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Focus on Adult Health Medical Surgical Nursing 2nd Edition Linda Honan Test Bank new version
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1Focus on Adult Health Medical Surgical Nursing
2nd Edition Linda Honan Test Bank new version
A nurse is caring for a postoperative patient on POD 2. The patient had a large upper
abdominal incision. While assessing the patient at the beginning of the shift, the nurse
noted decreased breath sounds, crackles, and a mild cough. What is the patient most
likely experiencing?
A. Atelectasis
B. Pneumonia
C. Acute bronchitis
D. Hypoxemia - A. Atelectasis
RATIONALE Many factors such as age, smoking, long duration of surgery, incisional site
(chest and upper abdomen), as well as comorbidities and associated with an increased
risk for postoperative pulmonary complications. Atelectasis remains a risk for the patient
who is not moving well, not coughing well or performing deep-breathing as a result of a
large incisional site. The nurse must be alert and aware of these signs and symptoms.
Surgical wound healing occurs in:
A. Two phases: inflammatory and maturation
B. Three phases: inflammatory, proliferative, and maturation
C. First-, second-, and third-intention wound healing
D. First and proliferative phase - B. Three phases: inflammatory, proliferative, and
maturation
RATIONALE Wounds heal in three phases and the duration of the phases can vary in
length. First- second- and third-intention wound healing is the mechanical process of
wound healing.
Before an ABG is drawn from the patient's radial artery, what test should be performed?
A. Doppler flow test
B. Allen test
C. Babinski test
D. Ankle Brachial Index (ABI) - B. Allen test
RATIONALE
, 2
The Allen test is used to assess for adequate perfusion of the hand via the
ulnar artery prior to puncturing the radial artery for an arterial blood gas.
This test assesses patency of the ulnar artery and/or collateral circulation.
A patient has a chronic cough with thick sputum. He undergoes a bronchoscopy for
diagnostic purposes. Following the bronchoscopy, which action by the nurse is most
appropriate?
A. Encourage fluid intake to promote elimination of contrast media.
B. Monitor hemoglobin and hematocrit to evaluate blood loss.
C. Check vital signs every 15 minutes for 4 hours.
D. Keep NPO until the gag reflex returns. - D. Keep NPO until the gag reflex returns.
RATIONALE
Preoperative sedation and local anesthesia impair the protective laryngeal reflex and
swallowing for several hours after a bronchoscopy. To prevent aspiration before
refeeding the patient, the nurse must reassess the return of the gag reflex (pharyngeal
reflex; ninth, tenth cranial nerve).
A 70-year-old elderly patient is admitted to the preoperative unit for a liver resection that
is scheduled for 6 hours of surgery. What is one of the basic principles that should guide
the preoperative nurse's assessment?
A. Elderly patients do not experience as much preoperative anxiety as younger patients.
B. The elderly patient has less physiologic reserve than the younger patient.
C. Elderly patients experience less pain.
D. Preoperative pain assessment and teaching should occur following the procedure as
the elderly patient may not retain the information. - B. The elderly patient has less
physiologic reserve than the younger patient.
RATIONALE Preoperative pain assessment and teaching are important to the elderly
patient. These patients may have a combination of chronic illnesses and health issues in
addition to the specific one for which surgery is indicated. Health care staff must
remember that the hazards of surgery for the aged are proportional to the number and
severity of coexisting health problems and the nature and duration of the operative
procedure. It is, therefore, important to be guided by the principle that the elderly has less
physiologic reserve (the ability of an organ to return to normal after a disturbance in its
equilibrium).
A nurse is caring for a postoperative patient who had spinal anesthesia. The patient
complains of headache. What action should the nurse take?
A. Lower the head of the patient's bed.
B. Keep the patient lying flat, maintain a quiet environment, and keep the patient
hydrated.
, 3
C. Encourage the patient to lay on his right side.
D. Do nothing, as this is a normal response to the spinal anesthesia. - B.
Keep the patient lying flat, maintain a quiet environment, and keep the patient hydrated.
RATIONALE Headache may be an after-effect of spinal anesthesia. Factors related to
headache include, size of the spinal needle used, the leakage of the fluid from
subarachnoid space through the puncture site and the patients hydration status.
Measures that increase cerebrospinal pressure are helpful in relieving headache.
When does the postoperative phase begin?
A. Admission of the patient to the OR
B. Admission of the patient to the PACU and ending when the patient is discharged to
the unit/ home
C. Admission of the patient to the PACU and ending with follow-up evaluation in the
clinical setting/home
D. Admission to the PACU - B. Admission of the patient to the PACU and ending when
the patient is discharged to the unit or home
RATIONALE The postoperative phase does not just end when the patient is discharged
to the unit or to home. The goal of postoperative management is to restore the patient to
previous state or acceptable return of equilibrium. This phase includes teaching,
promoting recovery, follow-up care, and referrals essential for recovery and rehabilitation.
A patient is admitted to the ICU after falling from a roof and sustaining fractures of the
first three ribs on the right side. The patient is dyspneic, and crepitus (subcutaneous
emphysema) can be palpated. Auscultation reveals decreased breath sounds on the
right. The chest x-ray reveals a pneumothorax. Upon percussion, what does the nurse
expect to hear?
A. Dullness on the right
B. Resonance on the right
C. Tympany on the right
D. Hyperresonance on the right - D. Hyperresonance on the right
RATIONALE
Hyperresonance is expected with a pneumothorax due to accumulation of air in the
pleural space.
The finding of normal breath sounds on the right chest and diminished, distant breath
sounds on the left chest of a newly intubated patient is probably due to which of the
following?
A. A left pneumothorax
B. A right hemothorax
C. Intubation of the right mainstem bronchus
, 4
D. A malfunctioning mechanical ventilator - C. Intubation of the right
mainstem bronchus
RATIONALE
The right mainstem is wider, shorter (about 2.5 cm long), and more vertical in direction
than the left main bronchus; therefore, accidental placement in the right lung is a
potential complication. It is imperative that after intubation, the nurse auscultate for the
presence of bilateral breath sounds.
A patient presents to the emergency room with pulmonary edema. The nurse expects to
hear what adventitious sound?
A. Decreased breath sounds
B. Inspiratory and expiratory wheezing
C. Crackles
D. Friction rub - C. Crackles
RATIONALE
Crackles are associated with heart failure.
The nurse is providing preoperative teaching for the patient who is to undergo a total
laryngectomy. Which nursing intervention is most important?
A. Having the patient restrict food and fluids
B. Teaching the care required for the tracheostomy tube
C. Assessing the patient's ability to read and write
D. Demonstrating cough and deep breathing exercises - C. assessing the patient's ability
to read and write
A patient who has just had a total laryngectomy for cancer is being discharged. Which
statement indicates the patient needs further teaching on care of the tracheostomy?
A. "I must avoid getting any objects in the stoma."
B. "I can take a shower when I get home."
C. "I can learn to speak with an electric larynx."
D. "I need to clean around the stoma everyday." - B. "I can take a shower when I get
home."
(bathing is the preferred method over showering, in order to avoid getting water in the
stoma, and thus into the bronchial tree)
Which statement indicates further teaching is required for the patient diagnosed with
obstructive sleep apnea (OSA)?
A. "The CPAP machine will help me be more awake during the day."
B. "If I exercise and lose weight, I may not need to use CPAP."
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