each day, such as cataract removal, it is possible that the client and the record do not match. The nurse identifies the client and the client's consent form before the physicians are notified. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment 15. The client is to undergo a gynecologic surgical procedure that requires the client to be in the lithotomy position. At what point should the circulating nurse place the client in the lithotomy position? A. Before anesthesia is administered to allow the client to move her legs herself and tell the nurse if any discomfort is being felt B. During stage 1 of general anesthesia to take advantage of the client's relaxed state C. During stage 2 of general anesthesia to ensure that the client will not be embarrassed by the position D. During stage 3 of general anesthesia to avoid overstimulating the client or disrupting the attainment of a patent airway ANS: D Clients are positioned during stage 3 of general anesthesia after an appropriate level of anesthesia has been achieved, the airway is secured, and the client's sensations are lost. 16. What is the priority nursing diagnosis for the client under general anesthesia during surgery? A. Acute Pain related to surgical procedure B. Risk for Infection related to surgical wound C. Risk for Impaired Skin Integrity related to prolonged static position D. Disturbed Body Image related to presence of surgical wound or scar ANS: C The problem that nursing is most responsible for with this client is ensuring maintenance of skin integrity. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Physiological Integrity 17. During which of the following types of anesthesia should the nurse expect the client to maintain a gag reflex during surgery? A. Inhalation of general anesthesia B. Intravenous general anesthesia C. Balanced anesthesia D. Regional anesthesia ANS: D Regional anesthesia is a type of local anesthesia in which the nerves to a specific area are blocked. Regional anesthesia does not alter consciousness or general reflexes. 18. Which nursing intervention by the circulating nurse is most important for clients having surgery under regional anesthesia? A. Monitoring respiratory rate and depth B. Positioning for safety and comfort C. Minimizing external noise and stimuli D. Planning for nonpharmacologic pain interventions ANS: B With regional anesthesia, nerves to specific body areas are blocked and the client remains conscious, although unable to move or feel the affected body area. Thus, positions that disrupt circulation, bend joints inappropriately, or press on nerves should be avoided. 19. Which of the following method is the best for correctly identifying the client prior to surgery? A. Ask the client his or her date of birth and confirm it with the chart. B. Ask the client his or her name and social security number. C. Check the client’s armband and ask his or her name. D. Check the client’s medical record number and surgical consent form. ANS: C Correct identification of the client is the responsibility of everyone. Asking the client his or her name and confirming it with the armband is the most useful way to identify the alert client correctly. 20. Which function or assessment finding in a client being admitted to the postanesthesia care unit after surgery is the best indication that the client's respiratory status does not require immediate attention? A. The client is able to talk. B. The client is alert and oriented. C. The client's oxygen saturation is 90%. D. The client's chest rises and falls rhythmically during respiration. ANS: C The client may have impaired gas exchange at the alveolar capillary level and still be able to talk and be alert and oriented. The chest may continue to rise and fall rhythmically. The definitive assessment finding that indicates whether gas exchange is effective is the degree of oxygen saturation. 21. Which assessment finding in a postoperative client indicates to the nurse that the interventions to prevent hypovolemia need to be re-evaluated? A. The blood pressure changes from 136/80 to 122/80 mm Hg. B. The urine output decreases from 40 to 10 mL/hour. C. The client cannot count backward from 100 by threes. D. The client's temperature has changed from 100.2° to 100.4° F. ANS: B One of the most sensitive indicators of vascular volume loss is a decreased urine output in response to increased secretion of antidiuretic hormone (ADH). 22. The client is admitted to the postanesthesia care unit (PACU) after surgery that took place with the client in the lithotomy position. Which change in assessment findings alerts the nurse to a possible complication of this surgical position? A. The electrocardiogram (ECG) shows tall, peaked T waves and wide QRS complexes. B. The client only arouses in response to light shaking. C. The pulse pressure has increased from 28 to 40 mm Hg. D. The dorsalis pedis pulses are not palpable bilaterally. ANS: D The lithotomy position can compromise the client's peripheral circulation in the lower extremities. 23. In checking the neurologic status of the client just admitted to the PACU, the nurse notes that the right eye pupil is dilated more than the left pupil. What is the nurse’s best first action? A. Check the client's chart to compare these findings to the client's baseline neurologic assessment. B. Raise the head of the bed up to a 30-degree angle and administer oxygen. C. Test the client's deep tendon reflexes on all four extremities. D. Notify the physician and document the finding. ANS: A Any abnormal neurologic assessment finding discovered postoperatively should be compared to the client's preoperative neurologic status. Unequal pupil size is a relatively common assessment finding in otherwise healthy adults. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 24. Which client is at greatest risk for respiratory complications after surgery under general anesthesia? A. 65-year-old woman taking a calcium channel blocker for hypertension B. 55-year-old man with chronic allergic rhinitis C. 45-year-old woman with diabetes mellitus type 1 D. 35-year-old man who smokes two packs of cigarettes daily ANS: D Cigarette smoking greatly increases the risk for pulmonary problems following general anesthesia because the cilia of the mucous membranes may be absent or hypoactive, the lining of the airways may be hypertrophied, and the alveoli may be less compliant. Age and gender are not significant in this case. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 25. One hour after admission to the PACU, the postoperative client has become very restless. What is the nurse’s best first action? A. Ask the client if he or she is having pain. B. Check the client's oxygen saturation level. C. Document the finding as the only action. D. Explain to the client that he or she is in the “recovery room” after surgery. ANS: B The most common causes of restlessness in the immediate postoperative period are hypoxemia and pain. Although pain control is very important, determining the adequacy of ventilation in this case has higher priority. DIF: Cognitive Level: Application or higher 26. The postoperative client's arterial blood gas values are pH 7.22, HCO – 21 mEq/L, PCO 65 mm Hg, and PO2 58 mm Hg. What is the nurse’s best first action? A. Notify the physician. B. Assess the client's airway. C. Increase the oxygen flow rate. D. Document the finding as the only action. ANS: B The arterial blood gas values indicate acute respiratory acidosis. The client does need oxygen; however, if the airway is not patent, increasing the oxygen flow rate will be of minimal benefit. The best first action is to ensure a patent airway, and then apply oxygen. 27. Two hours after abdominal surgery, the nurse auscultates the client's abdomen. No bowel sounds are present. What is the nurse’s best first action? A. Position the client on the right side with the bed flat. B. Check the dressing and apply an abdominal binder. C. Palpate the bladder and measure abdominal girth. D. Document the finding as the only action. ANS: D Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented. No intervention specific to this finding is needed at this time. 28.The client who is 24 hours postoperative from abdominal surgery has light brown fluid with small particles that look like coffee grounds in the NG tube drainage. What is the nurse’s best action? A. Notify the physician. B. Irrigate the tube with normal saline. C. Clamp the tube and advance it 1 to 2 inches. D. Document the finding as the only action. ANS: A This type of drainage indicates possible gastrointestinal bleeding and should be explored further as soon as possible. 29. When changing the client's abdominal dressing on the second postoperative day, the nurse notes crusting on about half of the suture line and oozing of a small amount of serosanguineous drainage. What is the nurse’s best action? A. Clean the suture line gently and apply new dressings. B. Gently remove the crusts and culture the material beneath. C. Remove the sutures or staples in the area where crusts have formed. D. Apply a binder over the incision and notify the surgeon. ANS: A Serosanguineous drainage and a small amount of crusting are normal incision findings on the second postoperative day. 30. The client is 4 days postoperative from a bowel resection and has a large abdominal incision. When the nurse enters the client's room, he tells her that he felt the incision “pop” when he coughed just a moment ago. What is the nurse’s best response? A. “It is good that you are coughing and deep breathing to prevent lung complications.” B. “That is a normal feeling in the incision whenever you are moving.” C. “Be sure to splint the incision with a pillow or your hands when you cough.” D. “Lie down flat on the bed and let me examine your incision.” ANS: D Although wound dehiscence is not a common complication after surgery, it is usually painless and felt as a "popping" or "splitting" sensation. Any client report of such a sensation should be immediately investigated to avoid evisceration. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Physiological Integrity 31. When a nurse checks a postoperative client for pain relief 30 minutes after the client started patient-controlled analgesia (PCA) with morphine, the client is sleeping and has a respiratory rate of 8 breaths/minute. What is the nurse’s best first action? A. Attempt to arouse the client by calling his or her name and lightly shaking the client's arm. B. Administer oxygen by mask and apply an apnea monitor. C. Document the finding as the only action. D. Notify the physician immediately. ANS: A Many clients experience some degree of respiratory depression with opioid analgesics. If the client can be aroused with minimally intrusive techniques and increases the rate of respiration spontaneously, no further intervention is required. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity 32. Which precaution or issue should the nurse reinforce to the postoperative client about correct use of the patient-controlled analgesia (PCA) device? A. “Push the button when you feel the pain beginning rather than waiting until the pain is at its worst.” B. “Push the button every 15 minutes whether you feel pain at that time or not.” C. “Instruct your family or visitors to press the button for you when you are sleeping.” D. “Try to go as long as you possibly can before you press the button.” ANS: A Clients should be instructed to push the button to release medication when pain begins rather than waiting until the pain becomes so great that the dose administered by the pump cannot control the pain. DIF: Cognitive Level: Application or higher 33. Which maneuver or technique should the nurse avoid to prevent pulmonary emboli in a postoperative client? A. Application of elastic wraps to the lower extremities B. Measuring calf circumference every shift C. Calf muscle massage D. Early ambulation ANS: C Although massaging the calf and compressing the muscles can help prevent the formation of deep vein thrombosis, this practice is avoided because it can stimulate the movement of any clots that may have formed in the leg veins. 34. What dietary modifications should the nurse teach to the client who is going home with an extensive wound after surgery? A. “Drink at least 4 L of fluid every day.” B. “Eating dietary fiber can help prevent constipation.” C. “Be sure you are getting adequate amounts of vitamin C in your diet.” D. “Try to lose weight so that you don't put too much strain on the incision.” ANS: C Vitamin C promotes wound healing. 35. A maintenance man falls from a ladder into the unit hall, striking his head on some equipment. The man is unconscious and not breathing; the Code Team has already been paged and is on its way. The nurse should: 1. wait for the team to start CPR. 2. open airway with a jaw thrust. 3. give two rescue breaths after extending the neck. 4. start chest compressions. ANS: 2 The jaw thrust, rather than neck extension, is used when a head or neck injury is suspected. CPR should be initiated and then taken over by the Code Team when they arrive. PTS: 1 DIF: Cognitive Level: Analysis REF: 226 OBJ: 1 TOP: CPR with Suspected Head Injury KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 36. Standing in a fast food line, the person in front, while munching on a cookie, begins to cough heavily, with deep inspirations, and waves his arms around wildly. The nurse should immediately: 1. start rescue breathing as quickly as possible. 2. start chest compressions as quickly as possible. 3. perform the Heimlich maneuver. 4. do nothing at this point as long as there is air exchange. ANS: 4 When a person chokes, if he or she is alert enough to be attempting to cough and force the obstruction up and out by themselves, it is best to let them do it alone, because there is more expelling force that way. Only if the person is showing signs of not being able to breathe beyond the obstruction should the Heimlich maneuver be applied. PTS: 1 DIF: Cognitive Level: Application REF: 228 OBJ: 4 TOP: Immediate Intervention for a Choking Victim KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37. One-person CPR principles, as taught and practiced by professional nurses, require that the initial intervention for an unconscious patient who is not breathing is to: 1. lift the jaw to clear the airway. 2. call for assistance. 3. start chest compressions. 4. make two rescue breaths. ANS: 2 With one-person CPR, when the patient is unconscious and not breathing, the first thing to do is to call for help. PTS: 1 DIF: Cognitive Level: Analysis REF: 227 OBJ: 3 TOP: CPR Guidelines KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Physiological Integrity 38. The nurse assesses that the patient is in shock based on the findings of: 1. lack of urine output in the last hour, thready pulse, shallow respirations, decreased BP, and patient crying softly. 2. failure of the neurological system, thready pulse, decreased respirations, decreased BP, and decreased LOC. 3. failure of the renal system with bounding pulse, shallow respirations, decreased BP, 300 mL urine in the last hour, displaying unfounded anger. 4. unable to arouse patient, temperature 99.2º F, pulse 100, respiration 30, BP 120/78. ANS: 1 Shock is failure of the circulatory system, producing altered vital signs, as listed. PTS: 1 DIF: Cognitive Level: Application REF: 229 OBJ: 3 TOP: Shock, Signs and Symptoms KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. The nurse comes upon a traffic accident. One passenger is lying on the ground by an open door. The nurse stops and begins immediate nursing interventions by proceeding with assessing: 1. for uncontrolled bleeding. 2. ABC: airway, breathing, and circulation. 3. for abdominal deep wounds. 4. level of LOC and orientation. ANS: 2 The ABC method of emergency assessment reminds the caregiver to check the essentials first. PTS: 1 DIF: Cognitive Level: Knowledge REF: 224 OBJ: 1, 4 TOP: Emergency Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. The nurse finds a patient slumped to the floor and unconscious, with no pulse or respiration. The nurse should begin the protocol of: 1. basic life support. 2. advanced life support. 3. cardiopulmonary resuscitation. 4. first aid care. ANS: 1 Basic life support is the first level of care in keeping the brain oxygenated. PTS: 1 DIF: Cognitive Level: Knowledge REF: 226 OBJ: 4 TOP: Basic Life Support KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 41. As an immediate treatment for epistaxis, the nurse should give the following instructions: 1. “Stand still, lean your head backward so that the blood won’t get all over everything, and pinch your nose shut for at least 10 minutes.” 2. “Stand still, lean your head forward, and pinch your nose tightly for at least 10 minutes.” 3. “Sit down on a solid surface, lean your head forward to let the blood run out, and then pinch your nose closed for at least 30 minutes.” 4. “Sit down on a solid surface, lean your head forward so that you don’t choke on the blood, and pinch your nose shut for at least 10 minutes.” ANS: 4 Blood from a nosebleed in the anterior portion of the nasal cavity will usually stop with pinch pressure within 10 minutes. Blood from a nosebleed should not be swallowed. PTS: 1 DIF: Cognitive Level: Application REF: 230, Figure 16- 7 OBJ: 4 TOP: First Aid for a Nosebleed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 42. Which condition complicates the assessment of an older adult patient with a suspected head injury? 1. Sensory deficits 2. Slowed metabolism 3. Preexisting cerebral dysfunction 4. Decreased pulmonary function ANS: 1 Sensory deficits, circulatory disorders, and communication problems make it more difficult to assess an older adult patient with a suspected head injury. PTS: 1 DIF: Cognitive Level: Comprehension REF: 231 OBJ: 1 TOP: Head Injury in Older Adults KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 43. The nurse is called on to assist a neighbor who needs first aid. The nurse knows that legal responsibility for this action would be that the nurse: 1. is legally bound to help in any way possible. 2. is expected to demonstrate the same skill, knowledge, and care that would be provided by other nurses in the same community with the same credentials. 3. has no legal responsibilities outside the hospital setting and would be held accountable for nothing. 4. can legally perform any aid skill, even those not allowed the nurse in the hospital. ANS: 2 U.S. laws protect nurses when they act in the same manner as others licensed at their level would do in the same circumstances. PTS: 1 DIF: Cognitive Level: Comprehension REF: 243 OBJ: 9 TOP: Legal Assistance KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 44. A nurse comes upon a traffic accident where there are injured, unconscious people lying on the highway. The nurse is aware that first aid interventions are sanctioned by the: 1. Good Samaritan Act. 2. Emergency Care Doctrine. 3. Fifth Amendment. 4. Liability Protection Against Malpractice Act. ANS: 1 Most states have Good Samaritan Acts, which protect voluntary caregivers from malpractice claims. PTS: 1 DIF: Cognitive Level: Knowledge REF: 243 OBJ: 5 TOP: First Aid for an Unconscious Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 45. The nurse giving discharge instructions to the patient who is severely allergic to insect stings would caution the patient to: 1. wear bright colors to repel insects. 2. apply perfume liberally as a protection. 3. dress in sleeveless, easily removable garments. 4. obtain an emergency treatment kit. ANS: 4 An emergency kit with Benadryl and/or injectable epinephrine is recommended. Insects are attracted by bright colors and perfume. Arms and legs should be covered with clothing. PTS: 1 DIF: Cognitive Level: Application REF: 240, Table 16- 7 OBJ: 4 TOP: Severe Allergic Reaction Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 46. The patient is admitted to the emergency room after having been bitten on the hand by a black widow spider. The nursing intervention that is indicated is to: 1. monitor for respiratory distress. 2. wrap the hand in a warm compress. 3. seat the patient upright in a chair. 4. elevate the patient’s hand above his or her heart. ANS: 1 Neurotoxins frequently cause anaphylaxis, with severe respiratory distress and seizure. Therefore, the patient should be protected from falls and the hand be kept cool and below the heart to delay spread of the toxin. PTS: 1 DIF: Cognitive Level: Application REF: 241, Table 16- 7 OBJ: 4 TOP: Neurotoxins KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 47. The nurse can cease CPR when there is: 1. spontaneous breathing and absence of dyspnea. 2. spontaneous breathing and absence of cyanosis. 3. heartbeat and spontaneous breathing. 4. heartbeat and return of consciousness. ANS: 3 Cardiopulmonary resuscitation success refers to the lack of need for assisted respiration and assisted blood circulation. These two criteria are met when the heartbeat and spontaneous breathing are restored. 48. When the accident victim presents to the emergency room with an open sucking chest wound, the nurse should apply to the wound: 1. occlusive dressing taped on four sides. 2. tight Ace bandage wrap. 3. no dressing of any sort. 4. flutter dressing taped on three sides. ANS: 4 A flutter dressing taped on three sides allows no more air to enter the pleural space, but allows the expanding lung to push air out. A four-sided dressing allows the trapped air to remain and possibly collapse the lung. 49.A homeless person is brought to the ER after having been found asleep on a park bench under a layer of snow. He has a rectal temperature of 97 F. The nurse anticipates which of the following additional symptoms? 1. Diminished breath sounds, inadequate chest expansion 2. Shivering, decreased heart rate, and increased blood pressure 3. Confusion, increased hunger, hypertension 4. Decreased irregular heart and respiratory rates, decreased blood pressure ANS: 4 The hypothermic client will continue to chill as vital signs deteriorate. 50.A mother brings in her 2-year-old who has drunk gasoline 1 hour ago. After initial assessment, the nurse will: 1. prepare to administer syrup of ipecac. 2. turn patient on the stomach to induce vomiting. 3. prepare to administer milk of magnesia. 4. prepare to administer bowel lavage and cathartics. ANS: 4 Bowel lavage and cathartics will rid the body of the petroleum product. Inducing vomiting when the patient has consumed petroleum products is contraindicated. Ipecac is no longer recommended and milk of magnesia will not be effective.