NU 200 Unit I Practice Test PDF

NU 200 Unit I Practice Test Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 1. Which information does the post-anesthesia care unit (PACU) nurse include in the hand-off that to the nurse who will assume care on the medical-surgical unit? Select all that apply. A. Fluid intake and blood loss B. Placement of intravenous (IV) lines C. Patient identification using one identifier D. Information regarding the surgical procedure E. Over-the-counter (OTC) medications taken at home ____ 2. The nurse monitors for which clinical manifestations in the patient diagnosed with malignant hyperthermia? Select all that apply. A. pH 7.32 B. PaCO2 48 mm Hg C. Pulse 54 D. Dark brown urine E. Flaccid muscles ____ 3. Which is included in the scope of practice for the circulating registered nurse (RN)? Select all that apply. A. Obtaining informed consent B. Conducting the initial assessment in the operating room C. Assisting the certified RN anesthetist with patient monitoring D. Labeling patient samples and sending for analysis E. Documenting information pertinent to the surgical procedure ____ 4. The nurse correlates increased risk of deep vein thrombosis formation in patients placed in which position during a surgical procedure? Select all that apply. A. Fowler’s B. Jackknife C. Lateral D. Prone E. Reverse Trendelenburg ____ 5. The perioperative nurse educator is preparing an inservice for new staff. In describing settings where postanesthesia care is provided, the nurse includes which of the following? Select all that apply. A. Inpatient post-anesthesia care units B. Intensive care units C. Medical-surgical inpatient units D. Outpatient post-anesthesia care units E. Procedure areas ____ 6. During preoperative teaching, the nurse explains to the patient and family that which of the following staff will take part in providing care during the intraoperative period of the surgical process? Select all that apply. A. Surgeon B. Post-anesthesia care unit nurse C. Circulating nurse D. Anesthesiologist E. Respiratory therapist ____ 7. The nurse monitors for which potential complications in the patient who is receiving spinal anesthesia? Select all the apply. A. Headache B. Hematuria C. Hypotension D. Hyperthermia E. Hyperventilation ____ 8. Before advancing to phase II of postanesthesia care, the patient must achieve which outcomes? Select all that apply. A. Voiding clear urine B. Stable vital signs C. Alert and talking D. Oxygenation saturation 98% E. Stable airway ____ 9. Which statements are most true about the concept of acculturation? Select all that apply. A. An acculturated person accepts both their own culture and a new culture, adopting elements of each. B. It may take years and even generations for an immigrant group to acculturate. C. Integrating essential values, beliefs, and behaviors of the dominant culture is acculturation. D. Acculturation results from a minority group’s need to survive and flourish in a new culture. E. Acculturation is the maintenance of a culture within the presence of a dominant culture. ____ 10. The nurse is caring for a school-age child with tinea capitis. The child has open lesions from the disease and has lost hair in the areas affected. Which nursing diagnoses would be a part of this client's care plan? Select all that apply. A. Bathing, self-care deficit B. Disturbed body image C. Altered nutrition D. Impaired skin integrity E. Risk for infection ____ 11. The nurse working on the medical-surgical unit has received a patient from the post-anesthesia care unit (PACU). Which clinical manifestations are indicative of pain in the postoperative patient? Select all that apply. A. Restlessness B. Diaphoresis C. Hypotension D. Constricted pupils E. Piloerection ____ 12. A nurse demonstrates an understanding of multiculturalism when they can demonstrate which of the following? Select all that apply. A. Accommodates diversity B. Identifies cultural archetypes C. Incorporates inclusion D. Identifies cultural stereotypes E. Embraces ethnocentrism ____ 13. The home-health nurse learns that an elderly client isn’t able to get to the grocery store. They don’t have much food in their home, and they eat and drink little. Most of their time is spent sitting in their chair watching television, often not realizing that they have had bladder leakage. Which nursing actions would be implemented to reduce the risk of this client developing a pressure injury? Select all that apply. A. Help the client to get out of the chair every 2 hours. B. Change the client’s clothing frequently. C. Bath the client using soap and water. D. Promote intake of green tea throughout the day. E. Encourage the client to wear incontinence products. ____ 14. The nurse must verify a patient’s identity during the first time-out process. Which actions by the nurse are appropriate? Select all that apply. A. Asking the patient to state his or her name B. Asking the patient to state his or her date of birth C. Asking the patient to state his or her Social Security number D. Comparing the patient’s picture on the ID band to the patient E. Verifying the listed address in the medical record with the patient’s spouse ____ 15. Which of the following are examples of nonselective mechanical debridement methods? Select all that apply. A. Wet-to-dry dressings B. Sharp debridement C. Whirlpool D. Pulsed lavage E. Foam alginate ____ 16. What are common beliefs and practices associated with the North American (Western) professional healthcare system? Select all that apply. A. Values emphasize individualism and self-reliance. B. Health is defined as living in harmony with nature. C. Health is defined as absence or minimization of disease. D. Health is primarily dominated by a biomedical healthcare system. E. The system is run by a set of professional healthcare providers. ____ 17. A nurse is preparing a class for parents of infants about managing diaper dermatitis. What advice would the nurse include in the presentation? Select all that apply. A. Applying topical nystatin to the diaper area B. Using a blow dryer on warm to dry the diaper area C. Refraining from using rubber pants over diapers D. Using scented diaper wipes to clean the area E. Washing the diaper area with an antibacterial soap ____ 18. The nurse is caring for a patient in a rural rehabilitation facility. The patient uses a combination of folk medicine and traditional healing methods. The nurse notices that the patient has eaten very little since admission 10 days ago. When the nurse asks the patient about eating, the patient states, “I can’t eat any of this food. It just isn’t what I eat at home, and we don’t prepare our foods this way.” The nurse explains that the patient is on a very specific cardiac diet as a result of a heart attack and that the patient has lost 7 pounds since admission. Based on this scenario, which of the following are the most appropriate nursing diagnoses for this patient? Select all that apply. A. Noncompliance related to difficulty adhering to the medical regimen B. Possible knowledge deficit related to disease process C. Imbalanced nutrition: less than body requirement, related to cultural dietary practices D. Decreased appetite related to anxiety secondary to a heart attack E. Inability to adjust to a therapeutically prescribed diet due to cultural conflicts ____ 19. The nurse should question a patient prescription for surgical/sharp debridement in which situations? Select all that apply. A. The patient with a clean wound. B. The patient who has an allergy to adhesives. C. The patient who has an allergy to enzyme preparations. D. The patient who is diagnosed with a clotting disorder. E. The patient who is receiving chemotherapy and is neutropenic. ____ 20. Why is an accurate description of the location of a wound important? Select all that apply. A. Influences the rate of healing B. Determines the appropriate treatment choice C. Will affect the frequency of dressing changes D. Affects client movement and mobility E. Provides clues to wound etiology ____ 21. The nurse correlates which physiological responses that occur during the proliferative phase of healing? Select all that apply. A. Granulation B. Angiogenesis C. Bacterial phagocytosis D. Collagen synthesis E. Reorganization of collagen ____ 22. Which nursing actions are appropriate during phase I of the postoperative period? Select all that apply. A. Providing discharge instructions B. Assessing vital signs per protocol C. Monitoring electrocardiogram continuously D. Providing ongoing care until a bed is available E. Transferring to the medical-surgical unit ____ 23. Which statements about race and ethnicity are true? Select all that apply. A. Ethnicity refers to a person’s cultural use of the indigenous healthcare system. B. A person can have several aspects of a racial culture or be multicultural. C. Ethnicity refers to groups whose members share a common and social heritage that is passed on to the next generation. D. Race primarily reflects biology and refers to grouping of people based on biological similarities. E. People of Hispanic, Latino, or Spanish origin self-identify as members of the same race. ____ 24. Which of the following are strategies a new nurse can use to develop skills in achieving cultural competence? Select all that apply. A. Read the literature and study nursing theories and principles pertaining to culture. B. Take advantage of opportunities to interact with persons from diverse cultures. C. Reinforce the need for different cultures to follow the medical and nursing plan of care. D. Embrace practices of common cultures, and select the best interventions from those cultures. E. Learn and follow the culture guidelines created by regulating bodies in healthcare. ____ 25. Which should the nurse ask the patient to verify during the initial time-out, the “pause for cause”? Select all that apply. A. “What is the name of your surgeon?” B. “Which procedure are you having done today?” C. “Is the information on your identification band correct?” D. “Which side of the body is your procedure going to be completed on?” E. “Have you signed your informed consent for the scheduled procedure?” ____ 26. The nurse is admitting an older adult patient for surgery. Which specific assessments are most important to include when preparing this patient for surgery? Select all that apply. A. Number of living siblings B. Medications currently being taken C. Cognitive status D. Skin integrity E. Hobbies and entertainment preferences ____ 27. Which staffing ratios are appropriate nurse-to-patient ratios in the post-anesthesia care unit (PACU)? Select all that apply. A. 1:1 B. 1:2 C. 1:3 D. 1:4 E. 1:5 ____ 28. According to the World Health Organization, which members of the surgical team are required to be involved in the completion of the Surgical Safety Checklist before the skin incision is made? Select all that apply. A. Anesthesiologist or anesthetist B. Surgical technician C. Nurse D. Surgeon E. Operating room nurse manager ____ 29. The nurse educator for surgical services is planning an educational session related to informed consent. Which of the following situations requires two signatures on the consent form? Select all that apply. A. The patient can only mark with an “x.” B. The patient is deaf. C. The patient is a minor. D. The patient is incapable of signing. E. The patient speaks another language. ____ 30. Which actions would the nurse take when emptying the client’s closed-wound drainage system? Select all that apply. A. Don sterile gloves and personal protective equipment. B. Assess the drainage tube site and sutures, if in place. C. Check that the drainage system and connections are securely fastened. D. Test the suction apparatus at the prescribed pressure. E. Document the color, type, and amount of drainage. ____ 31. The nurse correlates the development of community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) infections to which skin conditions? Select all that apply. A. Abscess B. Eczema C. Cellulitis D. Impetigo E. Folliculitis ____ 32. Which statements about culture are true? Select all that apply. A. Culture exists on both material and nonmaterial levels. B. Culture mainly influences food choices and special holidays. C. Cultural customs change over time at different rates. D. Culture is learned through life experiences shared by culture members. E. Cultural practices are tightly regulated by customs. ____ 33. Which information does the post-anesthesia care unit (PACU) nurse receive from the operating room nurse during hand-off communication? Select all that apply. A. Estimated blood loss B. Anticipated length of hospital stay C. The surgical procedure D. Fluid intake during the procedure E. Names of family members in the waiting room ____ 34. Which statements are most accurate regarding values and beliefs? Select all that apply. A. A value is a standard or principle that has meaning and worth to an individual. B. Values are a set of behaviors that one follows to guide health practices. C. All members of certain cultures will share the same values and beliefs. D. A belief is something one accepts as being true. E. It is safe to assume a client shares the beliefs of the dominant culture. ____ 35. A patient’s leg wound is not healing as quickly as expected. What does the nurse do to determine the reason for the patient’s poor healing? Select all that apply. A. Obtain a referral for a dietitian. B. Elevate the extremity on a pillow. C. Increase the frequency of dressing changes. D. Encourage fluid intake. E. Obtain an order for prealbumin and albumin levels. ____ 36. The nurse performs preoperative teaching for a patient requiring a surgical intervention. Which actions by the patient indicate appropriate understanding of the information provided? Select all that apply. A. Demonstrating how to turn and get out of bed B. Having no anxiety about the impending surgery C. Demonstrating proper performance of leg exercises D. Demonstrating proper coughing and deep breathing E. Asking questions about and voicing understanding of information provided ____ 37. Which of the following assessment tools are used to assess risk for pressure injury? Select all that apply. A. Pressure Ulcer Healing Chart B. PUSH tool C. Braden scale D. Norton scale E. Braden Q Scale ____ 38. A group of students are preparing for a class exam on skin disorders. As part of their preparation, they are reviewing information about acne vulgaris and its association with increased sebum production. The students demonstrate understanding of the information when they identify which areas as having the highest sebaceous gland activity? Select all that apply. A. Shoulders B. Neck C. Back D. Face E. Upper chest ____ 39. The nurse is caring for a patient who refuses opioid pain medication based on their heritage despite the nurse’s explanation regarding its importance in the healing process. Which interventions by the nurse are appropriate for this patient? Select all that apply. A. Assess the patient’s pain levels at less frequent intervals. B. Document in the record that the patient does not want to take opioids. C. Use nonpharmacological measures to help control the patient’s pain. D. Notify the primary care provider of the patient’s noncompliance. E. Ask the patient about cultural influences on pain management. ____ 40. The nurse monitors for which clinical manifestations in the patient developing a complicated soft tissue bacterial infection? Select all that apply. A. Pain B. Fever C. Tachycardia D. Muscle atrophy E. Low blood pressure ____ 41. The surgical services nurse educator is preparing a class about the roles of staff in the operating room. In describing surgical assistants, the nurse includes which staff who have received specialty training for this role? Select all the apply. A. Certified registered nurse anesthetist (CRNA) B. Physician assistant (PA) C. Registered nurse first assistant (RNFA) D. Surgical first assistant (SFA) E. Surgical technologist ____ 42. The mother of a 15-year-old girl has contacted the clinic to report that her daughter has burned the back of her hand with a curling iron. The child's mother reports the burn is mild but states her daughter is complaining of pain. After consulting with the healthcare provider, what instructions can the nurse anticipate will be recommended? Select all that apply. A. Run cool water over the injured area. B. Take acetaminophen using the manufacturer's guidelines. C. Apply ice for 15 to 20 minutes each hour until the pain subsides. D. Apply a thin layer of petroleum jelly to the burned area. E. Apply a thin film of protective cocoa butter. ____ 43. The nurse learns in a report that the assigned client has a stage 3 pressure ulcer. What type of tissue does the nurse expect to visualize in the wound? Select all that apply. A. Muscle B. Eschar C. Subcutaneous tissue D. Dermis E. Fascia ____ 44. A patient is informed that a surgical procedure is to be scheduled in 2 weeks. Which teaching points does the nurse include to prepare the patient for the surgery? Select all that apply. A. The number of surgeries scheduled that day B. Deep breathing and coughing expectations C. Location of the surgical incision D. Presence of dressings or drains E. Components of the pain scale ____ 45. Which members of the surgical team are considered sterile? Select all that apply. A. Surgeon B. Scrub nurse C. Anesthesiologist D. Circulating nurse E. Surgical assistant ____ 46. The nurse monitors for which clinical manifestations in the patient is experiencing a recurrent herpes simplex virus infection? Select all that apply. A. Fever B. Anorexia C. Areas of redness D. Tingling sensation E. Fluid-filled vesicles ____ 47. The post-anesthesia care unit (PACU) nurse receives report from which of the following providers from the operating room? Select all that apply. A. Anesthesia care provider B. Operating room nurse C. Respiratory therapist D. Scrub technician E. Surgical team member ____ 48. Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply. A. Granulation B. Hemostasis C. Epithelialization D. Inflammation E. Maturation ____ 49. Which are actions the nurse implements during the informed consent process when providing patient care? Select all that apply. A. Reviewing the consent form B. Witnessing the patient’s signature on the consent form C. Teaching the patient why the procedure is being implemented D. Educating the patient on adverse effects associated with the procedure E. Validating patient understanding of the information presented for the procedure ____ 50. In working in perioperative services, the nurse understands that which of the following are the required components of the informed consent for the actual surgical procedure being planned? Select all that apply. A. Name and reason for the surgery B. Length of time of the surgery C. Name of surgeon performing the surgery D. Number of times the surgeon has performed the procedure E. All alternative options to surgery ____ 51. The nurse working in the post-anesthesia care unit (PACU) recognizes which of the following as risk factors for postoperative nausea and vomiting (PONV)? Select all that apply. A. Female B. Male C. History of smoking D. Undergoing a neurosurgical procedure E. Procedure performed under general anesthesia Numeric Response 52. The nurse sends 10 samples of body sites to assess an intensive care patient’s Candida colonization index. Seven of the samples came back as being positive. What is this patient’s colonization index? Record your answer to the nearest tenth decimal point. ______ Ordered Response 53. The post-anesthesia care unit (PACU) is receiving a patient from the operating room. What is the correct order to perform the following assessments? 1. Level of consciousness 2. Airway status 3. Skin color 4. Oxygen saturation 5. Apical pulse Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 54. Which of the following clients does the nurse recognize as being at greatest risk for pressure injury? A. An older adult requiring use of assistive device for ambulation B. A young adult with diabetes in skeletal traction C. A middle-aged adult with quadriplegia D. An infant with skin excoriations in the diaper region ____ 55. Which is the priority action by the nurse when a patient discloses a medication allergy during the health history before a surgical procedure? A. Documenting the information on the patient’s medical record B. Placing an alert bracelet on the patient before leaving the unit C. Asking the patient to describe the reaction that occurs D. Verifying the information with the patient’s family members at the bedside ____ 56. The nurse working in the emergency department is preparing heat therapy for one of the clients in the unit. Which one is it most likely to be? A. The client who is actively bleeding B. The client who has lower back pain C. The client who has a swollen, tender insect bite D. The client who has just sprained their ankle ____ 57. Which of the statements by a patient undergoing a craniotomy indicates the need for further teaching? A. “I will probably go to the intensive care unit immediately surgery.” B. “I will be attached to a cardiac monitor while recovering.” C. “My family will be able to visit me while I am recovering.” D. “I will be able to get some good sleep after I leave the operating room.” ____ 58. The nurse provides care to a patient who is having surgery later in the day. Which intervention is appropriate for the patient who is currently prescribed amiodarone? A. Monitoring for hyperglycemia B. Determining if a baseline electrocardiogram was completed C. Ensuring suction is available at all times D. Evaluating baseline coagulation studies ____ 59. A patient who speaks a different language is being prepared for surgery and needs to sign the surgical consent form. Existing regulations determine the healthcare organization’s responsibility for obtaining informed consent from this patient. Which action is the healthcare organization required to do? A. Ensure adequate resources necessary to comply with patient needs. B. Choose an interpreter, a translator, or a family member to interpret. C. Provide a translator approved by the organization. D. Provide a licensed interpreter. ____ 60. In providing preoperative teaching to a patient with a smoking history, which information does the nurse include in the teaching plan to encourage the patient not to smoke before surgery? A. “Smoking increases your risk of aspiration after surgery.” B. “Smoking increases your risk of bleeding after surgery.” C. “Smoking increases your risk of nausea and vomiting after surgery.” D. “Smoking increases your risk of respiratory depression during surgery.” ____ 61. Which statement by the nurse indicates an understanding of cultural competency? A. “Can you tell me about your cultural practices?” B. “Can you please provide me a list of your cultural preferences?” C. “What matters most to you about your illness and treatment?” D. “Do you understand how we do things here in the United States?” ____ 62. The nurse is providing care to a child with folliculitis. What would the nurse expect to administer? A. Oral cephalosporin B. Intravenous oxacillin C. Topical mupirocin D. Topical Eucerin cream ____ 63. The nurse is preparing to provide care to the client who has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound “heals a little more,” they will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? A. Secondary intention B. Tertiary intention C. Primary intention D. Regenerative healing ____ 64. The nurse includes what information about the mechanism of action of salicylic acid prescribed for the patient with psoriasis? A. Prevents formation of new lesions B. Suppresses cell division and decreases inflammation C. Diminishes proliferation of keratinocytes and decreases inflammation D. Decreases scaling and softens plaques ____ 65. When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include? A. Administration of most of the volume during the first 8 hours B. Administration of colloid initially followed by a crystalloid C. Monitoring of hourly urine output to achieve less than 1 mL/kg/hr D. Determination of fluid replacement based on the type of burn ____ 66. The nurse is teaching at a community fair about ways to reduce the risk of skin cancer. What should the nurse emphasize in this presentation? A. Use sunscreen with an SPF of at least 15 B. Wear clothing with UV protection C. Examine the body every 6 months for lesions D. Spend time in the sun between the hours of 10:00 a.m. and noon ____ 67. The nurse is completing the preoperative checklist on the night shift in preparation for the patient’s surgery, scheduled for 0800. Which tasks could the nurse complete at this time? A. Documenting the time of last voiding B. Removing the prosthesis C. Administering preoperative medication D. Checking the medical record for the history, physical, and signed informed consent ____ 68. The nurse is auscultating breath sounds on the patient during intubation with an endotracheal tube (ETT). Which findings correlate with a right main-stem bronchus intubation? A. Increased breath sounds on the right B. Increased breath sounds in the abdominal region C. Decreased breath sounds on the right D. Absence of breath sounds ____ 69. The patient is transferred to the operating table. Which dimension of the operative period is the patient currently experiencing? A. Preoperative period B. Perioperative period C. Intraoperative period D. Postoperative period ____ 70. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed warfarin? A. Tapering the drug 2 days before surgery B. Assessing for hyperglycemia C. Monitoring blood pressure D. Obtaining a baseline electrocardiogram ____ 71. Which is the priority laboratory test that the post-anesthesia care nurse monitors closely in the older adult patient with renal disease who retained fluid during a surgical procedure? A. Prothrombin time (PT) B. Blood urea nitrogen (BUN) C. Glucose D. Potassium ____ 72. A patient is undergoing a surgical procedure. Based on the figure, which intraoperative position does this represent? A. Trendelenburg B. Supine C. Fowler’s D. Low lithotomy ____ 73. The nurse provides care to a patient who is experiencing moderate pain in the post-anesthesia care unit (PACU). Which prescribed medication does the nurse administer to the patient? A. Naproxen sodium (Aleve) B. Hydromorphone (Dilaudid) C. Acetaminophen (Tylenol) D. Ibuprofen (Advil) ____ 74. A patient with a sacral stage III pressure injury has an elevated temperature. What diagnostic test is most definitive in determining if the patient is developing osteomyelitis? A. Bone biopsy B. Venous Doppler C. Computed tomography (CT) scan D. Complete blood count (CBC) ____ 75. A client hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. There is a pressure area on the client’s coccyx measuring 5 × 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? A. Stage 2 pressure injury B. Stage 3 pressure injury C. Unstageable pressure injury D. Stage 4 pressure injury ____ 76. The nurse is reviewing the medical records for patients who are scheduled for surgery the next day. Which patient may not provide consent to receive blood products? A. A Native American patient with no religious affiliation B. A Hispanic Catholic patient C. A Caucasian Jehovah’s Witness patient D. An African-American Baptist patient ____ 77. The nurse correlates an increased risk of infection because of immunosuppression to which patient condition? A. Pain B. Depression C. Delirium D. Anxiety ____ 78. A nurse is preparing a presentation for a local parent group about burn prevention and care in children. What would the nurse be least likely to include in the presentation when describing how to care for a superficial burn? A. Giving the child acetaminophen for pain relief B. Covering the burn with a clean, nonadhesive bandage C. Using cool water over the burned area until the pain lessens D. Applying ice directly to the burned skin area ____ 79. The nurse is providing care to a postoperative patient who is experiencing pain. The patient rates the pain at a 4 on a 1 to 10 numeric pain assessment scale. Which prescribed medication does the nurse administer to this patient? A. Morphine B. Ibuprofen C. Fentanyl D. Hydromorphone ____ 80. Which statement is most reflective of Madeleine Leininger’s theory of cultural care? A. The theory focuses on increasing levels of one’s consciousness to improve the possibilities to provide culturally competent care. B. The model focuses on five components of cultural competence: awareness, skills, knowledge, encounters, and desire. C. The model for cultural competence stresses teamwork in providing culturally sensitive and competent care to improve outcomes for individuals, families, and communities. D. The goal of the theory is to guide research that will assist nurses to provide culturally congruent care. ____ 81. The nurse is developing a plan of care for a client who was injured in a motor vehicle accident yesterday. The client is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for them at this time? A. Impaired tissue integrity related to ventilator dependency B. Impaired skin integrity related to ventilator dependency C. Risk for impaired skin integrity related to immobility D. Risk for infection related to subcutaneous injuries ____ 82. The nurse instructs a patient on medications prescribed to treat psoriasis. Which patient statement indicates that additional teaching is required? A. “This medication can cause my skin to get irritated.” B. “The condition can get worse if I stop this medication.” C. “This medication can stain my skin and clothes.” D. “This medication will cure the disease.” ____ 83. The nurse correlates which laboratory value as increasing the risk of infection in the postoperative patient? A. Potassium 3 mEq/L B. Glucose 120 mg/dL C. Sodium 150 mEq/L D. Hematocrit 32% ____ 84. A patient is undergoing a surgical procedure. Based on the figure, which intraoperative position does this represent? A. Jackknife B. Reverse Trendelenburg C. Trendelenburg D. Fowler’s ____ 85. Which action does the circulating nurse anticipate during the emergence phase of general anesthesia? A. Administering oxygen to the patient by face mask B. Suctioning the patient to decrease incidence of aspiration C. Maintaining the patient using balanced anesthesia D. Securing the patient’s airway ____ 86. The nurse is reviewing a wound care nurse’s narrative note that states there is a fistula in the lower abdominal wall as a result of a poorly healing surgical wound. What is a common cause of a fistula? A. Ischemic pressure to a bony prominence B. Diminished venous return to the site C. Abnormal straining over the incisional site D. Abscess formation from infection or debris ____ 87. The nurse is conducting a physical examination of a 9-month-old baby with a flat, discolored area on the skin. The nurse documents this as a: A. macule. B. vesicle. C. scale. D. papule. ____ 88. Which statement by the patient diagnosed with herpes simplex virus-2 (HSV-2) indicates the need for further teaching? A. “I will use condoms with sexual intercourse to decrease the risk of transmission.” B. “I will take my medication as prescribed so that I don’t have another outbreak.” C. “I will use warm water soaks to decrease my discomfort.” D. “I will contact my sexual partners to let them know about my diagnosis.” ____ 89. The nurse is developing a plan of care for the client with a stage 4 pressure injury. What would an appropriate goal/outcome be? A. Wound will close with no evidence of infection within 6 weeks. B. Clients will be repositioned at least every 2 hours. C. Pressure at the pressure injury site will be minimized. D. Client skin will remain intact throughout hospitalization. ____ 90. The nurse is preparing to perform wound irrigation. Which of the following is the best choice for performing wound irrigation? A. 35-mL syringe with a 19-gauge angiocatheter B. Clean bulb syringe and canister C. Sterile water irrigation D. 5-mL syringe with a 23-gauge needle ____ 91. The nurse is aware a patient incorporates alternative healthcare into regular health practices. For which alternative therapy is the nurse aware that the patient visits a formally trained practitioner? A. Acupuncture B. Use of herbs and roots C. Application of oils and poultices D. Burning of dried plants ____ 92. An instructor is developing a plan for a class of nursing students on various skin disorders. When describing urticaria, what would the instructor include? A. Histamine release leads to vasodilation. B. Wheals appear first followed by erythema. C. It is a type IV hypersensitivity reaction. D. The nonpruritic rash blanches with pressure. ____ 93. The nurse administers the preoperative medication to the patient 1 hour before elective surgery and then discovers the preoperative consent is not signed. Which action by the nurse is the most appropriate? A. Send the patient to the holding area without a signed consent. B. Notify the healthcare provider that surgery will need to be canceled. C. Have the patient sign the consent quickly, before the medication begins taking effect. D. Have a family member or medical power of attorney sign the consent. ____ 94. A nurse is performing a primary survey on a child who has sustained partial thickness burns over his upper body areas. What action should the nurse take first? A. Assess for a patent airway. B. Observe for symmetric breathing. C. Palpate the child's pulse. D. Inspect the child's skin color. ____ 95. The nurse correlates which treatment for the patient diagnosed with a carbuncle? A. Clindamycin and peroxide wash B. Incision and drainage C. Topical mupirocin ointment D. Moist heat ____ 96. What is the priority nursing action when providing patient care during the preoperative phase of care? A. Obtaining informed consent B. Ensuring NPO status C. Monitoring vital signs D. Completing a preoperative checklist ____ 97. Which patient is at greatest risk for the development of postoperative nausea and vomiting? A. 25-year-old female who underwent a cholecystectomy under general anesthesia B. 38-year-old male with a 15 pack-year history of smoking who had a fractured humerus repair under regional anesthesia C. 55-year-old female who had a mastectomy under general anesthesia D. 68-year-old male who had a total hip replacement under general anesthesia ____ 98. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of cisatracurium, which terminology does the nurse use? A. A depolarizing muscle relaxant B. A nondepolarizing muscle relaxant C. A narcotic analgesic D. An intravenous anesthetic ____ 99. The nurse monitors for which clinical manifestations on the patient’s elbows and knees in the patient diagnosed with plaque psoriasis? A. Red raised areas with inconsistent borders B. Large reddened areas of weeping and maceration C. Thick red plaques covered with silvery scales D. Small raised and reddened areas with fluid-filled pustules ____ 100. A patient is prescribed phototherapy as treatment for psoriasis. Which patient statement indicates that teaching about this treatment has been effective? A. “I should expect my skin to become red from the treatments.” B. “I should expect my skin to feel painful from the treatments.” C. “I should not have a treatment if my skin gets red or is blistered.” D. “I should expect occasional blisters and drainage from the treatments.” ____ 101. The nurse understands that the client who takes blood pressure medications is at risk for compromised skin integrity and poor wound healing. What is the rationale for that understanding? A. Blood pressure medications can delay wound healing. B. Blood pressure medications can cause cellular toxicity. C. Blood pressure medications predispose to hematoma formation. D. Blood pressure medications increase the risk of ischemia. ____ 102. The nurse provides care to a patient who is having surgery later in the day. The patient has contractures to both hands but is legally competent. Which action does the nurse implement during the informed consent process? A. Documenting that no consent form is required based on the patient’s procedure B. Obtaining consent for patient’s procedure from the surgeon C. Asking a family member to sign the patient’s consent form D. Telling the patient to place an “x” on the signature line of the consent form ____ 103. In teaching the patient about post-operative pain management, which statement by the nurse is best? A. “It is important that you request pain medication before the pain gets too severe.” B. “It is better not to have visitors if you are in pain,” C. “You will be given the lowest strength pain medication first.” D. “The goal for your pain is 0 on a 0 to 10 scale.” ____ 104. The nurse is providing care to a patient who had surgery 8 hours ago and has not voided. The physician has prescribed an indwelling urinary catheter be inserted. Which of the following statements should the nurse use to describe the procedure to the patient? A. “I will insert a Foley in you because you haven’t voided since your surgery.” B. “I need to place a catheter in your bladder because you haven’t voided since your surgery.” C. “The physician has prescribed catheterization because you haven’t urinated since your surgery.” D. “I will insert a tube into your bladder to drain the urine because you haven’t urinated since your surgery.” ____ 105. A patient is diagnosed with tinea corporis. The nurse correlates the mechanism of which medication to treat this infection? A. Topical selenium sulfide 1% (Selsun Blue) B. Topical butenafine (Lotrimin) C. Topical miconazole D. Topical terbinafine (Lamisil) ____ 106. Which American Society of Anesthesiologists’ classification does the circulating nurse document for a patient who has been declared brain-dead and whose organs are being procured for donation? A. 4 B. 6 C. 5 D. 3 ____ 107. What is the most useful tool for delegating pressure injury prevention to unlicensed assistive personnel (UAP)? A. Turning chart at the bedside B. Norton scale C. Braden scale D. At-risk sticker on the patient chart ____ 108. In providing preoperative care to a patient scheduled for an arthroscopic procedure, the nurse explains that postanesthesia care will most likely be provided in which setting? A. Medical-surgical unit B. Outpatient post-anesthesia care unit C. Procedure areas D. Intensive care unit ____ 109. A patient is diagnosed with herpes simplex viral encephalitis. Which medication does the nurse prepare to administer to this patient? A. Parenteral acyclovir B. Famciclovir C. Gentamycin D. Valacyclovir ____ 110. The nurse is providing care to the client who is 2 days post–cerebrovascular accident with residual decreased left-sided mobility. During the assessment, the nurse discovers a stage 1 pressure area on the client’s left heel. What is the initial treatment for this pressure ulcer? A. Normal saline irrigation of the ulcer daily B. Antibiotic treatment for 2 weeks C. Elevation of the left heel off the bed D. Debridement to the left heel ____ 111. An adult client is fully able to detect and respond to pain and discomfort. They have no incontinence or mobility limitations. They are of normal weight and consume a nutritious diet. The client has no problem with rubbing, friction, or shear. What is the Braden score for this client? A. 10 B. 15 C. 20 D. 23 ____ 112. The nurse is preparing an educational tool to teach high school students about skin cancer and highlights which finding as the most common precancerous lesion? A. Melanoma B. Actinic keratoses C. Squamous cell D. Basal cell ____ 113. The nurse is caring for a client with an infected full-thickness wound with moderate drainage and no odor. What type of dressing will be most appropriate for the nurse to apply? A. Antimicrobial collagen dressings B. Alginate C. Foam dressing D. Autolytic debridement ____ 114. The registered nurse first assistant (RNFA) scrubs with a long-acting, powerful antimicrobial sponge for before the surgical procedure. What is the required time frame for this surgical scrub? A. 3 to 5 minutes B. 7 to 10 minutes C. 1 to 3 minutes D. 5 to 7 minutes ____ 115. The nurse is developing a teaching plan for a client who has a surgical incision that has been left open. Which of the following points would the nurse make? A. The client will need to have twice daily wet-to-dry dressing changes until the wound is completely healed. B. The client will have more scar tissue formation than there would be for a wound closed at surgery. C. The client should expect to remain hospitalized in an isolation room until the wound is completely healed. D. The client will need to start a course of antibiotics for the infection until the wound is completely healed. ____ 116. The nurse obtains a swab culture from a chronic wound and understands that this may have limited findings. Why is the information obtained from a swab culture of a chronic wound limited? A. Most wound infections are viral, so the swab culture would not be indicative of an infection. B. A positive culture does not necessarily indicate infection because chronic wounds are often colonized by bacteria. C. A swab culture result does not include bacterial sensitivity information necessary to provide treatment. D. A negative culture may not indicate infection because chronic wounds are often colonized by bacteria. ____ 117. What would the nurse include when teaching an adolescent about tinea pedis? A. "Go barefoot when you are in the locker room at school." B. "Keep your feet moist and open to the air as much as possible." C. "Wear nylon or synthetic socks every day." D. "Dry the area between your toes really well." ____ 118. The nurse assesses the surrounding skin of the client’s colostomy. The client has been incorrectly applying his ostomy appliance, which caused a wound due to the continuous contact with liquid stool. The nurse notes bleeding and purulent drainage that has extended to the connective and adipose tissues. How will the nurse classify and document this contaminated wound? A. Acute, full thickness, open B. Chronic, partial thickness, closed C. Acute, partial thickness, closed D. Chronic, unstageable, open ____ 119. A client has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage 1 pressure ulcer. What would be the most important treatment for this client? A. Enzymatic debridement B. Hydrogel C. Transparent film dressing D. Frequent turn schedule ____ 120. The nurse shares with the nurse manager, “My patient believes in folk medicine, and when I tried to teach them about their antihypertensive medication, they replied by saying, “I’d rather eat chicken soup than take those medications.” Which is the most appropriate response by the nurse manager? A. “The patient can make their own choices and decisions, and there is nothing we can do about this.” B. “There is no scientific evidence to support chicken soup as a substitute for antihypertensive medications. Maybe you should do some research on this.” C. “This is common folk medicine. You can talk to them about taking their medications and eating chicken soup.” D. “You can tell the patient they can eat their soup, but they need to understand that they have to take their medications first.” ____ 121. In caring for a patient scheduled for a hip replacement surgical procedure, the nurse recognizes this procedure is an example of which surgical category? A. Curative B. Diagnostic C. Palliative D. Restorative ____ 122. The nurse is preparing to provide wound care to a client with many open wounds. Which of the following actions would be the most appropriate method for dressing changes of multiple open wounds that require treatment? A. Remove all of the soiled dressings before beginning wound treatment. B. Cleanse wounds from the most contaminated area to the least contaminated area. C. Treat wounds on the client’s side first and then the front and back of the client. D. Irrigate wounds from the least contaminated area to the most contaminated area. ____ 123. A teenage girl with psoriasis tells the nurse that she is so embarrassed by the plaque on her skin that she doesn't want to go to school. What is the best response by the nurse? A. "Have you been applying your medication and emollients to your skin as directed by your healthcare provider?" B. "You can't miss school because of your skin. Can you wear clothes that will cover the areas?" C. "Sunlight really helps the plaque areas heal. Maybe going to a tanning bed routinely will help." D. "It must be really difficult for you. Tell me how you are taking care of your skin on a daily basis." ____ 124. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of succinylcholine, which terminology does the nurse use? A. A narcotic analgesic B. An intravenous anesthetic C. A nondepolarizing muscle relaxant D. A depolarizing muscle relaxant ____ 125. The post-anesthesia care unit (PACU) nurse is caring for a patient who just arrived from the operating room after a colon resection. The patient is complaining of severe pain and becoming increasingly restless and tachycardic. Who does the nurse consult regarding this patient’s condition? A. Surgeon B. Surgical first assistant C. Anesthesiologist D. Circulating nurse ____ 126. The nurse correlates which potential risk factors to the development of several lacerations over the coccyx area? A. Pressure B. Moisture C. Shearing D. Heat ____ 127. The nurse is preparing to apply cold therapy. Which of the following diagnoses are contraindicated for cold therapy? A. The client with a sprained wrist B. The client with a pressure ulcer C. The client with an infected wound D. The client with a bleeding wound ____ 128. Which task is inappropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) during the intraoperative period of care? A. Transporting the patient to the operating room B. Delivering patient specimens to the laboratory C. Identifying the patient before the procedure D. Positioning the patient on the operating table ____ 129. The nurse is assessing the client who presents to the outpatient clinic with a wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? A. Stage 3 B. Stage 1 C. Stage 4 D. Stage 2 ____ 130. Which classification does the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a mild systemic disease? A. 2 B. 5 C. 3 D. 4 ____ 131. The nurse notes that a patient’s wound is weeping and edematous and correlates these findings to which phase of wound healing? A. Hemostasis B. Inflammatory C. Proliferative D. Maturation ____ 132. The nurse understands the terms related to culture. Which behavior is defined as a practice? A. Always drinking water after exercise B. Thinking often about cleanliness C. Placing an emphasis on success D. Maintaining youth ____ 133. A nurse is inspecting the skin of a child with atopic dermatitis. What would the nurse expect to observe? A. Pustular vesicles with honey-colored exudates B. Erythematous papulovesicular rash C. Hypopigmented oval scaly lesions D. Dry, red, scaly rash with lichenification ____ 134. The nurse is assessing the client with a chronic wound. The client asks the nurse to explain the difference between chronic and acute wounds. Which of the following would best describe the primary difference between chronic and acute? A. Chronic wounds are the result of pressure, but acute wounds result from surgery. B. Chronic wounds do not heal within an expected time frame, but acute wounds heal within 2 to 4 weeks. C. Chronic wounds are often full-thickness wounds, but acute wounds are superficial. D. Chronic wounds are usually infected, whereas acute wounds are contaminated. ____ 135. When conducting a skin assessment for a patient, which term does the nurse use to document soft, moist, tan- or green-colored devitalized tissue? A. Eschar B. Macerated tissue C. Slough D. Necrotic tissue ____ 136. The nurse is assessing a patient’s postoperative wound and finds it has separated from the suture line with extrusion of the bowel through the opening. How does the nurse document this finding? A. Wound tunneling B. Wound infection C. Wound evisceration D. Wound dehiscence ____ 137. The nurse is providing care for a 14-year-old girl with severe acne. The girl expresses sadness and distress about her appearance. Which response by the nurse would be most appropriate? A. "Your condition will most likely improve in a year or two." B. "Many people feel this way; I know someone who can help." C. "Are you using your medicine every day?" D. "If you have any scarring you can undergo dermabrasion." ____ 138. The nurse is developing a plan of care for a patient who sustained a hip fracture. Which intervention by the nurse indicates the nurse’s understanding of the patient’s indigenous healthcare system and should be included in the plan of care? A. Allowing the patient to discuss their traditional healing methods B. Requesting a consult from the patient’s acupuncturist C. Providing the patient with a favorite herbal tea D. Asking the family to bring in medals and amulets ____ 139. The nurse is providing parental teaching about home care for an 8-year-old boy with widespread sunburn on his back and shoulders. Which response indicates a need for further teaching? A. "Cool compresses may help cool the burn." B. "He should manually peel off any flaking skin." C. "Nonsteroidal anti-inflammatory drugs like ibuprofen are helpful." D. "He should avoid hot showers or baths for a couple of days." ____ 140. The nurse is completing the health history that is conducted during the preoperative period. What is the priority assessment? A. Oral intake over the last day B. Bowel elimination pattern C. Previous response to anesthesia D. Caretaker after discharge ____ 141. The nurse is teaching the mother of a toddler about burn prevention. Which response by the mother indicates a need for further teaching? A. "The handles of pots on the stove should face inward." B. "We will leave fireworks displays to the professionals." C. "All sleepwear should be flame retardant." D. "I will set our water heater at 130 degrees." ____ 142. Which identifier should the nurse use during the initial time-out to determine the right patient? A. Employer B. Medical record number C. Maiden name D. Date of birth ____ 143. Which of the following nursing actions is completed during phase III of postanesthesia care? A. Urinary catheterization if no voiding B. Discharge teaching C. Vital signs every 15 to 30 minutes D. Recovery from anesthesia ____ 144. The nurse is caring for an infant with candidal diaper rash. Which topical agent would the nurse expect the healthcare provider to order? A. Retinoids B. Corticosteroids C. Antifungals D. Antibiotics ____ 145. The nurse is caring for a patient who had a total hip replacement today. In reviewing the operating record, the nurse correlates which medication administered for its amnestic effects? A. Succinylcholine (Anectine) B. Fentanyl (Sublimaze) C. Vecuronium (Norcuron) D. Diazepam (Valium) ____ 146. After teaching a class about the differences in the skin of infants and adults, the nurse determines that additional teaching is necessary when the class states: A. "An infant's skin is thinner than an adult's, so substances placed on the skin are absorbed more readily." B. "The infant's epidermis is loosely connected to the dermis, increasing the risk for breakdown." C. "The infant has a lower risk for damage from ultraviolet radiation because the skin is more pigmented." D. "An infant has less subcutaneous fat, which places the infant at a higher risk for heat loss." ____ 147. A nurse is caring for a 5-year-old in Bucks traction. When conducting a skin examination for signs of pressure ulcers, the nurse pays particular attention to which area? A. Occiput B. Upper arm C. Sacral area D. Hip area ____ 148. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed dexamethasone? A. Assessing for hyperglycemia B. Obtaining a baseline electrocardiogram C. Tapering the drug 2 days before surgery D. Monitoring blood pressure ____ 149. A patient has a leg wound that has beige exudate and a fishy odor. The nurse correlates this assessment data to which microorganism? A. Proteus B. Streptococcus C. Staphylococcus D. Pseudomonas ____ 150. The nurse documents that the new wound has serosanguineous drainage. How is serosanguineous described? A. Purulent drainage B. Straw colored C. Bloody D. Red, watery, clear ____ 151. As part of a clinical conference with a group of nursing students, the instructor is describing the burn classification. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full-thickness burns? A. Skin appearing wet with significant pain B. Skin that is leathery and dry with some numbness C. Skin with blistering and swelling D. Skin that is reddened, dry, and slightly swollen ____ 152. A client developed a pressure injury on his sacrum. The wound appears to be a shallow crater involving only partial skin loss with a red pink wound bed. What would the nurse classify the pressure injury as? A. Stage 1 B. Stage 4 C. Stage 2 D. Stage 3 ____ 153. Which diagnostic test is indicated for the patient demonstrating signs of a herpes simplex virus (HSV) infection? A. HSV-1 antibody testing B. Tzanck’s smear C. Sedimentation rate D. Pap smear ____ 154. Which statement by the patient newly diagnosed with psoriasis indicates the need for further teaching? A. “I will limit my time outdoors because of my current medication regimen.” B. “I will wash my hands before and after applying the topical medication.” C. “I will be sure to wear long sleeves because my condition is contagious.” D. “I will contact my provider if I develop redness or any skin drainage.” ____ 155. A nurse is caring for a patient who avoids asking for narcotics for pain. Which of the following statements by the nurse indicates an understanding of cultural archetype? A. “The patient believes in using herbal teas for pain.” B. “The patient refuses to acknowledge pain.” C. “The patient’s cultural beliefs indicate how to deal with pain.” D. “The patient denies pain.” ____ 156. Vulnerable populations are those most likely to develop health problems and experience poorer outcomes because of limited access to care and a wide variety of other stressors. Which is most important for the nurse to focus on when caring for a patient from a vulnerable group? A. Identify the patient’s difficulties and risks. B. Identify the patient’s strengths and resources. C. Identify the need for a referral to a social worker. D. Identify the interactions between family members in planning care. ____ 157. As part of the nurse’s cultural assessment, which question is most appropriate for the nurse to ask prior to documenting the patient’s race? A. “Can you tell me a little about your background?” B. “How long have you lived in the United States?” C. “Which country are you from?” D. “What race do you identify with and what name do you prefer to use for it?” ____ 158. What type of wound can be described as a superficial wound, usually self-inflicted due to excessive scratching or mechanical force? A. Laceration B. Contusion C. Excoriation D. Incision ____ 159. The nurse monitors for which clinical manifestations in the patient diagnosed with basal cell carcinoma? A. Reddish brown plaque B. Asymmetrical black lesion C. Translucent papule D. Crusted ulcerated plaque ____ 160. The nurse is providing care to a patient in the post-anesthesia care unit (PACU) who lost a large amount of blood during a surgical procedure. Which assessment finding correlates to this post-operative complication? A. Tachycardia B. Bradypnea C. Hypothermia D. Hypertension ____ 161. Which action does the circulating nurse anticipate when the patient is intubated with the administration of general anesthesia? A. Suctioning the patient to decrease incidence of aspiration B. Maintaining the patient using balanced anesthesia C. Securing the patient’s airway D. Administering oxygen to the patient by face mask ____ 162. A patient with a pressure injury is prescribed a zinc supplement. What does the nurse explain to the patient about this supplement? A. It aids with red blood cell formation. B. It helps strengthen capillaries. C. It helps with immune function. D. It is needed for protein synthesis. ____ 163. The post-anesthesia care nurse is providing care to a patient with fluid volume overload who is experiencing cardiac dysrhythmias. Which laboratory result does the nurse correlate to this finding? A. Blood urea nitrogen (BUN) 15 mg/dL B. Potassium 3 mEq/L C. Sodium 136 mEq/L D. Glucose 60 mg/dL ____ 164. Which classification does the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a severe systemic disease that is a threat to life? A. 3 B. 4 C. 5 D. 2 ____ 165. The nurse is interviewing the mother of a 6-month-old being seen at a well-child visit. The mother reports she has used an over-the-counter topical ointment intended for adults on her child for a skin rash. What is the most appropriate response by the nurse? A. "Why did you do that instead of contacting your healthcare provider?" B. "This is dangerous so please do not do this again." C. "How often do you use this medication?" D. "Children have thin skin and can absorb medications differently than adults." ____ 166. The nurse assesses assigned clients and determines which of the following has the highest risk for altered skin integrity? A. An older client diagnosed with well-controlled type 2 diabetes B. An adolescent in bed with influenza, having periods of high fever and diaphoresis C. A middle-aged adult with metabolic syndrome taking antihypertensives D. A young adult in traction who has a low-protein diet and dehydration ____ 167. Which laboratory test is the most important for the postanesthesia care nurse to monitor closely in the patient who is prescribed warfarin in the treatment of atrial fibrillation? A. Hematocrit B. Prothrombin time (PT) C. Hemoglobin D. White blood cell count ____ 168. The nurse is preparing to apply cold therapy to a wound. In which case is this not appropriate? A. A 24-year-old patient 12 hours post–vaginal delivery B. A 36-year-old male waiting on an x-ray of the right ankle C. An 8-year-old patient post-tonsillectomy D. A 92-year-old patient on antihypertensives ____ 169. A patient in the operating room develops malignant hyperthermia. The nurse prepares which medication for administration to treat this medical emergency? A. Atropine B. Propofol C. Dantrolene D. Diazepam ____ 170. Which is the priority initial assessment for a patient who is admitted to the post-anesthesia care unit (PACU) after surgery with general anesthesia? A. Temperature B. Respirations C. Blood pressure D. Heart rate ____ 171. The nurse caring for a patient who is 24 hours post-op after a major abdominal surgery is assessing the operative site. The nurse observes internal viscera protruding through the incision site. The nurse acts quickly and should complete all of the following, except: A. Covering the wound with a sterile saline dressing. B. Immediately notifying the surgeon. C. Having the patient bend their knees and remain in bed. D. Putting a binder on the patient. ____ 172. The nurse correlates an increased risk of which complication related to a patient wearing jewelry in the operating suite? A. Burns B. Bleeding C. Intravenous infiltration D. Infection ____ 173. The nurse receives care of a postoperative patient in the post-anesthesia care unit (PACU). Which is the priority action by the nurse? A. Monitoring level of pain B. Monitoring oxygen saturation C. Monitoring blood pressure D. Monitoring peripheral pulses ____ 174. The nurse is teaching a clinic patient about hypertension. Which statement by the patient indicates they are present-oriented? A. “I know I need to lose weight. I’ll have to begin an exercise program right away.” B. “If I change my diet and begin exercising, maybe I can control my blood pressure without medications.” C. “I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult.” D. “I will reduce the amount of calories, salt, and fat that I eat. I certainly do not want to have a stroke.” ____ 175. The nurse correlates which material as being used to treat the patient requiring a secondary closure of a surgical wound? A. Tape B. Sutures C. Staples D. Grafts ____ 176. The nurse is preparing a class for a group of adolescents about reducing the risk of skin cancer. What information would the nurse include? A. Applying sunscreen at least 1 hour before going outside in the sun B. Using artificial ultraviolet (UV) tanning beds instead of sun exposure C. Using a sunscreen with para-aminobenzoic acid (PABA) with an SPF of at least 10 D. Avoiding sun exposure between the hours of 10 AM and 2 PM ____ 177. Which laboratory test does the post-anesthesia care unit (PACU) nurse monitor in the patient who is having difficulty regaining consciousness after a surgical procedure? A. Glucose B. Blood urea nitrogen (BUN) C. Potassium D. Prothrombin time (PT) ____ 178. What information does the nurse teach the patient regarding NPO status before a surgical procedure? A. Nothing solid by mouth for 6 to 8 hours before surgery B. Nothing solid by mouth for 12 to 14 hours before surgery C. Nothing solid by mouth for 10 to 12 hours before surgery D. Nothing solid by mouth for 8 to 10 hours before surgery ____ 179. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed metoprolol? A. Obtaining a baseline electrocardiogram B. Tapering the drug 2 days before surgery C. Monitoring blood pressure D. Assessing for hyperglycemia ____ 180. The client has ulcerations over the medial calf of the right leg. The surrounding skin is reddened. There is a moderate amount of fluid drainage. The client takes anticoagulants because of recurrent deep vein thrombosis. They also report a sedentary lifestyle. How would this chronic wound be classified? A. Pressure injury B. Diabetic foot ulcer C. Arterial ulcer D. Venous stasis ulcer ____ 181. A 6-year-old boy has been admitted to the hospital with burns. The nurse notes carbonaceous sputum. What action would be the priority? A. Eliciting a description of the burn B. Ensuring a patent airway C. Determining the burn depth D. Estimating burn extent ____ 182. The nurse is caring for a child with widespread itching and has recommended bathing as a relief measure. After teaching the mother about this, which statement from the mother indicates a need for further instruction? A. "After bathing, I need to rub his skin everywhere to make sure he is completely dry." B. "I must make sure I use lukewarm water instead of hot water." C. "We should leave his skin moist before applying medication or moisturizer." D. "Oatmeal baths are helpful; we can add Aveeno skin relief bath treatment." ____ 183. The nurse is assessing the client’s wound and notes that the wound bed shows granulation. What phase of wound healing is described by the nurse’s note? A. Inflammation B. Proliferative C. Maturation D. Hemostasis ____ 184. Which drug does the nurse prepare for the anesthesiologist to reverse the effects of cisatracurium during a surgical procedure? A. Fentanyl B. Glycopyrrolate C. Neostigmine D. Atropine ____ 185. An adult patient is admitted for observation after sustaining injuries in a motor vehicle accident. The nurse understands that cultural beliefs may affect beliefs and behaviors related to health. Which observation by the nurse is an indication for the nurse to assess the patient’s injuries? A. The patient endures pain longer and reports it less frequently. B. The patient reports immediate relief of pain. C. The patient requests herbal teas to manage the pain. D. The patient discusses the taboos against narcotic use to relieve pain. ____ 186. A female patient informs the charge nurse that she wants a change in the nurse providing her care. The patient states, “I don’t want a man taking care of me.” Which cultural barrier is this patient exhibiting? A. Prejudice B. Ethnocentrism C. Chauvinism D. Racism ____ 187. A nurse is assessing the skin of a child with cellulitis. What would the nurse expect to find? A. Papules progressing to vesicles B. Red, raised hair follicles C. Warmth at skin disruption site D. Honey-colored exudate ____ 188. The nurse monitors for which assessment data in the patient diagnosed with a Staphylococcus skin infection? A. Beige-colored pus drainage with a fishy odor B. Greenish-blue drainage with a fruity odor C. Creamy, yellow pus drainage D. Serosanguinous drainage ____ 189. During the time-out for a surgical procedure, who is responsible for marking the surgical site? A. Surgical technician B. Patient’s primary nurse C. Surgeon D. Circulating nurse ____ 190. The nurse correlates a change in the ST segment on the cardiac monitoring to which potential complication? A. Pulmonary edema B. Blood loss C. Myocardial infarction D. Atrial fibrillation ____ 191. A 3-year-old child has sustained severe burns and is ordered to receive 100% oxygen. What would the nurse use to administer the oxygen? A. Oxygen hood B. Nasal cannula C. Venturi mask D. Nonrebreather mask ____ 192. Which action does the circulating nurse anticipate during the induction of general anesthesia? A. Securing the patient’s airway B. Administering oxygen to the patient by face mask C. Maintaining the patient using balanced anesthesia D. Suctioning the patient to decrease incidence of aspiration ____ 193. While applying a wet-to-dry dressing, the nurse explains to the client how the procedure promotes healing. A wet-to-dry dressing is a: A. Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed. B. Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue. C. Method that involves soaking the wound in water and then drying the wound bed. D. Form of debridement that removes debris and healing granulation tissue. ____ 194. The nurse is reviewing the client’s surgical report and notes that the client has a history of evisceration. The nurse researches the differences between dehiscence and evisceration. Which of the following describes the difference between dehiscence and evisceration? A. Dehiscence involves the protrusion of internal viscera from the incision site; evisceration involves a separation of one or more layers of wound tissue. B. Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue. C. Dehiscence involves a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. D. Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. ____ 195. Which patient finding indicates the need for further monitoring rather than discharge home after an outpatient surgical procedure? A. Lethargy that resolves after several hours B. Inability to void without fluid retention C. Pain management with opioid analgesics D. Persistent nausea without vomiting ____ 196. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of propofol, which terminology does the nurse use? A. A nondepolarizing muscle relaxant B. A narcotic analgesic C. An intravenous anesthetic D. A depolarizing muscle relaxant ____ 197. Which action is the priority when providing care to a patient in the preoperative period? A. Admitting the patient to the facility B. Educating the patient on the surgical process C. Answering all questions for the patient about surgery D. Ensuring the patient’s preoperative checklist is complete ____ 198. A patient is experiencing scaly, patchy skin changes on the upper back, chest, and arms. In some areas the skin is either red, dark in color, or lighter in color. The nurse correlates these findings to which type of fungal infection? A. Tinea corporis B. Tinea unguium C. Intertrigo D. Tinea versicolor ____ 199. The nurse admits an older adult client to the long-term care facility. When assessing for pressure injury risk, what should the nurse do after conducting the Braden scale assessment? A. Massage areas over the bony prominences. B. Conduct another assessment in 3 days. C. Apply transparent film dressings to buttocks. D. Reassess by using the Braden Q scale. ____ 200. The mother of a 5-year-old child with eczema is getting a check-up for her child before school starts. What will the nurse do during the visit? A. Assess the compliance with treatment regimens. B. Discuss systemic corticosteroid therapy. C. Assess the child’s fluid volume. D. Change the bandage on a cut on the child’s hand. ____ 201. A client underwent emergency abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: A. Tertiary intention healing. B. Primary intention healing. C. Approximation intention healing. D. Secondary intention healing. ____ 202. A nurse is caring for a 14-year-old girl who received an electrical burn. The nurse would anticipate preparing the girl for which diagnostic tests as ordered? A. Fiberoptic bronchoscopy B. Xenon ventilation–perfusion scanning C. Pulse oximetry D. Electrocardiographic monitoring ____ 203. A child is diagnosed with atopic dermatitis. Which laboratory test would the nurse expect the child to undergo to provide additional evidence for this condition? A. Potassium hydroxide prep B. Wound culture C. Erythrocyte sedimentation rate D. Serum immunoglobulin E (IgE) level ____ 204. Which member of the intraoperative nursing team is considered sterile? A. Circulating nurse B. Nurse anesthetist C. Registered nurse first assistant (RNFA) D. Certified registered nurse anesthetist (CRNA) ____ 205. The nurse is reviewing the chart of a newly admitted client. The history and physical state that there is an absence of the stratum corneum. Which of the following explains why this is a concern? A. The stratum corneum provides insulation for temperature regulation. B. The stratum corneum produces new skin cells on a continuing basis. C. The stratum corneum promotes strength and elasticity to the skin. D. The stratum corneum protects the body against the entry of pathogens. ____ 206. The nurse is preparing to perform a dressing change on a tunneling wound. The wound is located on the client’s right hip, with tunneling at the 8 o’clock position, extending 5 cm. The wound is draining large amounts of serosanguinous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? A. Hydrocolloid dressing B. Dry gauze dressing C. Hydrogel D. Alginate dressing ____ 207. The nurse is caring for a 15-year-old boy who has sustained burn injuries. The nurse observes the burn developing a purplish color with discharge and a foul odor. The nurse suspects which infection? A. Burn wound cellulitis B. Invasive burn cellulitis C. Burn impetigo D. Staphylococcal scalded skin syndrome ____ 208. The nurse correlates hypertension and tachycardia in the post-anesthesia care unit to which of the following factors? A. Hypothermia B. Regional anesthesia C. Stress D. Oversedation ____ 209. Which of the following would be the most appropriate outcome for the client with an open stage 2 pressure injury? A. The wound will be completely healed within 14 days. B. The wound bed contains 100% granulated tissue. C. The wound remains free of scab. D. The wound is completely healed without scarring. ____ 210. Which classification does the nurse document, according to the American Society of Anesthesiologists, for a patient who is not expected to survive without the planned surgical procedure? A. 6 B. 5 C. 3 D. 4 ____ 211. Which gauge catheter does the nurse use when initiating intravenous (IV) access for a preoperative patient? A. 22 B. 24 C. 18 D. 20 ____ 212. In providing care to a patient diagnosed with a squamous cell lesion, the nurse prepares the patient for which treatment? A. Curettage and electrodessication B. Radiotherapy C. Mohs’ surgery D. Photodynamic therapy ____ 213. The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client: A. Begins an aggressive exercise program. B. Remains free of foot wounds. C. Follows a diet plan of 1,200 calories per day. D. Is fitted for deep-depth diabetic footwear. ____ 214. The nurse is providing care for a patient who is Cuban American. Which information about the patient will enable the nurse to best care for this patient? A. The nurse understands the patient’s individual cultural beliefs. B. The nurse has an understanding of the patient’s cultural language. C. The nurse understands practices of the patient’s ethnic group. D. The nurse understands their own cultural values. ____ 215. A patient recovering from reconstructive surgery is experiencing unrelenting postoperative pain. The nurse correlates this finding to which potential complication? A. Electrolyte imbalance B. Infection C. Fluid imbalance D. Delayed wound healing ____ 216. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed phenobarbital? A. Maintaining the drug during the perioperative period B. Assessing blood glucose levels closely during the perioperative period C. Obtaining a baseline electrocardiogram D. Monitoring blood pressure ____ 217. The nurse is reviewing the chart of a client. The nurse reads the following documentation: “healing stage 3 pressure injury to client’s right hip with 100% granulation tissue in wound bed, moderate serous drainage noted, surrounding skin intact.” What is the most important information missing from this documentation? A. Malodorous B. Client tolerated dressing change well C. 3 x 2 cm D. Periwound slightly macerated ____ 218. A 4-year-old is brought to the emergency department with a burn. What would alert the nurse to the possibility of child abuse? A. The burn area appears asymmetric and nonuniform. B. Parents state that the injury occurred approximately 15 to 20 minutes ago. C. Clear delineations are noted between burned and nonburned skin areas. D. Burn assessment correlates with mother's report of contact with a portable heater. ____ 219. The nurse recognizes that pressure injuries are directly caused by which of the following processes? A. Edema B. Impaired circulation C. Advanced age D. Ischemia ____ 220. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed insulin? A. Obtaining a baseline electrocardiogram B. Assessing blood glucose levels closely during the perioperative period C. Holding the drug during the perioperative period D. Monitoring blood pressure ____ 221. Which classification does the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a severe systemic disease? A. 3 B. 5 C. 2 D. 4 ____ 222. A client is post-abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? A. T-binder B. Paper tape C. Steri-Strips D. Abdominal binder ____ 223. At a clinical post-conference, a nursing student states, “I had a Chinese American patient today, and while I understand some of their cultural practices, they should follow our practices because we use scientific evidence.” Which cultural barrier is the student demonstrating? A. Racism B. Stereotyping C. Ethnocentrism D. Archetyping ____ 224. The nurse in the emergency department admits a client with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see on the dressing? A. Serous B. Purulent C. Purosanguineous D. Sanguineous ____ 225. Which clinical manifestations does the nurse correlate to inadequate anesthesia reversal in a patient in the post-anesthesia care unit (PACU)? A. Decreased oxygen saturation B. Elevated temperature C. Decreased urinary output D. Elevated blood pressure NU 200 Unit I Practice Test Answer Section MULTIPLE RESPONSE 1. ANS: A, B, D Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: 4. Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 331-332 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)/Nursing Management/Actions/Box 17.3 – Hand-Off of Care – PACU to Inpatient Unit Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is correct. Fluid intake and blood loss is included in the hand-off communication process between the post-anesthesia care unit (PACU) and medical-surgical nurses. 2 This is correct. Information regarding the placement of IV lines is included in the hand-off communication process between the PACU and medical-surgical nurses. 3 This is incorrect. Patient identification during the hand-off process should include two patient identifiers, not one. 4 This is correct. Information regarding the surgical procedure is included in the hand-off communication process between the PACU and medical-surgical nurses. 5 This is incorrect. Important medications taken by the patient at home, not over-the-counter medications, should be included in the hand-off process. MSC: Communication 2. ANS: A, B, D Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: 5. Examining risks and complications for the surgical patient Chapter page reference: 308-311 Heading: Complications of General Anesthesia Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Assessment Difficulty: Difficult Feedback 1 This is correct. Malignant hyperthermia (MH) is a hypermetabolic state that causes sustained muscular contractions related to an increase in intracellular calcium ion concentration. The sustained contractions result in signs of hypermetabolism. These include acidosis, tachycardia, hypercarbia, glycolysis, hypoxemia, and hyperthermia. This pH of 7.32 is acidotic. 2 This is correct. MH is a hypermetabolic state that causes sustained muscular contractions related to an increase in intracellular calcium ion concentration. The sustained contractions result in signs of hypermetabolism. These include acidosis, tachycardia, hypercarbia, glycolysis, hypoxemia, and hyperthermia. This PaCO2 of 48 mm Hg reflects hypercarbia. 3 This is incorrect. Malignant hyperthermia causes a hypermetabolic state that includes tachycardia. This pulse rate is slow. 4 This is correct. Myoglobinuria is another early sign of malignant hyperthermia. The patient’s urine turns from dark amber to brown. 5 This is incorrect. The most specific sign of malignant hyperthermia is skeletal muscle rigidity. MSC: Assessment 3. ANS: B, C, D, E Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: 1. Identifying the roles and responsibilities of operating room (OR) team members Chapter page reference: 304-305 Heading: Nonsterile Team Members/Circulating Registered Nurse Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Perioperative Difficulty: Moderate Feedback 1 This is incorrect. The surgical provider is responsible for obtaining the informed consent during the preoperative period. 2 This is correct. The circulating RN conducts the initial assessment when the patient is received to the surgical suite. 3 This is correct. The circulating RN assists the anesthesia provider with patient monitoring. 4 This is correct. The circulating RN labels patient samples and sends them for analysis. 5 This is correct. The circulating RN documents information pertinent to the surgical procedure. MSC: Perioperative 4. ANS: A, B, C, E Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: 5. Examining risks and complications for the surgical patient Chapter page reference: Heading: Positioning the Patient in the Operating Room/Table 16.5 – Risks and Interventions for Surgical Positions Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 This is correct. In Fowler’s position, there is increased risk of deep vein thrombosis (DVT) formation as a result of venous pooling that shifts toward the lower body. 2 This is correct. In the jackknife position, there is increased risk of DVT formation as a result of venous pooling that shifts toward the lower body. 3 This is correct. In the lateral position, venous pooling that shifts toward the dependent side of the body increases the risk for DVT in lower extremities. 4 This is incorrect. Patients placed in the prone position are at greater risk for diminished lung capacity and injury to shoulders, arms, and upper extremity nerves. 5 This is correct. In the reverse Trendelenburg position, venous pooling in the legs increases the risk of DVT in the lower extremities. MSC: Safety 5. ANS: A, B, D, E Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: 1. Discussing the significance of the postoperative period Chapter page reference: 324-325 Heading: Post-Anesthesia Care Unit Settings Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Perioperative Difficulty: Moderate Feedback 1 This is correct. Postanesthesia care is provided in a variety of settings, including inpatient and outpatient post-anesthesia care units (PACUs), intensive care units, and procedure areas. 2 This is correct. Postanesthesia care is provided in a variety of settings, including inpatient and outpatient PACUs, intensive care units, and procedure areas. 3 This is incorrect. Patients do not receive postanesthesia care on a medical-surgical unit because they require more intensive, close monitoring of airway, breathin

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