315 Test 3

Chapter 29 Bowel Elimination

Bowel elimination is a normal process by which waste products are eliminated

from the body. Feces are a mixture of insoluble fiber and other indigestible
material, bacteria, and water.

During defecation, the internal and external anal sphincters relax; the rectum
contracts; and peristalsis increases in the sigmoid colon, propelling feces
through the anus.

The frequency of bowel movements (BMs) varies. As long as stools are passed
without excessive urgency, with minimal effort and no straining, and without
the use of laxatives, bowel function is regarded as normal.

The bowel pattern set in childhood normally continues into adulthood.

Adequate fiber, fluid, and exercise are required to maintain this pattern.

Factors affecting bowel function include developmental stage, personal and

sociocultural factors, nutrition, hydration, activity level, stress, anesthesia,
medications, pregnancy, surgery and other procedures, and pathological
conditions.

To promote regular defecation, provide privacy for the patient and allow time
to use the toilet.

Constipation is a decrease in frequency of BMs and the passage of dry, hard

stool that requires more effort to pass.

Bulking agents are the preferred medication for treating constipation.

Habitual use of laxatives, with the exception of bulking agents, may cause
reliance on medication for bowel elimination.

Fecal impaction is detected by digital examination of the rectum. To treat a

fecal impaction, enemas or digital removal of stool is required.

An enema is the introduction of solution into the rectum to soften feces,

distend the colon, and stimulate peristalsis and evacuation of feces.

Flatulence can be managed by avoiding foods that trigger this response and
maintaining regular bowel movements.

Diarrhea is the passage of frequent, watery stools.

Monitor patients with diarrhea for intake and output, body weight, and vital
signs to assess for fluid losses; provide hygiene measures to protect the skin.

Bowel incontinence may be managed by providing assistance to the bathroom

at regular intervals and at the times BMs are most likely to occur, and by
beginning a bowel training program.
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External or internal fecal collection devices can be used to protect perianal skin
or to collect large stool samples. They minimize odor, allow for accurate
measurement of output, and improve patient comfort.

A bowel diversion is a surgically created opening for elimination of digestive

waste products.

The effluent (fecal matter) of an ostomy ranges from liquid to solid, depending
on the part of the bowel that is being diverted.

A healthy stoma ranges in color from deep pink to brick red and is shiny and
moist at all times.

A moisture-proof skin barrier is usually placed around a stoma to protect

surrounding skin.

A client with a bowel diversion must adapt to the stoma for elimination and
learn to care for the stoma.

Ileostomy
An ileostomy brings a portion of the ileum through a surgical opening in the
abdomen, bypassing the large intestine entirely. Drainage at this level is liquid and
continuous. The patient must wear an ostomy appliance at all times to collect the
drainage. Some variations of an ileostomy are designed to control drainage more
effectively and to cause less body image disturbance. However, many clients are not
candidates for these procedures because of their underlying disease.

A Kock pouch, or continent ileostomy, creates an internal pouch, or reservoir, to

collect ileal drainage (ESG Fig. 29-1A). To drain the pouch, the patient inserts a tube
through the external stoma into the pouch several times per day. This alternative
avoids continuous drainage and allows the patient to be free of an ostomy
appliance.

A total colectomy with ileoanal reservoir is a surgical procedure in which the colon
is removed, a pouch is created from the ileum, and the ileum is connected to the
rectum (ESG Fig. 29-1B). The patient evacuates the bowel on the commode in the
usual manner. Although this procedure should result in continence of bowel
elimination, the feces will still be liquid.

Ultrasonography (Ultrasound)
Detects tissue abnormalities such as masses, cysts, edema, or stones. An ultrasound
probe, called a transducer, is moved over the skin surface of the abdomen. The
probe emits a sound wave that abdominal tissue and organs reflect back based on
their density. The sound waves may be transformed into images visible on a
computer screen.
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Esophagogastroduodenoscopy
Sigmoidoscopy
Fiberoptic Colonoscopy
Barium Enema (BE)
Ultrasonography (Ultrasound)
Computed Tomography (CT) Scan
Examines body sections from different angles using a narrow x-ray beam. It
produces a three-dimensional picture of the area of the body being scanned. This
test is useful in diagnosis of many abdominal disorders. A CT scan may be
enhanced by injecting contrast dye that allows for improved visualization of
circulatory function. The patient needs to lie very still during the procedure.

Preparation

If contrast dye is to be used:

Determine that the patient is not allergic to contrast medium, iodine, or shellfish.

Check blood urea nitrogen and creatinine levels to ensure adequate kidney
function.

Patients taking metformin (Glucophage) should discontinue it on the day of the test
and withhold it for 48 hours after to prevent lactic acidosis. Restrict food and fluids
for 6 to 8 hours if contrast medium is to be given.

Sometimes the patient is asked to drink about 450 mL of a dilute barium solution 1
hour before the CT scan to distinguish GI from other abdominal organs.

NCLEX-Style Review Questions Answers

1. Normal flora contained in the colon aid digestion and produce which nutrients?
Select all that apply.
.
1) Vitamin A
.
2) Vitamin B
.
3) Vitamin C
.
4) Vitamin K
.
5) Iron
.
6) Zinc
Answer:
2) Vitamin B 4) Vitamin K
Rationale:
The normal flora in the colon produce vitamin K and several of the B vitamins. They are
not responsible for production of vitamins A and C, iron, and zinc.

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2. When a patient with heartburn takes antacids, for which problem is he especially at
risk?
.
1) Diarrhea
.
2) Constipation
.
3) Stomach ulceration
.
4) Flatulence
.

Answer:
2) Constipation
Rationale:
Antacids slow peristalsis, placing the patient at risk for constipation. Antibiotics
increase the risk for diarrhea. Stomach ulceration is an adverse effect associated
with nonsteroidal anti-inflammatory drugs (NSAIDs). Iron supplementation may
cause flatulence.

3. Which type of bowel diversion allows the patient to be free from an appliance?
.
1) Colostomy in the transverse colon
.
2) Double-barreled colostomy
.
3) Ileostomy
.
4) Kock pouch
.

Answer:

4) Kock pouch
Rationale:
A Kock pouch, also known as a continent ileostomy, creates an internal pouch to
collect ileal drainage. To drain the pouch, the patient inserts a tube through the
external stoma into a pouch several times a day. This allows the patient to be free from
an appliance. A colostomy, double-barreled colostomy, and ileostomy all require an
appliance.
4. The nurse has taught a client how to manage constipation. Which action by the
client would provide evidence of learning? (Select all that apply.) The patient:
.
1) increases his intake of high-fiber foods.
.
2) drinks at least four 8-ounce glasses of water a day.
.
3) goes to the bathroom to evacuate after meals.
.
4) takes a daily laxative.
Answer:

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1) increases his intake of high-fiber foods.
3) goes to the bathroom to evacuate after meals.
Rationale:
The urge to defecate typically comes after eating; the nurse can help manage the
patient's constipation by assisting the patient to the bathroom after meals. The nurse
should also encourage the patient to increase his intake of high-fiber food and drink at
least eight glasses of water a day (not four). Laxatives should be administered or taken
only when absolutely necessary.
5. A patient is admitted to the hospital with severe diarrhea. The patient should be
monitored for which complication associated with diarrhea? 1) Hypokalemia
2) Hypocalcemia
3) Hyperglycemia
4) Thrombocytopenia
Answer:
1) Hypokalemia
Rationale:
Diarrhea causes fluid loss and hypokalemia, not hypocalcemia, hyperglycemia, or
thrombocytopenia.
6. For a patient with a newly fractured pelvis, not yet in a cast, which of the following
actions is appropriate when placing the patient on a bedpan?
.
1) Place the patient in semi-Fowler's position to defecate.
.
2) Ask the patient to push up with his feet to lift his hips while you place
the bedpan.
.
3) Place a fracture pan under the buttocks, small end toward the feet.
.
4) Raise the side rail on the opposite side from where you are working.
Answer:
4) Raise the side rail on the opposite side from where you are working.
Rationale:
The nurse should always raise the side rail on the opposite side from where he is
working to protect the patient from falls. Placing the patient in semi- Fowler's position
or asking the patient to push up with his feet would cause pain and possible
dislocation of the fracture. A fracture pan should be used, but the small end is pointed
toward the feet.

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Knowledge Map
Pathological
Conditions:
- Pain
- Immobility
- Neurological
- Cognitive changes
- Food allergies
- Diverticulosis/itis

- Developmental stage
- Personal/cultural
- time
- privacy
- Nutrition/hydration
- Activity level
- Medications
- Procedures
- Pregnancy

Bowel Diversions
Ileostomy/Kock pouch
Colostomy:
- permanent
- temp
loop

Factors
Affecting

Assessment

Bowel sounds
Elimination pattern
Appearance of stool
Change in bowel habits/patterns
Use of elimination aids

Structures:
- Mouth: digestion begins
- Esophagus: transit of
food to stomach
- Stomach: mechanical
digestion
- Small intestine: digestion/
absorption; passage to
large intestine
- Large intestine: absorption
of vitamins/minerals
- Rectum/anus: waste
elimination

Bowel
Elimination
Promoting Normal/
Regular Defecation

Manage
Diarrhea
Provide privacy
Position properly
Timing related to meals
Promote adequate fluids
and balanced diet
Encourage exercise

Diagnostic
Testing:
- Visualization:
- direct
- indirect
- Labs:
- occult blood
- parasites

Manage
Constipation

Manage
Impactions

Manage bowel
Diversion

- Assess stools
- Attend to fluid
needs
- Provide hygiene/
skin care
- Antidiarrheals

- Increase dietary
fiber
- Increase fluid
intake
- Increase activity

Manage bowel
Incontinence
- Assessing effluent
amount,
consistency
- Stoma assessment/care
size,
color
- Peristomal skin care
- Patient teaching: diet, appliance
management
- Supporting patient self-concept

- Fecal collection pouch

- Bowel training
- Promote hygiene; skin care
- Review diet/fluid intake

- Enemas: cleansing;
retention; return flow
- Digital removal of stool

315 Test 3
Chapter 30 Urinary

The urinary system consists of two kidneys, two ureters, the urinary bladder, and the
urethra.

The kidneys filter nitrogen and other metabolic wastes, toxins, excess ions, and
water from the bloodstream and excrete them as urine.

The bladder has a normal average storage capacity of 500 mL (1 pint), but it may
distend, when needed, to a capacity twice that amount.

Voiding occurs when contraction of the detrusor muscle pushes stored urine
through the relaxed internal urethral sphincter into the urethra.

The kidneys produce urine at a rate of approximately 60 mL per hour, or 1,500 mL

per day. Most people urinate about five to six times per day.

Voiding and control of urination require normal functioning of the bladder and the
urethra, as well as an intact brain, spinal cord, and nerves supplying the bladder and
urethra.

As an adult ages, the number of functional nephrons gradually decreases, along

with the ability to dilute and concentrate urine. The potential volume of the bladder
also decreases as the bladder wall loses elasticity; thus, older adults need to urinate
more frequently.

Substances that contain caffeine act as diuretics and increase urine production.

A diet high in salt causes water retention and decreases urine production.

Medications with anticholinergic effects inhibit the free flow of urine and may
contribute to urinary retention.

An adequately hydrated adult produces clear yellow urine. Concentrated urine is

darker in color, but dilute urine can appear colorless.

A clean-catch urine specimen is preferred for many diagnostic tests. To collect this
specimen, the client must cleanse the genitalia before voiding and collect the
sample in midstream.

Sterile urine specimens may be obtained by inserting a catheter into the bladder or
withdrawing a sample from an indwelling catheter.

24-hour urine collection requires collection of all urine voided in the time period.
The start time of the 24-hour collection begins when the first-voided urine is
discarded.

A routine urinalysis is one of the most commonly ordered laboratory tests. It is used
as an overall screening test as well as an aid to diagnose renal, hepatic, and other
diseases.

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Normal urine is free of bacteria, viruses, and fungi. Urinary tract infections are often
caused by the introduction of Escherichia coli (E. coli), which normally live in the
colon, into the urethra and bladder.

Urinary retention is an inability to empty the bladder. It may be due to obstruction,

nerve problems, infection, surgery, medications, or anxiety. Urinary catheterization is
the introduction of a pliable tube (catheter) into the bladder to allow drainage of
urine.

Urinary incontinence (UI) is a lack of voluntary control over urination. Nurses can
independently perform the primary interventions to manage UI.

A urinary diversion, or urostomy, is a surgically created opening for elimination of

urine.

A patient with a urinary diversion requires physical and psychological care. The goal
is to have the patient become comfortable with his changed body and assume selfcare.

NCLEX-Style Review Questions Answers

Chapter 30 - Urinary Elimination
1. When inserting an indwelling urinary catheter in a male patient, the nurse cleanses
the penis with an antiseptic wash. Which step should she take next?
.
1) Gently insert the tip of the prefilled syringe into the urethra to instill the
lubricant.
.
2) Ask the patient to bear down as though trying to void.
.
3) Slowly insert the end of the catheter into the urinary meatus.
.
4) Insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows.
Answer:
1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant.
Rationale:
The steps of the procedure for inserting an indwelling urinary catheter are as follows.
The nurse should gently insert the tip of the prefilled syringe into the urethra and instill
the lubricant. Then the nurse should ask the patient to bear down as though trying to
void, as she slowly inserts the end of the catheter into the meatus. She should continue
to insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows. When
urine appears, she should advance the catheter 1 to 2 inches (2.5 to 5 cm) more. She
should hold the catheter securely with her dominant hand while the urine flows. After
urine flows, she should stabilize the catheter's position in the urethra and use the other
hand to pick up the saline-filled syringe and inflate the catheter balloon.

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2. The nurse is obtaining the history of a newly admitted patient. Which element in the
history places the patient at risk for urinary tract infection?
1) Hypertension
2) Hypothyroidism
3) Diabetes mellitus
4) Hormonal contraceptive use
Answer:
3) Diabetes mellitus
Rationale:
Diabetes mellitus places the patient at risk for urinary tract infection because glucose
in the urine provides a medium favorable for bacterial growth. Hypertension,
hypothyroidism, and hormonal contraceptive use are not directly related to an
increased risk for urinary tract infection.
3. A patient who underwent surgery for removal of a pituitary tumor develops a
condition in which the kidneys are unable to conserve water and the quantity of urine
voided increases. Which urine specific gravity would the nurse expect to find in the
patient with this disorder?
1) 1.001
2) 1.010
3) 1.025
4) 1.030
Answer:
1) 1.001
Rationale:
The patient with diabetes insipidus would have a low specific gravity, such as 1.001.
This indicates dilute urine that results from poor concentrating ability of the kidneys.
Normal urine specific gravity ranges from 1.010 to 1.025. A specific gravity of 1.030
indicates concentrated urine or deficient fluid volume (dehydration).
4. Which blood level is commonly tested to help assess kidney function?
1) Hemoglobin
2) Potassium
3) Sodium
4) Creatinine
Answer:
4) Creatinine
Rationale:
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The nurse would examine laboratory results for blood urea nitrogen and creatinine to
assess kidney function. Hemoglobin, potassium, and sodium levels can be
affected by kidney disease, but they do not directly assess kidney function.
5. A patient is admitted with pyelonephritis. Which anatomic structure is affected by
this disorder?
.
1) Kidneys
.
2) Bladder
.
3) Urethra
.
4) Prostate gland
Answer:
1) Kidneys
Rationale:
Pyelonephritis is an infection of the kidneys. Cystitis is an infection involving the
bladder. An infection of the urethra is known as urethritis. Prostatitis is an infection
involving the prostate gland.
6. The parent of a 7-year-old son brings the child to the pediatric care provider to
discuss her child's nighttime bedwetting. She reports he has never achieved
consistent dryness at night. What is the nurse's best response to the mother's
concern?
.
1) "We'll start medication right away to control it."
.
2) "Family history is not associated with bedwetting."
.
3) "We will look for a urinary tract infection."
.
4) "Wait it out. Your son will likely outgrow it."
Answer:
4) "Wait it out. Your son will likely outgrow it."
Rationale:
Based on the history, the nurse understands the condition is nocturnal enuresis
because the child has not yet achieved dryness at night at an age where continence
would be expected. Nocturnal enuresis is most common among boys. Ninety-five
percent of children outgrow it by age 10. Nighttime bedwetting runs in families. So if
one parent experienced nocturnal enuresis as a child, then the chances the child will
also have trouble with achieving continence at night will be likely. Pharmacologic
intervention can be useful for older children, particularly when the child is not sleeping
at home. However, prior to age 8 or 10, medication is not indicated.

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7. The nurse is teaching an older female patient how to manage stress incontinence at
home. She instructs her to contract her pelvic floor muscles for at least 10 seconds
followed by a brief period of relaxation. What is this intervention called?
.
1) Prompted voiding
.
2) Cred technique
.
3) Valsalva maneuver
.
4) Kegel exercises
Answer:
4) Kegel exercises
Rationale:
Kegel exercises strengthen the pelvic floor muscles that support the uterus, bladder,
and bowel. Doing Kegel exercises regularly can reduce urinary incontinence. These
exercises involve tightening and relaxing the muscles around the vaginal area.
Prompted voiding is a part of a bladder training program where the person learns to
void based on a schedule, rather than empty the bladder. The Cred technique is
applying manual pressure with your hands to the top portion of the bladder to initiate
a urine flow. The Valsalva is the maneuver in which a person tries to exhale forcibly with
a closed glottis (the windpipe) so that no air exits through the mouth or nose, for
example, in strenuous coughing, straining during a bowel movement, or lifting a heavy
weight.

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Knowledge Map
Structures:
Kidneys filter; regulate
Nephrons urine formation
Ureters urine transport
Bladder urine storage
Urethra urine transport
Sphincters flow control

Factors Affecting:
- Developmental stage:
infants, elders
- Personal; sociocultural;
environmental
- time; privacy; loss of
dignity
- Nutrition; hydration
- Activity
- Medications
- Surgery/ anesthesia

Pathological Conditions
Affecting Urination:
- UTI
- Calculi
- BPH
- Cardiovascular & metabolic
diseases
- Neurogenic bladder
- Impairments: mobility,
communication, cognition

Urination
Assessing Urine:

Promoting Normal
Urination:
Provide privacy
Position properly
Establish toileting routines
Provide adequate fluids/
nutrition
Assist with voiding

Urinary catheterization
- Straight catheter
- Indwelling catheter
- Suprapubic catheter

- Skin care
- Lifestyle changes
- Bladder training
- Scheduled voiding
- Kegels
- Biofeedback
- Anti-incontinent devices

Common Urinary Problems:

Urinary tract infections
- urethritis; cystitis;
pyelonephritis
Urinary retention
Urinary incontinence:
- urge
- stress
- overflow
- functional
- transient
- reflex
- enuresis
Urinary diversions
- cutaneous ureterostomy
- ileal conduit
- Kock pouch (continent
urostomy)

Intake and output

Urine studies
- analysis
- specific gravity
- dipstick
Specimens from:
- fresh-voided
- clean catch
- sterile specimen
- 24-hour collection

315 Test 3
Chapter 39 Fluid & Electrolytes

Water is the largest single constituent of the body. Total body water content varies
with age, gender, and the number of fat cells.

Intracellular fluid (ICF) is contained within the cells. It is essential for cell function
and metabolism and accounts for approximately 40% of body weight.

Extracellular fluid (ECF) consists of three types of fluid: interstitial, intravascular, and
transcellular fluid. ECF carries water, electrolytes, nutrients, and oxygen to the cells
and removes the waste products of cell metabolism. ECF accounts for 20% of body
weight.

Electrolytes that carry a positive charge are called cations. They include sodium (Na
+), potassium (K+), calcium (Ca2+), and magnesium (Mg2+). Electrolytes that carry a
negative charge are called anions.

Potassium and magnesium are the major cations in the ICF. Phosphate and sulfate
are the major anions.

The major electrolytes of ECF are sodium, chloride, and bicarbonate. Albumin is
also present in the ECF.

Osmosis is a mechanism to maintain homeostasis through the movement of water

across a membrane from a less concentrated solution to a more concentrated
solution.

Diffusion is a passive process by which molecules move through a cell membrane

from an area of higher concentration to an area of lower concentration. Filtration is
the movement of both water and smaller particles from an area of high pressure to
an area of low pressure.

Active transport occurs when electrolytes move from an area of low concentration
to an area of high concentration. Active transport requires energy expenditure for
the movement to occur against a concentration gradient.

General recommendations for total fluid intake are 2700 mL per day for women and
3700 mL per day for men.

Fluid loss occurs throughout the day, creating a constant need to replenish fluid.
Loss occurs through urine, skin, insensible losses, and feces. When the body is in a
healthy state, fluid losses are equivalent to fluid intake.

Sodium is the major cation in the ECF. Its function is to regulate fluid volume.

Potassium is the major cation of the ICF. It is a key electrolyte in cellular metabolism.

Calcium is a vital electrolyte responsible for bone health, neuromuscular function,

and cardiac function, and it is an essential factor in blood clotting. Approximately
99% of body calcium is located in the bones and teeth. The remaining 1% circulates
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in the blood and is responsible for calcium's actions. Magnesium is a mineral used
in more than 300 biochemical reactions in the body. As with calcium, only about 1%
of magnesium is found in the blood. The remaining 99% is divided between the ICF
and combined with calcium and phosphorus in bone.

Chloride is the most abundant ion in the extracellular fluid. It is usually bound with
other ions, especially sodium or potassium. Chloride works with sodium to regulate
osmotic pressure between fluid compartments and assists in regulating acidbase
balance through the bicarbonate buffer system. Phosphorus is the most abundant
intracellular anion. Most phosphorus is found bound with calcium in teeth and
bones. Phosphorus and calcium levels exist in an inverse relationship.

Bicarbonate is present in intracellular and extracellular fluids. Extracellular

bicarbonate levels, important in acidbase regulation, are regulated by the kidneys.

The amount of acid or base present in a solution is measured as pH. The pH is

reported on a scale of 1 to 14, with 1 to 6.9 being acidic, 7 neutral, and 7.1 to 14
basic, or alkaline. Normal blood pH is slightly alkalotic between 7.35 and 7.45.

A buffer system consists of a weak acid and a weak base. These molecules react
with strong acids or bases to keep them from altering the pH by either absorbing
free hydrogen ions or releasing free hydrogen ions. The principal buffer system in
the ECF is the carbonic acid (H2CO3) and sodium bicarbonate (NaHCO3) system.

When the serum pH is too acidic (pH is low), the lungs remove carbon dioxide
through rapid, deep breathing. If the serum pH is too alkaline (pH is high), the lungs
try to conserve carbon dioxide through shallow respirations.

Physical assessment of a client's fluid, electrolyte, and acidbase balance includes

examination of the skin, mucous membranes, cardiovascular and respiratory
systems, and neurological status. Data are correlated with the nursing history and
laboratory studies.

Intake and output (I&O) are monitored to assess fluid status. To monitor, measure all
fluids consumed and excreted in a 24-hour period.

Tests used to monitor fluid, electrolyte, and acidbase balance include

measurement of serum electrolytes and osmolality, complete blood count,
urinalysis, and measurement of arterial blood gases.

Nursing interventions for patients experiencing alterations in fluid, electrolyte, or

acidbase balance address preventing imbalances, modifying oral intake, providing
parenteral replacement, and transfusing blood products.

Intravenous fluids are classified as isotonic, hypotonic, and hypertonic solutions,

according to how they compare to the osmolality of blood serum. Vascular access
devices may provide access to peripheral or central veins.
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Intravenous equipment consists of the IV catheter, an administration set, extension

tubing, and the IV solution.

Nurses are responsible for maintaining the correct rate of flow and for monitoring
the client's response to the infusion.

Calculate the drip rate by multiplying the number of milliliters to be infused in 60

minutes (hourly rate) by the drop factor in drops per milliliter and then dividing by
60 minutes. For example, an hourly rate of 100 mL multiplied by 15 drops/mL and
divided by 60 minutes equals the drip rate. Therefore, the drip rate equals 25 drops
per minute. Use this formula to calculate flow:

Hourly rate in mls (drops/mL)

(drops/mL)

60 minutes
Local complications at the IV site include infiltration, extravasation, infection,
thrombus, and thrombophlebitis. Systemic complications include fluid volume
excess, sepsis, and embolus. Systemic complications occur less frequently than local
complications but may be life-threatening.

Meticulous aseptic technique is required for initiation and care of intravenous

infusions, especially when using central venous catheters, which are associated with
higher bloodstream infection rates.

Blood products are infused when the client has experienced significant blood loss,
diminished oxygen-carrying capacity, or a deficiency in one of the blood
components.

Chapter 39
NCLEX-Style Review Questions Answers

1. A patient was brought to the emergency department with complaints of extreme

fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the
following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dl; Mg2+ = 1.6

1)
2)
3)
4)

mg/dL; and Cl = 96 mEq/L. The electrocardiogram (ECG) tracing

has a flat T wave and frequent PVCs (premature ventricular contractions). The
patient's prescribed daily oral medications include furosemide 20 mg, digoxin
0.25 mg, and aspirin 81 mg. The nurse recognizes that these symptoms and
diagnostic information are consistent with which of the following?
Hypocalcemia
Hypernatremia
Hypokalemia
Hypermagnesemia
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315 Test 3
Answer:
3) Hypokalemia
Rationale:
The serum potassium level is low (norm = 3.5 to 5.0 mEq/L). PVCs related to cardiac
irritability and a flat T wave on an ECG are also indicative of hypokalemia. The
patient takes furosemide (Lasix), a diuretic that can induce hypokalemia.
2.

A patient was brought to the emergency department with complaints of

extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the
following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dL; Mg2+ = 1.6
mg/dL; and Cl = 96 mEq/L. The electrocardiogram (ECG) tracing
has a flat T wave and frequent PVCs (premature ventricular contractions). The
patient's prescribed daily oral medications include furosemide 20 mg, digoxin
0.25 mg, and aspirin 81 mg. Why might the nurse question the order for
digoxin 0.25 mg orally daily?
.
1) Based on the digoxin level, the dose may need to be
increased.

2) The patient is at risk for an elevated digoxin level at this time.

3) Digoxin and furosemide should never be taken together.

4) The nurse should not be concerned about the order as written.

Answer:
2) The patient is at risk for an elevated digoxin level at this time.
Rationale:
The hypokalemic patient on digoxin is at high risk for digoxin toxicity. The patient's
serum digoxin level will need to be assessed as she receives potassium
supplementation. Digoxin and furosemide can be taken together.
3. Which of the following is considered a first-line intravenous solution for a patient
with hypovolemia?
.
1) 0.9% NaCl (normal saline)
.
2) 0.45% NaCl (1/2 normal saline)
.
3) Dextran (a plasma expander)
.
4) D5W (5% dextrose in water)
Answer:
1) 0.9% NaCl (normal saline)
Page 14 of 29

315 Test 3
Rationale:
Hypovolemia occurs when there is a proportional loss of water and electrolytes from
the extracellular fluid. Normal saline is an isotonic fluid that remains inside the
intravascular space, thus increasing volume. Solutions of 0.45% NaCl and D5W are

hypotonic fluids and therefore would pull body water from the intravascular
compartment into the interstitial fluid compartment, leading to cellular death. Dextran
is a hypertonic fluid that pulls fluid and electrolytes from the intercellular and
interstitial compartments into the intravascular compartment and can be used in cases
of hypovolemia but is not considered as a first choice.
4. A physician has prescribed 1,000 ml of 0.9% NaCl (normal saline) over 4 hours for a
hypovolemic patient. The drop (gtt) factor is 60. What would the nurse set the drip
rate at?
.
1) 75 gtt/min
.
2) 100 gtt/min
.
3) 250 gtt/min
.
4) 500 gtt/min
Answer:
3) 250 gtt/min
Rationale:
Calculate the drip rate by multiplying the hourly rate by the drop factor in drops/mL
divided by 60 min. An infusion of 1,000 mL over 4 hours yields an hourly rate of 250
mL.
250 ml (hourly rate) 60 (gtt/mL)
= 250 gtt/min
60 min
5. A patient is to receive two units of packed red blood cells. Her blood group is O+.
The nurse knows that the patient may receive blood from which of the following
donors?
.
1) AB+, A, B+, and O
.
2) A+ and O+
.
3) AB and O+
.
4) O+ and O
Answer:
4) O+ and O
Rationale:

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315 Test 3
Persons with O+ blood may receive O+ or O-. Blood group O persons are considered
"universal donors." Rh+ persons may receive Rh+ and Rh blood. Persons who are Rh
may receive only Rh blood.
6. A patient has been admitted to the hospital with medical diagnoses of
hypervolemia, acute renal failure, and cardiac dysrhythmias. The patient's vital signs
are the following: T = 98.4F (36.9C); P = 110 beats/min; R = 32 breaths/min; BP =
162/102 mm Hg. On physical examination the nurse notes distended neck veins and
3+ pitting edema in both lower extremities. The patient reports he has been drinking
and eating as usual but has been
distended neck veins and 3+ pitting edema in both lower extremities. The patient
reports he has been drinking and eating as usual but has been unable to urinate.
Which is the most appropriate nursing diagnosis for this patient?
.
1) Excess Fluid Volume related to excessive food and fluid intake
.
2) Deficient Fluid Volume related to increased metabolic demands
.
3) Imbalanced Electrolytes secondary to fluid shifts
.
4) Excess Fluid Volume secondary to acute renal failure
Answer:
4) Excess Fluid Volume secondary to acute renal failure
Rationale:
This patient is experiencing Excess Fluid Volume secondary to acute renal failure.
There is no indication that he has engaged in excessive food or fluid intake. There is no
laboratory result to indicate an electrolyte imbalance, although his test results will most
likely demonstrate abnormalities because of the acute renal failure.
7. A patient is in respiratory distress. The physician has ordered arterial blood gases
(ABGs). The results are the following: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. How
should the nurse interpret the ABGs?
.
1) Respiratory acidosis
.
2) Respiratory alkalosis
.
3) Metabolic acidosis
.
4) Metabolic alkalosis

Answer:
2) Respiratory alkalosis
Rationale:
The ABGs are consistent with respiratory alkalosis. The pH is elevated, indicating
alkalosis. The PCO2 is decreased, which is also consistent with alkalosis. The HCO3 is
within normal range.

Page 16 of 29

315 Test 3

8. For a patient in respiratory distress, the first arterial blood gases (ABGs) were the
following: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. The ABGs were repeated the
next morning. The new results are the following: pH = 7.47; PCO2 = 26 mmol/L;
HCO3 = 28 mEq/L. The nurse recognizes that the values
have changed and that the patient is now experiencing
.
1) respiratory acidosis.
.
2) metabolic alkalosis.
.
3) partial compensation.
.
4) complete compensation.

Answer:
3) partial compensation.
Rationale:
Although the pH remains alkalotic, the bicarbonate level has begun to rise to
compensate for the low PCO2. Complete compensation occurs when the pH returns to
normal.

9. The nurse is discontinuing a central venous access device. When she removes the
catheter, she notes that a portion of the tip is missing. What action must she take?
.
1) Apply a tourniquet above the site.
.
2) Start a new peripheral IV.
.
3) Apply warm compresses to the site.
.
4) Notify the physician and radiologist.
Answer:
4) Notify the physician and radiologist.
Rationale:
Loss of the catheter tip places the patient at risk for an embolus. Because the catheter
was in a central vein, it is not possible to place a tourniquet above the site. Warm
compresses are appropriate follow-up care for IV extravasation or infiltration. A new
peripheral IV may be needed, but this is not the priority. The nurse must notify the
physician and radiologist.
10. The student nurse is reviewing a patient's laboratory reports. Which of the
following results should be reported to the primary care provider?
1) Na+ = 126 mEq/L
2) K+ = 3.8 mEq/L
3) Ca2+ = 9.2 mg/dL
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315 Test 3
4) Mg2+ = 1.8 mg/dL
Answer:
1) Na+ = 126 mEq/L
Rationale:
Serum sodium of 126 mEq/L indicates significant hyponatremia. The student nurse
should report the findings to the nurse with whom she is working (or the primary care
provider, depending on agency policy) who will report the findings to the primary care
provider. The other laboratory results are all within normal limits.

Page 18 of 29

Knowledge Map

Fluid Volume
Deficit:

Output

Hypovolemia
Dehydration

Intake

Hormonal
Regulation

Imbalances

Fluid Volume
Excess:
Regulation

Hypovolemia
Fluid overload

Excesses or deficits
in the ICF or ECF
Imbalances

Interstitial
Intravascular
Transcellular

ICF:

Locations

Movement
Active transport
Passive transport;
osmosis, diffusion,
and filtration

Body
Fluids
Maintain blood
volume
Regulate
temperature
Cellular transport/
metabolism
Digestion/excretion

Functions

Skin, mucous
membranes, CV,
neuro, respiratory
Vital signs
Weight/I&O
Labs/ABGs

Functions

Homeostasis:
Balance

AcidBase

Nursing
Care
Assessment

Electrolytes

Prevention

Parenteral

Regulation

ECF:
Na , chloride,
bicarb,
albumin

Fluid volume
Impulse conduction
Muscle contraction
Acidbase balance
Cellular activity/
metabolism

Imbalances

Acid:

Buffers:

Acidosis:

H donor

Carbonic acid/bicarb
Phosphate system
Protein system

Respiratory
Metabolic

Respiratory:

Respiratory
Metabolic

Base:
H acceptor
Dietary changes
Oral electrolyte
supplements
Facilitate fluid
restriction or intake

K , Mg,
phosphate,
sulfate

Carbon dioxide
Retention/elimination

Renal:
Conserve/excrete
bicarb
Ammonium formation

Alkalosis:

315 Test 3
Chapter 37 Oxygenation

The structures of the airways, lungs, chest cavity, heart, and blood vessels function
together to supply oxygen to the tissues; thus, abnormalities in any of these
structures can interfere with tissue oxygenation.

Developmental stage, environment, individual characteristics, lifestyle, medications,

and pathological factors can interfere with ventilation, circulation, or gas exchange,
leading to problems with tissue oxygenation.

A health assessment related to oxygenation includes assessment of ventilation

(breathing), circulation (blood flow), and gas exchange (exchange of oxygen and
carbon dioxide). The length and focus of the assessment vary with the purpose and
urgency of the clinical situation.

A physical examination related to adequacy of oxygenation includes observations

of adequacy of breathing, circulation, and gas exchange.

Pulse oximetry and arterial blood gases are used to monitor oxygen saturation.

Small changes in oxygen saturation are associated with large shifts in the amount of
oxygen available to the tissues and organs.

Interventions to promote optimal respiratory function include deep regular

breathing, flu and pneumonia immunizations for at-risk individuals, frequent
position changes, incentive spirometry, and preventing aspiration.

Deep breathing, coughing exercises, and hydration promote deep inhalation and
forceful expulsion of secretions.

Supplemental oxygen is used to prevent hypoxemia. It may be delivered by a

variety of methods.

Artificial airways provide an open airway for patients who cannot maintain their own
airway. The most common artificial airways are oropharyngeal, nasopharyngeal, and
endotracheal.

Airways can be suctioned to remove secretions and maintain patency. Signs that
indicate the need for suctioning include gurgling sounds during respiration,
restlessness, labored respirations, decreased oxygen saturation, increased heart
and respiratory rates, and the presence of adventitious breath sounds during
auscultation.

Mechanical ventilation with a positive pressure ventilator requires the patient to

have an artificial airway.

Chest tubes remove air or fluid from the pleural space so that the lungs can fully
expand. Chest tubes should be clamped only for changing the drainage system;
clamping can lead to tension pneumothorax.
Page 19 of 29

Knowledge Map
Airways
Upper
Lower
Trachea
bronchial tree
Lungs
Alveoli
Surfactant
Pleura

Ventilation
Inhalation
Exhalation

Oxygenation

Respiration
External
Internal

Factors Affecting
Developmental stage
Environment
Stress
Lifestyle: occupation, pregnancy
nutrition, obesity; exercise;
smoking, substance abuse
Medications

Pulmonary/Lung
Component

Structural abnormalities
Airway inflammation/
obstruction
Infection
Alveolar-capillary
membrane disorders
Atelectasis
Pulmonary embolus
Pulmonary hypertension

Caused by

Promoting optimum
respiratory function

Immunization/Screening
Influenza, pneumonia,
tuberculosis
Prevent URIs
Position for maximum
ventilation
Teach/assist with incentive
spirometry
Implement aspiration
precautions
Mobilize Secretions
Cough/deep breathe;
hydration; chest PT
Supplemental oxygen
CPR
Pharmacotherapy

Alterations in
Oxygenation
Hypoxemia
Hypoxia
Hypercarbia/capnia
Hypocarbia/capnia

Nursing

Assessments
Breathing pattern
Cough
Respiratory effort: retractions,
orthopnea, dyspnea, stridor
Advantitious breath sounds
Pulse oximetry

Artificial Airway Management

Oropharyngeal; nasopharyngeal; endotracheal; tracheostomy
Care includes maintaining placement; suctioning
Mechanical Ventilation
Intubaton; maintaining proper settings; troubleshooting problems
Can be used long term in home settings
Chest Tubes
Monitor breathing/gas exchange and drainage
Keep drainage system intact and functioning properly
Promote lung reexpansion
Prevent tension pneumothorax; recollapse of lung

315 Test 3

Respiratory medications promote ventilation and oxygenation by their effects on the

respiratory system. The major types of respiratory medicines include
bronchodilators, corticosteroids, cough preparations, decongestants,
antihistamines, and mucolytics.

NCLEX-Style Review Questions Answers

1. In what structure of the pulmonary system does inhaled air come in contact with
the blood of the pulmonary circulation? 1) Apex of the lungs
2) Alveolar-capillary membrane
3) Cilia in the bronchi
4) Right and left main-stem bronchi
Answer:
2) Alveolar-capillary membrane
Rationale:
The lungs are composed of millions of alveoli. The alveoli are tiny air sacs with thin
walls surrounded by a fine network of capillaries. Gases easily pass back and forth
between the alveoli and capillaries. It is at the alveolar-capillary membrane that
inhaled air comes in contact with the blood of the pulmonary circulation.
2. Respiratory function involves, in addition to the respiratory system, which three
body systems?
1) Neurological
2) Endocrine
3) Cardiovascular
4) Musculoskeletal
Answer:
1, 3, & 4) Neurological, cardiovascular, and musculoskeletal
Rationale:
The musculoskeletal and neurological systems regulate the movement of air into and
out of the respiratory system. The cardiovascular system transports oxygen and
carbon dioxide, which are exchanged in the lungs.
3. The nurse is caring for an adolescent with a history of asthma. The patient is
currently being treated for acute bronchitis. A thorough nursing assessment of
the patient's pulmonary status will include: Select all that apply.
.
1) Skin color
.
2) Temperature
.
3) Auscultation of breath sounds
.
4) Testing of cough reflex
Page 20 of 29

315 Test 3
.
Answer:
.
.
.

5) Chest x-ray

1) Skin color
2) Temperature
3) Auscultation of breath sounds

Rationale:
Auscultation of the lungs will detect any adventitious breath sounds (e.g., wheezing)
that may be present with asthma and bronchitis. Evaluations of skin color and
temperature are indirect methods to assess tissue oxygenation. A chest x-ray
requires a physician order and is not a part of the nursing assessment. The
cough reflex should be assessed in clients with decreased levels of
consciousness.
4. What assessment findings might the nurse expect to see in a patient experiencing
hypoxia? Select all that apply.
.
1) Altered level of consciousness
.
2) Peripheral pitting edema
.
3) Cyanosis of skin and mucous membranes
.
4) Weak or absent peripheral pulses
.
5) Jaundiced sclera
Answer:
1) Altered level of consciousness
3) Cyanosis of skin and mucous membranes
Rationale:
Hypoxia leads to decreased oxygenation of organs and tissues. To determine
adequacy of tissue oxygenation, you must assess both circulation and tissue/organ
function. An altered level of consciousness may result from hypoxic central nervous
system tissue. Poor peripheral circulation is characterized by weak or absent pulses;
pale, ashen, or cyanotic skin and mucous membranes; and cool skin temperature.
Peripheral edema does not result from hypoxia.
5. Which of the following goals is appropriate for a client without underlying
cardiopulmonary disease who is being monitored with continuous pulse oximetry?
.
1) Patient will refrain from movement while monitored in order to ensure
accurate readings.
.
2) Oxygen saturation will remain at 80% to 90% during hospitalization.

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315 Test 3
.
.

3) Patient will report pain as less than 3 on a scale of 1 to 10 during

monitoring.
4) Oxygen saturation will remain at 95% to 100% while monitored.

Answer:
4) Oxygen saturation will remain at 95% to 100% while monitored.
Rationale:
Normal oxygen saturation is 95% to 100%. Values of 94% or less are considered
abnormal in healthy people and should be investigated to determine the cause.
Although movement may affect oximetry monitoring, it is essential that patients move
and turn in order to prevent atelectasis. Pulse oximetry is a noninvasive form of
monitoring that involves placing a probe on a part of the body where capillary blood
flow is near the surface (e.g., a nail bed, earlobe, nose, or forehead). It does not cause
pain.
6. A 45-year-old woman presents to the emergency department with complaints of
shortness of breath, anxiety, dizziness, and numbness and tingling around her mouth.
Her respirations are deep, at a rate of 28 breaths/min. Her lungs are clear with good
aeration throughout. Oxygen saturation is 100%. An arterial blood gas shows a PO2
of 110 and PCO2 of 29 mm Hg. Based on this assessment, an appropriate nursing
diagnosis would be:
.
1) Ineffective Airway Clearance
.
2) Decreased Cardiac Output
.
3) Impaired Gas Exchange
.
4) Hypocarbia
Answer:
3) Impaired Gas Exchange
Rationale:
Hypocarbia (hypocapnia) is a low level of dissolved CO2 in the blood because of
hyperventilation. In most cases, blood oxygen levels remain normal. Severe
hypocarbia stimulates the nervous system, leading to muscle twitching or spasm
(especially in the hands and feet) and numbness and tingling in the face and lips. This
patient is experiencing hypocarbia; however, this is a medical diagnosis. A
corresponding nursing diagnosis is Impaired Gas Exchange. A person with Impaired
Gas Exchange may very well be anxious. However there are no defining characteristics
given for Anxiety in this scenario, nor for Decreased Cardiac Output or Ineffective
Airway Clearance.

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315 Test 3
7. The nurse is caring for an older adult woman who was admitted 3 days ago
following a cerebrovascular accident. She has had trouble swallowing and has been
placed on aspiration precautions. Care of this patient will include the following: Select
all that apply.
.
1) Ensure she is sitting upright or with the head of the bed elevated to eat and
drink.
.
2) Break or crush her pills (if appropriate) before administration.
.
3) Provide only thin, clear liquids.
.
4) Keep suction setup available at all times.
Answer:
1) Ensure she is sitting upright or with the head of the bed elevated to eat and drink.
2) Break or crush her pills (if appropriate) before administration.
4) Keep suction setup available at all times.
Rationale:
Aspiration is a risk for patients with a decreased level of consciousness, diminished
gag or cough reflex, or difficulty with swallowing. You should keep suction setup
available for routine and emergency use. Keeping the head of the bed elevated will
also help to prevent aspiration. Breaking or crushing pills will make it easier for her to
swallow her medications. Thin, clear liquids are more likely to be aspirated than are
thickened liquids, and there is no indication for clear liquids.
8. While caring for a young adult on a mechanical ventilator, the ventilator alarms
sound. On entering the patient's room, the nurse notes that he is agitated and his skin
is ashen and diaphoretic. His pulse oximetry shows an oxygen saturation of 78%. The
nurse is unable to identify any obvious mechanical problems with the ventilator. The
first step the nurse should take is to:
.
1) assess his breath sounds.
.
2) call the respiratory therapist to troubleshoot the problem.
.
3) manually ventilate him with an Ambu-bag.
.
4) contact the physician.
Answer:
3) manually ventilate him with an Ambu-bag.
Rationale:
All the actions listed are appropriate and necessary. However, if you cannot quickly
identify and correct a problem with the ventilator, you must ensure adequate
ventilation until the problem can be identified and corrected. Your immediate
response should be to manually ventilate the patient with an Ambu-bag. Your

Page 23 of 29

315 Test 3
colleagues should assist you by troubleshooting the problem, assessing breath
sounds, and notifying the physician.

Page 24 of 29

Knowledge Map
Airways
Upper
Lower
Trachea
bronchial tree
Lungs
Alveoli
Surfactant
Pleura

Ventilation
Inhalation
Exhalation

Oxygenation

Respiration
External
Internal

Factors Affecting
Developmental stage
Environment
Stress
Lifestyle: occupation, pregnancy
nutrition, obesity; exercise;
smoking, substance abuse
Medications

Pulmonary/Lung
Component

Structural abnormalities
Airway inflammation/
obstruction
Infection
Alveolar-capillary
membrane disorders
Atelectasis
Pulmonary embolus
Pulmonary hypertension

Caused by

Promoting optimum
respiratory function

Immunization/Screening
Influenza, pneumonia,
tuberculosis
Prevent URIs
Position for maximum
ventilation
Teach/assist with incentive
spirometry
Implement aspiration
precautions
Mobilize Secretions
Cough/deep breathe;
hydration; chest PT
Supplemental oxygen
CPR
Pharmacotherapy

Alterations in
Oxygenation
Hypoxemia
Hypoxia
Hypercarbia/capnia
Hypocarbia/capnia

Nursing

Assessments
Breathing pattern
Cough
Respiratory effort: retractions,
orthopnea, dyspnea, stridor
Advantitious breath sounds
Pulse oximetry

Artificial Airway Management

Oropharyngeal; nasopharyngeal; endotracheal; tracheostomy
Care includes maintaining placement; suctioning
Mechanical Ventilation
Intubaton; maintaining proper settings; troubleshooting problems
Can be used long term in home settings
Chest Tubes
Monitor breathing/gas exchange and drainage
Keep drainage system intact and functioning properly
Promote lung reexpansion
Prevent tension pneumothorax; recollapse of lung

315 Test 3
Chapter 32 Pain

Pain is whatever the person says it is and exists whenever the person says it does.

Pain has a protective function, warning us of potential or actual tissue damage and
prompting us to take action.

Pain can be classified by its origin, cause, duration, and quality.

Pain begins when mechanical, thermal, or chemical stimuli activate nociceptors,

which send pain impulses to the spinal cord.

Fast-pain impulses are carried on large-diameter A-delta fibers, whereas slow-pain

impulses are carried on thinner C fibers.

Perception of pain occurs in the frontal cortex of the brain.

Pain can be modulated by the endogenous analgesic system or by the gate-control

mechanism.

Some of the factors that influence pain are emotional factors, lifespan variations,
past pain experiences, sociocultural factors, inability to communicate, and cognitive
impairment.

Serious physiological as well as psychological problems can result from unrelieved

pain.

Nonpharmacological pain relief measures include cutaneous stimulation,

immobilization, and cognitivebehavioral intervention.

Pharmacological measures include nonopioid analgesics, opioid analgesics, and

adjuvant analgesics.

Local and regional anesthesia, nerve blocks, and ablation therapy can relieve shortand long-term pain.

Surgical interruption of pain conduction pathways is an option for intractable pain.

Options depend on the type and location of pain.

Opioid addiction among individuals being treated for pain is rare.

Pain should be considered the fifth vital sign and assessed when the patient is
admitted to a healthcare facility, with each vital signs check, before and after an
intervention, and when the patient complains of pain.

The patient's self-report is the most reliable indicator of pain, especially for those
suffering chronic pain.

Misconceptions about pain can interfere in pain management.

Older adults are at risk for undertreatment of pain.

Page 25 of 29

315 Test 3

Planning for the patient's pain management program includes discovering the
patient's own goals, educating the patient and family, and developing a nursing
plan of care.

It is important to assess continually the effectiveness of pain management

strategies.

NCLEX-Style Review Questions Answers

1. A 73-year-old patient who sustained a right hip fracture in a fall requests pain
medication from the nurse. Based on his injury, which type of pain is this patient most
likely experiencing?
.
1) Phantom
.
2) Visceral
.
3) Deep somatic
.
4) Referred
Answer:
3) Deep somatic
Rationale:
Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones.
Therefore, a hip fracture causes deep somatic pain. Phantom pain is pain that is
perceived to originate from a part that was removed during surgery. Visceral pain is
caused by deep internal pain receptors and commonly occurs in the abdominal cavity,
cranium, and thorax. Referred pain occurs in an area that is distant to the original site.
2. Which pain management task can the nurse safely delegate to nursing assistive
personnel?
.
1) Asking about pain during vital signs
.
2) Evaluating the effectiveness of pain medication
.
3) Developing a plan of care involving nonpharmacological interventions
.
4) Administering over-the-counter pain medications
Answer:
1) Asking about pain during vital signs
Rationale:
The nurse can delegate the task of asking about pain when nursing assistive personnel
(NAP) obtain vital signs. The NAP must be instructed to report findings to the nurse
without delay. The nurse should evaluate the effectiveness of pain medications and
develop the plan of care. Administering over-the-counter and prescription
medications is the responsibility of the registered nurse or licensed practical nurse.

Page 26 of 29

315 Test 3
3. Which factor in the patient's past medical history dictates that the nurse exercise
caution when administering acetaminophen (Tylenol)?
.
1) Hepatitis B
.
2) Occasional alcohol use
.
3) Allergy to aspirin
.
4) Gastric irritation with bleeding
Answer:
1) Hepatitis B
Rationale:
Even in recommended doses, acetaminophen can cause severe hepatotoxicity in
patients with liver disease, such as hepatitis B. Patients who consume alcohol regularly
should also use acetaminophen cautiously. Those allergic to aspirin or other
nonsteroidal anti-inflammatory drugs (NSAIDs) can use acetaminophen safely.
Acetaminophen rarely causes gastrointestinal (GI) problems; therefore, it can be used
for those with a history of gastric irritation and bleeding.
4. Which action should the nurse take before administering morphine 4.0 mg
intravenously to a patient complaining of incision pain?
.
1) Assess the patient's incision.
.
2) Clarify the order with the prescriber.
.
3) Assess the patient's respiratory status.
.
4) Monitor the patient's heart rate.
Answer:
3) Assess the patient's respiratory status.
Rationale:
Before administering an opioid analgesic, such as morphine, the nurse should assess
the patient's respiratory status because opioid analgesics can cause respiratory
depression. It is not necessary to clarify the order with the physician because morphine
4 mg IV is an appropriate dose. It is not necessary to monitor the patient's heart rate.
5. Which action should the nurse take when preparing patient-controlled analgesia
for a postoperative patient?
.
1) Caution the patient to limit the number of times he presses the dosing
button.
.
2) Ask another nurse to double-check the setup before patient use.
.
3) Instruct the patient to administer a dose only when experiencing pain.

Page 27 of 29

315 Test 3
.

4) Provide clear, simple instructions for dosing if the patient is cognitively

impaired.

Answer:
2) Ask another nurse to double-check the setup before patient use.
Rationale:
As a safeguard to reduce the risk for dosing errors, the nurse should request another
nurse to double-check the setup before patient use. The nurse should reassure the
patient that the pump has a lockout feature that prevents him from overdosing even if
he continues to push the dose administration button. The nurse should also instruct
the patient to administer a dose before potentially painful activities, such as walking.
Patient-controlled analgesia is contraindicated for those who are cognitively impaired.
6. The nurse administers codeine sulfate 30 mg orally to a patient who underwent
craniotomy 3 days ago for a brain tumor. How soon after administration should the
nurse reassess the patient's pain?
1) Immediately
2) In 10 minutes
3) In 15 minutes
4) In 60 minutes
Answer:
4) In 60 minutes
Rationale:
Codeine administered by the oral route reaches peak concentration in 60 minutes;
therefore, the nurse should reassess the patient's pain 60 minutes after administration.
The nurse should reassess pain after 10 minutes when administering codeine by the
intramuscular or subcutaneous routes. Drugs administered by the intravenous (IV)
route are effective almost immediately; however, codeine is not recommended for IV
administration.
7. Which nonsteroidal anti-inflammatory drug might be administered to inhibit
platelet aggregation in a patient at risk for thrombophlebitis?
.
1) Ibuprofen (Motrin)
.
2) Celecoxib (Celebrex)
.
3) Aspirin (Ecotrin)
.
4) Indomethacin (Indocin)
Answer:
3) Aspirin (Ecotrin)
Page 28 of 29

315 Test 3
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy
is commonly administered to decrease the risk of thrombophlebitis, myocardial
infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do
not inhibit platelet aggregation.
8. A client who is receiving epidural analgesia complains of nausea and loss of motor
function in his legs. The nurse obtains his blood pressure and notes a drop in his
blood pressure from the previous reading. Which complication is the patient most
likely experiencing?
.
1) Infection at the catheter insertion site
.
2) Side effect of the epidural analgesic
.
3) Epidural catheter migration
.
4) Spinal cord damage
Answer:
3) Epidural catheter migration
Rationale:
The patient is exhibiting signs of epidural catheter migration, which include nausea, a
decrease in blood pressure, and loss of motor function without an identifiable cause.
Signs of infection at the catheter site include redness, swelling, and drainage. Loss of
motor function is not a typical side effect associated with epidural analgesics. These
are common signs of catheter migration, not spinal cord damage.

Page 29 of 29

Knowledge Map
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Cause
Duration

Origin

Factors
Influencing
Pain

Classified
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Definitions

Pain
Management

Pain

Physiology
of Pain

Transduction:
Nonpharmacologic:

Pharmacologic:
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Transmission:
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Nursing Considerations
in Pain Management:
Use of

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Perception:
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Nursing Assessment: Pain

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