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Ngoại page 1-26

Total questions: 155

Worksheet time: 1hrs 18mins

Name
Class
Date
1.

Non mechanical obstruction is also known as paralytic ileus or adynamic ileus. Select True or False.

a)

True

b)

False

2.

Hypovolemia is a common complication of intestinal obstruction. Select True or False.

a)

True

b)

False

3.

An obstruction high in the small intestine often results in metabolic acidosis. Select True or False.

a)

True

b)

False

4.

Intussusception is twisting of the intestine. Select True or False.

a)

True

b)

False

5.

Volvulus is telescoping of a segment of the intestine within itself. Select True or False.

a)

True

b)

False

6.

Hypokalemia is the most common electrolyte disturbance that predisposes the patient to intestinal obstruction. Select True or False.

a)

True

b)

False

7.

Intestinal obstruction due to phytobezoar is a mechanical obstruction. Select True or False.

a)

True

b)

False

8.

Ileus is a paralytic or functional variety of obstruction. Select True or False.

a)

True

b)

False

9.

In order, the main clinical signs of bowel obstruction include nausea or vomiting, colicky abdominal pain, and blockage of gas or stool. Select True or False.

a)

True

b)

False

10.

Nausea and vomiting may be caused from anesthetic agents or narcotics, delayed gastric emptying, slowed peristalsis, resumption of oral intake too soon after surgery. Select True or False.

a)

True

b)

False

11.

Which key feature does the nurse most likely find when performing a physical assessment on the patient with a small-bowel obstruction?

a)

Visible peristaltic waves in the upper and middle abdomen.

b)

Minimal or no vomiting.

c)

No major fluid and electrolyte imbalances.

d)

Metabolic acidosis.

12.

Crohn’s disease can cause mechanical obstruction. Select True or False.

a)

True

b)

False

13.

What does nursing care of the patient with intestinal obstruction who reports discomfort in the early diagnostic period consist of?

a)

Administration of opioid analgesics.

b)

Placing the patient in a semi-Fowler’s position.

c)

Providing the patient with fluids.

d)

Offering the patient semi-soft food.

14.

Which intervention apply to patients with fluid volume deficit related to an intestinal obstruction?

a)

Provide frequent mouth care with lemon glycerin swabs.

b)

Offer ice chips to suck on before surgery.

c)

Offer a small glass of water.

d)

Assess for edema from third spacing.

15.

Which observation of the patient with an intestinal obstruction does the nurse report immediately?

a)

Urinary output of 1000 ml in an 8 hour period.

b)

The patient’s request for something to drink.

c)

Abdominal pain changing from colicky to constant discomfort.

d)

The patient who is changing positions frequently.

16.

Which discharge information does the nurse include for the patient who has had an intestinal obstruction caused by fecal impaction?

a)

Encourage the patient to report abdominal distention, nausea or vomiting, and constipation.

b)

Provide the patient a written description of a low-fiber diet.

c)

Remind the patient to limit activity.

d)

Remind the patient to decrease fluid intake.

17.

The nurse is teaching the patient about colostomy care. Which information does the nurse include in the teaching plan?

a)

The stoma will enlarge within 6 to 8 weeks of surgery.

b)

Use a moisturizing soap to cleanse the area around the stoma.

c)

Place the colostomy bag on the skin when the skin sealant is still damp.

d)

An antifungal cream or powder can be used if a fungal rash develops.

18.

Which statement about the care of the patient with a colostomy is correct?

a)

A healthy stoma should be dry.

b)

The stoma should protrude about 5 cm from the abdominal wall.

c)

When palpating the stoma, it should feel firm.

d)

A slight amount of edema is normal in the initial postoperative period.

19.

The nurse immediately reports to surgeon all but which sign/symptom related to a colostomy?

a)

Liquid stool immediately postoperatively.

b)

Unusual bleeding.

c)

Signs of ischemia and necrosis.

d)

Mucocutaneous separation.

20.

After colostomy surgery, which intervention does the nurse employ?

a)

Cover the stoma with a dry, sterile dressing.

b)

Apply a pouch system as soon as possible.

c)

Make a hole in the pouch for gas to escape.

d)

Watch for the colostomy to start functioning day 1.

21.

Patients with pancreatitis often have Turner's sign which is a gray-blue discoloration of the abdomen and periumbilical area. Select True or False.

a)

True

b)

False

22.

The pain of acute pancreatitis is often described as intense, boring and continuous. Select True or False.

a)

True

b)

False

23.

Typically, a patient is diagnosed with acute pancreatitis after presenting with severe abdominal pain in the mid-epigastric area or left upper quadrant. Select True or False.

a)

True

b)

False

24.

Abdominal pain is the prominal symptom of pancreatitis. Select True or False.

a)

True

b)

False

25.

Anticholinergics are given to increase vagal stimulation, motility and pancreatic flow. Select True or False.

a)

True

b)

False

26.

Pain management for acute pancreatitis should begin with rapid infusion of opioids by means of patient-controlled analgesia (PCA). Select True or False.

a)

True

b)

False

27.

Helping the patient to assume a supine position decreases the abdominal pain of pancreatitis. Select True or False.

a)

True

b)

False

28.

Patients in the early stages of acute pancreatitis are usually maintained on NPO status. Select True or False.

a)

True

b)

False

29.

What is the priority nursing diagnosis for acute pancreatitis?

a)

Risk for deficient fluid volume related to abnormal and normal routines.

b)

Nausea related to pancreatic disease.

c)

Risk for infection related to necrotic pancreatic tissue.

d)

Acute pain related to biologic and injury agents.

30.

Which diagnostic test is the most accurate in verifying a diagnosis of acute pancreatitis?

a)

Trypsine

b)

Lipase

c)

Alkaline phosphatase

d)

Alanine aminotransferase

31.

The patient with acute pancreatitis is at risk for the development of paralytic (adynamic) ileus. Which action provides the nurse with the best indication of bowel function?

a)

Observing contents of the nasogastric drainage

b)

Auscultation of bowel sounds

c)

Asking the patient if he or she has passed flatus or had a stool

d)

Obtaining a computed tomography (CT) scan of the abdomen with contrast medium

32.

Which drug is contraindicated for the patient with paralytic ileus?

a)

Ranitidine (Zantac)

b)

Cefuroxime (Zinacef)

c)

Papaverine (Pavabid)

d)

Dicyclomine (Bentyl)

33.

The nurse has instructed the patient in the recovery phase of acute pancreatitis about diet therapy. Which statement by the patient indicates that teaching has been successful?

a)

"I will eat the ususal three meals a day that I am used to".

b)

"I am eating tacos for my first meal back home".

c)

"I will avoid eating chocolate".

d)

"I will limit the amound of protein in my diet".

34.

The surgical intervention for acute pancreatitis may be indicated: If complications of pancreatitis such as pancreatic pseudocyst and abscess appear may necessitate surgical drainage.

a)

True

b)

False

35.

The surgical intervention for acute pancreatitis may be indicated: If pancreatitis is caused by biliary tract obstruction, the physician may perform a laparotomy (abdominal exploration) for common bile duct exploration and the release of obstruction.

a)

True

b)

False

36.

A postoperative plan of care for clients undergoing a surgical intervention: Monitors drainage tubes for patency by assessing for kinks in the tubes.

a)

True

b)

False

37.

A postoperative plan of care for clients undergoing a surgical intervention: Maintain the ordered drain suction pressure and system integrity.

a)

True

b)

False

38.

A postoperative plan of care for clients undergoing a surgical intervention: Records the output amount from the drain and describes the character of the drainage.

a)

True

b)

False

39.

A postoperative plan of care for clients undergoing a surgical intervention: Provides meticulous skin care and dressing changes, assesses for further deterioration of the tissue.

a)

True

b)

False

40.

A postoperative plan of care for clients undergoing a surgical intervention: Collaborate with an enterostomal therapist (ET) for measures to promote skin integrity.

a)

True

b)

False

41.

Peritonitis is caused by contamination of the peritoneal cavity by bacteria or chemicals.

a)

True

b)

False

42.

Continuous ambulatory peritoneal analysis can cause peritonitis.

a)

True

b)

False

43.

White blood cell counts are often decreased with peritonitis.

a)

True

b)

False

44.

Abdominal wall rigidity is a classic finding in patients with peritonitis.

a)

True

b)

False

45.

The fluid shift that occurs in peritonitis may result in which of following?

a)

Intracellular fluid moving into the peritoneal cavity

b)

Significant increase in circular volume

c)

Eventual renal failure and electrolyte imbalance

d)

Increased bowel motility caused by increased fluid volume

46.

The source of inflammation in peritonitis rarely comes from

a)

Gastrointestinal tract

b)

Internal reproductive organs

c)

The bloodstream

d)

Abdominal gunshot wound

47.

A rare cause of peritonitis is

a)

Appendicitis

b)

Perforated peptic ulcer

c)

Peritoneal dialysis

d)

Bowel perforation secondary to cancer, penetrating wound

48.

Which complication is not due to peritonitis:

a)

Adhesion of small intestine

b)

Abscess formation

c)

Intraabdominal haemorrhage

d)

Paralytic ileus

49.

The respiratory problems that may accompany peritonitis are a result of which factor?

a)

Associated pain interfering with ventilation

b)

Decreased pressure against the diaphragm

c)

Fluid shifts to thoracic cavity

d)

Decreased oxygen demands related to the infectious process

50.

Which nursing intervention is part of nonsurgical management for the patient with peritonitis?

a)

Monitor weekly weight and intake and output

b)

Insert a nasogastric tube to decompress the stomach

c)

Order a breakfast tray when the patient is hungry

d)

Administer NSAIDs for pain

51.

What are the cardinal signs of peritonitis?

a)

Fever and headache

b)

Dizziness and vomiting

c)

Abdominal pain and tenderness

d)

Nausea and loss of appetite

52.

Which character of abdominal pain is not observed in peritonitis

a)

Constant and diffuse

b)

Intermittent

c)

More intense near the site of inflammation

d)

Movement aggravates pain

53.

Which assessment is not priority in diagnostic of peritonitis

a)

Blood cell count

b)

Abdominal x-ray

c)

CT scan of the abdomen

d)

Peritoneal lavage

54.

Nursing intervention for the patient with peritonitis preoperatively don’t include

a)

Give broad-spectrum antibiotics

b)

Give foods when the patient arrive at hospital

c)

Place the patient on bed rest

d)

Obtain a history and assess the abdomen

55.

Nursing intervention for the patient with peritonitis postoperatively don’t include

a)

Assess vital signs

b)

Monitor the fluid and electrolyte balance

c)

Immobilize the patient on the bed

d)

Report any manifestation of sepsis

56.

The nurse is instructing the patient about home care after an exploratory laparotomy for peritonitis. Which statement by the patient indicates that teaching has been effective?

a)

“It is normal for the incision site to be warm”

b)

“I will stop taking the antibiotics if diarrhea develops”

c)

“I will call the health care provider for a temperature greater than 38°C”

d)

“I will resume activity with my bowling league this week for exercise”

57.

The patient is a 65-years-old man who sustained a neck injury during a fall. He has a medical diagnosis of anterior cord syndrome and a nursing diagnosis of Disturbed Sensory Perception. The nurse assesses the patient expecting to observe which type of motor and sensory findings below the level of injury?

a)

No motor functions; no sensation to touch, position, and vibration.

b)

Partial motor function; full sense of pain and temperature.

c)

Independent movement; no sense of pain or touch.

d)

No independent movement; full sense of touch or position.

58.

The patient with a cervical neck injury is able to spontaneously move the legs when attempting to move himself in bed, but he is not using or moving his arms or hands. What is this observation consistent with?

a)

Anterior cord syndrome.

b)

Posterior cord syndrome.

c)

Central cord syndrome.

d)

Brown-Sequard syndrome.

59.

The patient involved in a high-speed motor vehicle accident with sustained multiple injuries and active bleeding is transported to the emergency department by ambulance with immobilization devices in place. There is a high probability of cervical spine fracture; the patient has altered mental status and extremities are flaccid. What is the priority assessment for this patient?

a)

Check the mental status using the Glasgow Coma scale.

b)

Assess the respiratory pattern and ensure a patent airway.

c)

Observe for intra-abdominal bleeding and hemorrhage.

d)

Assess for loss of motor function and sensation.

60.

The emergency department nurse is assessing and monitoring the patient with a gunshot wound to the middle of the back. Because the patient is at risk for spinal shock, what does the nurse monitor for?

a)

Decreased blood pressure, bradycardia, and flaccid paralysis.

b)

Tachycardia and a change in the level of consciousness.

c)

Decreased respiratory rate and loss of sensation to pain and touch.

d)

Paralytic ileus and loss of bowel and bladder function.

61.

Which neurologic assessment technique does the nurse use to test the patient for proprioceptive function?

a)

Touch the skin with a clean safety pin and ask whether it is a sharp or dull sensation.

b)

Ask the patient to elevate both arms off the bed and extend wrists and fingers.

c)

Have the patient close the eyes and move the toes up or down; the patient identifies the positions.

d)

Have the patient sit with the legs dangling; use a reflex hammer to test reflex responses.

62.

The patient with an upper spinal cord injury is at risk for autonomic dysreflexia. Which nursing diagnosis is the priority for this patient?

a)

Risk for Ineffective Tissue Perfusion, Cerebral.

b)

Nausea.

c)

Acute Pain, Headache.

d)

Impaired Physical Mobility.

63.

The nurse is caring for the patient with a recent spinal cord injury (SCI). Which intervention does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia ?

a)

Frequently perform passive ROM exercises.

b)

Keep the room warm and control environmetal stimuli.

c)

Keep the patient immobilizied with neck back braces.

d)

Monitor urinary output and check for bladder distention.

64.

What is the potential adverse outcome of autonomic dysreflexia in the patient with a spinal cord injury?

a)

Heat stroke

b)

Paralytic ileus

c)

Hypertensive crisis

d)

Aspiration and pneumonia

65.

After suffering a spinal cord injury, the patient develops autonomic dysfunction, including a neurogenic bladder. Which nursing diagnosis is the priority for this condition?

a)

Risk for Infection: urinary tract

b)

Risk for Fluid Volume Deficit: polyuria

c)

Risk for Self‑Care Deficit: toileting

d)

Risk for Urinary Incontinence: urge

66.

The nurse and the nursing assistant are working together to bathe and reposition the patient who is in a halo fixator device. Which action by the nursing student causes the supervising nurse to intervene?

a)

Uses the log‑roll technique to clean the patient’s back and buttocks

b)

Turns the patient by pulling on the top of the halo device

c)

Positions the patient with the head and neck in alignment

d)

Supports the head and neck area during the repositioning

67.

The nurse is caring for several patients with spinal cord injuries. Which task is best to delegate to the nursing assistant?

a)

Encourage use of incentive spirometry; evaluate the patient’s ability to use it correctly

b)

Log‑roll the patient; maintain proper body alignment and place a bedpan for toileting

c)

Check for skin breakdown under immobilization devices during bathing

d)

Insert a Foley catheter and report the amount and color of the urine

68.

The patient with a spinal cord injury has paraplegia and paraparesis. The nurse has identified a nursing diagnosis of Impaired Physical Mobility. The nurse assesses the calf area of both legs for swelling, tenderness, or redness. The patient is at increased risk for which condition?

a)

Contractures of joints

b)

Bone fractures

c)

Pressure ulcers

d)

Deep vein thrombosis

69.

A patient who has been in a long‑term care facility for several months following a spinal cord injury has had issues with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. Which is an expected outcome of the training program?

a)

Demonstrates a predictable pattern of voiding

b)

Is able to independently catheterize himself

c)

Pours warm water over the perineum to stimulate voiding

d)

Takes bethanechol chloride (Urecholine) 1 hour before voiding

70.

Paralysis of lateral gaze indicates a lesion of cranial nerve

a)

II

b)

III

c)

IV

d)

VI

71.

A primary brain injury is caused by

a)

Increased intracranial pressure (ICP)

b)

An external force

c)

An abnormal growth of brain tissue

d)

An internal force

72.

A 16‑year‑old football player is confused after being struck in the head by another player. He states he does not remember much of what happened, just waking up in the hospital about two hours after being hit. This client most likely is suffering from

a)

Concussion

b)

Moderate brain injury

c)

Severe brain injury

d)

Locked‑in syndrome

73.

The nurse is educating a group of 7‑year‑old children on preventing brain injury. One of the most important things to tell them is to

a)

Always wear a helmet when riding your bike, skateboard, or inline skates

b)

Always wear knee and arm pads when riding your bike, skateboard, or inline skates

c)

Look both ways before crossing the street

d)

Always wear supportive shoes when playing outdoors

74.

A client is admitted to the intensive care unit following a fall down a flight of stairs. Upon assessment, the client responds only to pain by withdrawing his hand and he curses frequently. Using the Glasgow Coma Scale, the nurse rates this patient as

a)

15

b)

4

c)

12

d)

9

75.

A common medication given to help decrease intracranial pressure is

a)

Aspirin

b)

Ibuprofen

c)

Lasix

d)

Mannitol

76.

The most important nursing diagnosis when caring for a client with an open skull fracture is

a)

Risk for infection

b)

Risk for impaired skin integrity

c)

Risk for impaired physical mobility

d)

Risk for impaired swallowing: aspiration

77.

The consensual pupillary response is tested by

a)

Asking the client if he or she has trouble closing the eyes

b)

Directing a light toward one eye and observing the pupil on the opposite side

c)

Instructing the client to cover one eye while you observe the opposite eye for extraocular movements

d)

Evaluating the ability of the client’s eyes to converge

78.

Which factor is most likely to depress nerve cell activity in a patient with a neurologic disorder?

a)

Metabolic alkalosis

b)

IV infusion of theophylline

c)

Drinking too much coffee

d)

Low oxygen saturation and hypoxia

79.

Which statement about the Glasgow Coma Scale is correct?

a)

It is a thorough neurologic assessment tool

b)

It establishes a baseline for eye opening and motor and verbal response

c)

It establishes a baseline cognitive function

d)

A score of 15 indicates serious neurologic impairment with poor prognosis

80.

The nurse is assessing several patients using the Glasgow Coma Scale. Which factors indicate the most serious neurologic presentation based on the scale’s information?

a)

Eye opening to sound, localizes pain, confused conversation

b)

Eye opening to sound, obeys commands, inappropriate words

c)

Eye opening spontaneous, obeys commands, confused conversation

d)

Eye opening to pain, abnormal flexion, incomprehensible sounds

81.

The nurse performing neurologic checks every 4 hours for a patient who sustained a head injury notes which early sign indicating a decline in neurologic status?

a)

Nonreactive, dilated pupil

b)

Change in level of consciousness

c)

Decorticate posturing

d)

Loss of remote memory

82.

A nurse is caring for a client who was recently admitted to the emergency department following a head‑on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time?

a)

Keep neck stabilized

b)

Insert nasogastric tube

c)

Monitor pulse and blood pressure frequently

d)

Establish IV access and start fluid replacement

83.

A nurse is caring for a client who has just been admitted from surgery for the evacuation of a subdural hematoma. Which of the following is the priority assessment?

a)

Glasgow Coma Scale

b)

Cranial nerve function

c)

Oxygen saturation level

d)

Pupillary response

84.

A client who has increased intracranial pressure has been prescribed mannitol (Osmitol) IV. For which of the following side effects should the nurse monitor?

a)

Hyperglycemia

b)

Hyponatremia

c)

Hypervolemia

d)

Oliguria

85.

The lesions in the chest cage that can be seen in chest trauma include

a)

Pneumothorax, hemothorax, lung contusion, flail chest

b)

Lung contusion, flail chest, liver lesion

c)

Hemothorax, pneumothorax, lung contusion, femur fracture

d)

Flail chest, blood clots in the brain, intestinal rupture

86.

List six life‑threatening chest injuries in chest trauma

a)

Airway obstruction; tension pneumothorax; cardiac tamponade; open pneumothorax (sucking chest wound); flail chest; massive hemothorax

b)

Airway obstruction; tension pneumothorax; cardiac tamponade; open pneumothorax (sucking chest wound); flail chest; massive hemothorax

c)

Cardiac tamponade; open pneumothorax (sucking chest wound); clavicle fracture; airway obstruction; flail chest; rib fracture

d)

Airway obstruction; simple pneumothorax; cardiac tamponade; flail chest; massive hemothorax; pleural effusion

87.

Physical therapy of respiratory system should be taken

a)

Sitting up early, stimulates coughing, clapping shaking, breathing exercise (blowing balls)

b)

 Fowler posture, breathing exercise, stimulates coughing

c)

 Not eat and drink, stomach tube, blowing balls

d)

 Clapping shaking, stomach tube, completely immobile, infusion

88.

The most important issue when caring for patients after drainage of the pleural cavity:

a)

To ensure good nutrition for the patient, lying motionless

b)

Body hygiene, mental stability to patients

c)

The physical therapy as soon as possible and ensure good drainage system

d)

Antibiotics for patients, enhancing health, anti-pain

89.

Flail chest is:

a)

Rib fracture

b)

Fracture of two ribs and more

c)

Fracture of three ribs and more

d)

Fracture of three consecutive ribs and more, each fractured rib has two fracture positions

90.

The steps in the planning and implementation of care plans chest injuries, chest wounds and flail chest:

a)

Receiving patients, management of shock, prepare to drain pleural

b)

Prevention and management of shock, management of respiratory failure, control infection, make preparation for patient, prepare drainage of pleural

c)

Management of respiratory failure, control pain, prepare drainage of pleural, management of shock

d)

Management of shock, control infection, make preparation for patient, prepare drainage of pleural

91.

Monitor circulation need follow

a)

Monitor pulse, blood pressure, number of drainage, skin color, mucous, blood formula test; monitor bleeding at the other location & call doctor.

b)

Monitor breathing; chest tube, color skin, mucosa; ultrasound; monitor bleeding at the other location & call doctor.

c)

Monitor respiratory; chest tube, computerized tomography of chest, blood biochemical tests; monitor bleeding at the other location & call doctor.

d)

Monitor pulse, chest tube; respiration, blood tests, check the open chest wound.

92.

Counters skills of breathing per minute

a)

See the up and down mobile of chest per minute

b)

Listen to the lung sound per minute

c)

See the up and down mobile of abdominal wall per minute

d)

To hand on the abdominal wall and count the number of mobile of the abdominal wall per minute

93.

Chest trauma: operative indication in all cases

a)

T

b)

F

94.

Principles for chest tube: closed, continuous suction and one-way, sterile

a)

T

b)

F

95.

Respiratory physical therapy plays an important role in postoperative care to chest tube

a)

T

b)

F

96.

All flail chest cases are treated with mechanical ventilation method

a)

T

b)

F

97.

Rib fractures with chest tube, especially the elderly: respiratory physical therapy and nursing care is not required

a)

T

b)

F

98.

Pain symptom is always show in chest wounds

a)

T

b)

F

99.

Tension pneumothorax (valve pneumothorax) management of emergencies like the other type of pneumothorax

a)

T

b)

F

100.

Need replacement pleural drainage bottle daily for nursing care chest tube

a)

T

b)

F

101.

Clotted blood and retained haemothorax never show in the chest wound

a)

T

b)

F

102.

All chest wounds should always indicate operation to manage injuries

a)

T

b)

F

103.

Respiratory physical therapy need: patients always lie in bed and not be taken analgesics

a)

T

b)

F

104.

A nurse is caring for a client who has a compound fracture of the right forearm that was recently casted. Which of following is an early sign of neurovascular compromise?

a)

Paresthesia.

b)

Pulselessness

c)

Paralysis

d)

Polar.

105.

A nurse is stabilizing for a client who has a compound fracture of the right arm. Which did he/she have to do before?

a)

Elevate the limb and apply ice.

b)

Place the client in supine position.

c)

Cover open wounds with a sterile dressing.

d)

Remove clothing and jewelry near injury.

106.

Casts secure the arm fracture in order to:

a)

Prevent further injury, reduce pain, and promote circulation.

b)

Prevent further injury, reduce pain, and correct a deformity.

c)

Reduce pain, promote circulation, and correct a deformity.

d)

Prevent further injury, reduce pain, promote healing and correct a deformity.

107.

Use the short-arm cast for:

a)

Distal radial fracture.

b)

Fracture of ulna.

c)

Fracture of radia.

d)

Fracture of the thumb.

108.

Use the long-arm cast for:

a)

Fracture of humeral shaft.

b)

Fracture of distal humerus.

c)

Fracture of proximal humerus.

d)

Fracture of humeral head.

109.

The 3 disadvantages of external fixation for the arm, except:

a)

Pin site infection.

b)

Potential overwhelming appearance.

c)

Early mobilization.

d)

Noncompliance.

110.

A nurse is caring for client who had open reduction and internal fixation for the radius 7 days ago. Which of following is a sign of infection:

a)

Swelling at the site of incision.

b)

Erythema and edema at the site of incision.

c)

Loss of function.

d)

Loss of sensation.

111.

A nurse is caring for a client who has a fracture of the right forearm that was recently casted. The client complains of more pain after cast. What action should the nurse do?

a)

Remove cast and reassessment.

b)

Change another cast and reassessment.

c)

Loosening cast and reassessment.

d)

Remove cast and use another immobilizer.

112.

An indication of traction for the arm fracture exclude:

a)

Type of traction.

b)

Traction time.

c)

Traction weight.

d)

Pin site care.

113.

Traction is more effective than cast in:

a)

Decreasing pain.

b)

Decreasing muscle spasm.

c)

Preventing neurovascular injury.

d)

Promoting circulation.

114.

The most valuable sign to diagnose radius fracture is:

a)

Swelling.

b)

Crepitus.

c)

Pain.

d)

Tenderness.

115.

The most valuable sign to diagnose humerus fracture is:

a)

Loss of forearm function.

b)

Deformity of the arm.

c)

Arm bruising

d)

Swelling.

116.

The most effective of procedure to diagnose arm fracture is:

a)

Two view x-rays.

b)

Bone scan.

c)

MRI.

d)

Ultrasound.

117.

A nurse is caring for a client who has fracture of the right arm that was recently applied standard side-arm skeletal traction. The client complains of more pain after traction. What action should the nurse do?

a)

Maintain body alignment and realign.

b)

Remove weights.

c)

Stop traction.

d)

Give some analgesics to the client.

118.

A nurse is caring for a client who has fracture of the right arm that was recently applied standard side-arm skeletal traction. The client complains of severe pain after traction. What action should the nurse do?

a)

Reduce some weights of traction.

b)

Remove traction, apply cast.

c)

Notify this problem to provider.

d)

Give some analgesics and muscle relaxants to the client.

119.

What makes for displaced fractures?

a)

Large muscle groups spasm

b)

Disrupted muscles

c)

Fractures fragments

d)

Broken bone size

120.

How many stages occur during bone healing?

a)

4

b)

5

c)

6

d)

3

121.

What time period the stage 3 takes place?

a)

1–3 days

b)

3 days to 2 weeks

c)

2–6 weeks

d)

6 weeks to 1 years

122.

“Callus formation” occurs in:

a)

stage 1

b)

stage 2

c)

stage 3

d)

stage 4

123.

“Fibrocartilage formation” occurs in:

a)

stage 1

b)

stage 2

c)

stage 3

d)

stage 4

124.

Which of the following is the UNFAVORABLE factors for bone healing process?

a)

Minimal damage to soft tissue

b)

Anatomic reduction possible

c)

Effective immobilization

d)

Fragments widely separated

125.

Which of the following is the FAVORABLE factors for bone healing process?

a)

Fragments distracted by traction

b)

Severe comminuted fracture

c)

Bone loss from injury or surgical excision

d)

Anatomic reduction possible

126.

The following factors AFFECT the bone healing process, except:

a)

Weight bearing on long bones

b)

Location

c)

Sex

d)

Decreased blood supply

127.

Which of the following is the most significant signs of fracture?

a)

Bruising

b)

Muscle spasm

c)

Abnormal mobility and crepitus

d)

Pain

128.

Which of the following is the GOALS of medical management:

a)

Discover all injuries

b)

Reduction and stabilization of the fracture

c)

Monitoring for complications

d)

a+b+c

129.

Which of the following is INCORRECT?

a)

Assessment and treatment are performed simultaneously

b)

During primary assessment, the rescuer focuses on airway management, bleeding, and manifestations of the shock

c)

Any potentially life-threatening injuries must be stabilized immediately

d)

An injured client should be moved although the current location is not safe

130.

Which of the following is the GOALS of reduction?

a)

To restore alignment, position, and length

b)

To make sure that the bone have been broken

c)

To permit the client can walk

d)

To rescue the client from shock

131.

Which of the following is INCORRECT for closed reduction?

a)

To perform closed reduction, a health care provider applies manual traction to move the fracture fragments and restore bone alignment

b)

Closed reduction should be performed as soon as possible

c)

Fracture reduction is an emergency procedure

d)

An immobilization device must be applied after x-ray

132.

Which of the following is INCORRECT for closed reduction?

a)

The immobilizer most commonly used after closed reduction is a traction

b)

The immobilizer most commonly used after closed reduction is a cast

c)

The immobilizer most commonly used after closed reduction is a polymer of plaster

d)

Cast are used for prevention or correction of deformity; maintenance; support; and protection of realigned bone

133.

Which of the following is CORRECT for Open Reduction and Internal Fixation?

a)

The surgeon makes an incision and realigns the fracture fragments under direct visualization

b)

Realignment of the fracture fragments without any incision

c)

Open reduction is usually performed in combination with internal fixation by plates, screws, nails, wires

d)

Internal fixation provides essential immobilization and helps to prevent deformity, but it is not a substitute for bone healing

134.

Which of the following is NOT complication after fracture?

a)

Blood Vessel injury

b)

Nerve injury

c)

Brain-sick

d)

Compartment Syndrome

135.

Which of the following NEEDN’T in care of the client in a Cast?

a)

Neurovascular Assessment

b)

Assessment of Pain

c)

Assessment of the Cast

d)

Assessment of the Knee Movement

136.

Which statement best describes the preoperative period?

a)

It begins when the patient makes the appointment with the surgeon to discuss the need for surgery.

b)

It is the time during which the patient receives education and testing related to the impending surgery.

c)

It is a time during which the patient’s need for surgery and willingness to have it is established

d)

It begins when the patient is scheduled for surgery and ends at the time of transfer to the surgical suite.

137.

The patient is scheduled for resection of nerve roots. What type of surgery is this?

a)

Palliative

b)

Restorative

c)

Diagnostic

d)

Ablative

138.

Specify whether the urgency of the surgery is elective (EL), urgent (U), or emergent (EM): A 22-year-old nursing student is scheduled for an appendectomy.

a)

EL

b)

U

c)

EM

139.

Specify whether the urgency of the surgery is elective (EL), urgent (U), or emergent (EM): A 77-year-old woman is scheduled for a total knee replacement.

a)

EL

b)

U

c)

EM

140.

Specify whether the urgency of the surgery is elective (EL), urgent (U), or emergent (EM): A 55-year-old man is scheduled for a colon resection due to a small bowel obstruction.

a)

EL

b)

U

c)

EM

141.

The nurse screens the preoperative patient for conditions that may increase the risk for complications during the perioperative period. Which condition is a possible risk factor

a)

The patient is 70 years old and obese.

b)

The procedure planned is a bunionectomy.

c)

The patient is 5 feet tall and weighs 100 pounds.

d)

The surgery is planned as an ambulatory/same-day surgical procedure

142.

The nurse functions as the patient advocate by reporting to the surgeon and anesthesiology personnel any abnormalities found on the physical assessment.

a)

T

b)

F

143.

Throughout the physical assessment, the nurse focuses on the problem areas identified from the patient’s history that are limited to body systems affected directly by the surgical procedure.

a)

T

b)

F

144.

In the preoperative setting, the nurse is functioning as a patient advocate when the patient’s home environment, self-care capabilities, and support systems are assessed and used in the discharge planning process.

a)

T

b)

F

145.

As a patient advocate, the nurse can provide the patient with educational materials appropriate to the patient’s ability to learn.

a)

T

b)

F

146.

When the nurse evaluates preoperative laboratory test values, only abnormal values related to the surgery need to be reported to the surgeon and anesthesia personnel.

a)

T

b)

F

147.

Patients who have had minor outpatient surgery do not usually require discharge planning.

a)

T

b)

F

148.

Which statement is true regarding the patient who has given consent for a surgical procedure?

a)

Information necessary to understand the nature of and reason for the surgery has been provided.

b)

The length of stay in the hospital has been preapproved by the managed care provider.

c)

Information about the surgeon’s experience has been provided.

d)

The nurse has provided detailed information about the surgical procedure.

149.

Which statement best describes the collaborative roles of the nurse and surgeon when obtaining the informed consent?

a)

The nurse is responsible for having the in-formed consent form on the chart for the physician to witness.

b)

The nurse may serve as a witness that the patient has been informed by the physician before surgery is performed.

c)

The nurse may serve as witness to the patient’s signature after the physician has the consent form signed before preoperative sedation is given and before surgery is performed.

d)

The nurse has no duties regarding the consent form if the patient has signed the informed consent form for the physician, even if the patient then asks additional questions about the surgery.

150.

The nurse has received the patient in the holding area who is scheduled for a left breast biopsy. What is the priority safety measure for this patient before surgery?

a)

Ensure the patient knows who will be performing the surgery.

b)

Ask the patient to mark the site with a marker.

c)

Instruct the patient to perform leg exercises to prevent a deep vein thrombosis.

d)

Determine who the support persons are for the patient.

151.

The diabetic patient is scheduled for surgery in the morning. Which procedure does the nurse expect on the morning of surgery?

a)

Usual dose of insulin will be given to maintain the patient’s blood glucose level.

b)

Increased dose of insulin will be given to offset the physical stress caused by the procedure.

c)

Modified dose of insulin will be given, based on the patient’s blood glucose.

d)

No insulin will be given because the patient is NPO.

152.

What percentage of all hospital trauma admissions involve renal trauma?

a)

Approximately 3%.

b)

Approximately 10%.

c)

Approximately 13%.

d)

Approximately 20%.

153.

What is the key clinical symptom of the kidney trauma?

a)

 Flank pain

b)

Hematuria (gross or microscopic)

c)

Abdominal distention

d)

Fever

154.

What is the following finding on clinical examination indicating possible renal involvement ?

a)

 Fever

b)

Flank ecchymoses or abdominal mass

c)

Flank pain

d)

Abdominal distention

155.

True or False: The presence or absence of hematuria is not a good indicator of traumatic injury

a)

True

b)

False