Homework Lance
1. Development of which complication is considered a never event?
a. Fever
b. Atelectasis
c. Pressure ulcer
d. Thrombophlebitis
ANS: C
Feedback
A Fever is a common occurrence in ill patients that may indicate inflammation or infection.
B Atelectasis is collapse of alveoli that may occur due to the patient’s hypoventilation, such as after surgery.
C Pressure ulcer is termed a never event because it refers to preventable, medical errors that should never occur.
D Thrombophlebitis is inflammation of veins that may occur due to immobility.
DIF: Cognitive Level: Understand REF: 545
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems
2. For which patient does the nurse make assessment of the oral mucous membrane a priority?
a. The patient who has an arteriovenous (AV) fistula
b. The patient who has a gastrostomy tube
c. The patient who uses a Ventimask
d. The patient who has a colostomy
ANS: B
Feedback
A The AV fistula is required by patients who need hemodialysis for kidney failure. They are able to drink fluids by mouth.
B Which patient can drink fluids by mouth is the distinguishing fact. This patient has this gastrostomy tube because he or she has difficulty swallowing. Thus this patient may not have fluids by mouth, which increases the risk for dry mucous membranes and makes the assessment most important compared with the other listed patients.
C The Ventimask fits over the nose and mouth to deliver oxygen. This patient is able to drink fluids by mouth.
D This patient has had part or all of the colon removed, but this patient is able to drink fluids by mouth.
DIF: Cognitive Level: Apply REF: 550
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems
3. How does a nurse assess perfusion to the foot when a patient has a cast from the left middle calf to the toes?
a. Palpate the popliteal pulse of the left leg.
b. Palpate the posterior tibial pulse of the left leg.
c. Assess movement and sensation of the left toes.
d. Assess the capillary refill of the left toes.
ANS: D
Feedback
A This pulse is above the foot and does not indicate perfusion of the foot.
B The pulse is not palpable because it is covered by the cast.
C This assessment is important for this patient but assesses neurologic function rather than perfusion.
D The presence of capillary refill in less than 2 seconds indicates perfusion of the left foot when the dorsalis pedis pulse cannot be palpated.
DIF: Cognitive Level: Understand REF: 553
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems
4. A nurse uses the Glasgow Coma Scale to assess which patient?
a. The patient who has a new onset of quadriplegia
b. The patient who has tonic-clonic seizures
c. The patient who requires stimuli for responses
d. The patient who has dementia
ANS: C
Feedback
A Although this patient is paralyzed, he or she is conscious. The Glasgow Coma Scale would not yield useful data about this patient.
B Although this patient may be unconscious during seizures, consciousness will return. The Glasgow Coma Scale would not yield useful data about this patient.
C The Glasgow Coma Scale is applicable only to patients who are unconscious, meaning they do not respond unless stimulated in some way from touch to pain.
D This patient is not unconscious. The Glasgow Coma Scale would not yield useful data about this patient.
DIF: Cognitive Level: Apply REF: 555-556
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems
5. During the assessment, the nurse determines that the patient’s Glasgow Coma Scale score is 15. What is the meaning of this number for this patient?
a. This patient is fully conscious.
b. This patient has movement but does not open the eyes or speak.
c. This patient is unable to respond to any stimuli.
d. This patient opens the eyes but does not speak or move.
ANS: A
Feedback
A A score of 15 is the expected value for the Glasgow Coma Scale.
B This patient would score a 9 on the Glasgow Coma Scale.
C This patient would score a 3 on the Glasgow Coma Scale.
D This patient would score a 4 on the Glasgow Coma Scale.
DIF: Cognitive Level: Understand REF: 556
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments
6. When performing a neurologic assessment of a male patient, a nurse discovers that shouting and shaking are necessary to arouse the patient enough to assess his neurologic status. After the patient answers questions about who he is and squeezes the nurse’s hand as requested, he returns to “sleep.” How does the nurse document this patient’s level of consciousness?
a. Lethargic
b. Obtunded
c. Stuporous
d. Semicomatose
ANS: B
Feedback
A Lethargic patients can be aroused by saying their names and touching them.
B Obtunded patients require shouting and vigorous shaking to arouse them; they carry out requests while awake, but return to “sleep” when stimuli stops.
C Stuporous patients require painful stimuli to respond and the response usually is a withdrawal from the source of pain.
D Semicomatose patients require painful stimuli and respond with abnormal flexion or extension.
DIF: Cognitive Level: Understand REF: 555
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems
MULTIPLE RESPONSE
1. What data do nurses collect when assessing a patient’s wound? Select all that apply.
a. Skin turgor
b. Width, length, and depth
c. Presence of pulsations
d. Wound color
e. Presence of edema
f. Drainage color
ANS: B, D, E, F
Correct: These data are collected when assessing a wound.
Incorrect: Skin turgor is assessed in intact skin rather than wounds. Presence of pulsations is not indicated when assessing a wound.
DIF: Cognitive Level: Understand REF: 546
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems
2. Which patient using respiratory equipment requires skin assessment? Select all that apply.
a. A patient using a nasal cannula
b. A patient with a tracheostomy
c. A patient using an incentive spirometer
d. A patient using a Ventimask
e. A patient with an IV
ANS: A, B, D
Correct: Patients using a nasal cannula need inspection of the nares and behind the helix of the ears. Patients with a tracheostomy need inspection of skin around the stoma where the tracheostomy tube enters the trachea. Patients using a Ventimask need inspection of skin where the mask comes in contact with the face and behind the helix of the ears. Patients with IVs need inspection of the skin to verify the catheter is secured and to assess for redness or edema.
Incorrect: Using an incentive spirometer requires the patient to take deep breaths, thus a skin assessment is not indicated.
DIF: Cognitive Level: Understand REF: 547-548
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems
3. Which tube interferes with hearing lung sounds during auscultation? Select all that apply.
a. Gastrostomy tube
b. Chest tube
c. Nasogastric tube
d. Tracheostomy tube
e. Oral endotracheal tube
ANS: B, C
Correct: When attached to suction, chest and nasogastric tubes can create sounds that may mimic lung sounds.
Incorrect: Gastrostomy tube is in the stomach and not attached to suction that might create a false sound similar to lung sounds. Tracheostomy tube is not attached to suction that might create a false sound similar to lung sounds. Oral endotracheal tubes are not attached to suction that might create a false sound similar to lung sounds.
DIF: Cognitive Level: Understand REF: 548| 551
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems
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