Text Mode Text version of A. The palms and axillary C.

Explain how his being

the exam regions upset dangerously disturbs his
1. The nurse is assisting in planning B. Both feet placed wide need for rest
care for a client with a diagnosis of apart D. Attempt to explain the
immune deficiency. The nurse C. The palms of her hands purpose of different hospital
would incorporate which of the ff. as D. Her axillary regions routines
a priority in the plan of care? 7. Joey is a 46 year-old radio 13. Twenty four hours after
A. providing emotional technician who is admitted because admission for an Acute MI, Joses
support to decrease fear of mild chest pain. He is 5 feet, 8 temperature is noted at 39.3 C. The
B. protecting the client inches tall and weighs 190 pounds. nurse monitors him for other
from infection He is diagnosed with a myocardial adaptations related to the pyrexia,
C. encouraging discussion infarct. Morphine sulfate, Diazepam including:
about lifestyle changes (Valium) and Lidocaine are A. Shortness of breath
D. .identifying factors that prescribed. B. Chest pain
decreased the immune function The physician orders 8 mg of C. Elevated blood pressure
2. Joy, an obese 32 year old, is Morphine Sulfate to be given IV. D. Increased pulse rate
admitted to the hospital after an The vial on hand is labeled 1 ml/ 10 14. Jose, who is admitted to the
automobile accident. She has a mg. The nurse should administer: hospital for chest pain, asks the
fractured hip and is brought to the A. 8 minims nurse, Is it still possible for me to
OR for surgery. B. 10 minims have another heart attack if I watch
After surgery Joy is to receive a C. 12 minims my diet religiously and avoid
piggy-back of Clindamycin D. 15 minims stress? The most appropriate initial
phosphate (Cleocin) 300 mg in 50 8. Joey asks the nurse why he is response would be for the nurse to:
ml of D5W. The piggyback is to receiving the injection of Morphine A. Suggest he discuss his
infuse in 20 minutes. The drop after he was hospitalized for severe feelings of vulnerability with his
factor of the IV set is 10 gtt/ml. The anginal pain. The nurse replies that physician.
nurse should set the piggyback to it: B. Tell him that he certainly
flow at: A. Will help prevent erratic needs to be especially careful
A. 25 gtt/min heart beats about his diet and lifestyle.
B. 30 gtt/min B. Relieves pain and C. Avoid giving him direct
C. 5 gtt/min decreases level of anxiety information and help him
D. 45 gtt/min C. Decreases anxiety explore his feelings
3. The day after her surgery Joy D. Dilates coronary blood D. Recognize that he is
asks the nurse how she might lose vessels frightened and suggest he talk
weight. Before answering her 9. Oxygen 3L/min by nasal cannula with the psychiatrist or
question, the nurse should bear in is prescribed for Joey who is counselor.
mind that long-term weight loss best admitted to the hospital for chest 15. Ana, 55 years old, is admitted to
occurs when: pain. The nurse institutes safety the hospital to rule out pernicious
A. Fats are controlled in the precautions in the room because anemia. A Schilling test is ordered
diet oxygen: for Ana. The nurse recognizes that
B. Eating habits are altered A. Converts to an alternate the primary purpose of the Schilling
C. Carbohydrates are form of matter test is to determine the clients
regulated B. Has unstable properties ability to:
D. Exercise is part of the C. Supports combustion A. Store vitamin B12
program D. Is flammable B. Digest vitamin B12
4. The nurse teaches Joy, an obese 10. Myra is ordered laboratory tests C. Absorb vitamin B12
client, the value of aerobic after she is admitted to the hospital D. Produce vitamin B12
exercises in her weight reduction for angina. The isoenzyme test that 16. Ana is diagnosed to have
program. The nurse would know is the most reliable early indicator of Pernicious anemia. The physician
that this teaching was effective myocardial insult is: orders 0.2 mg of Cyanocobalamin
when Joy says that exercise will: A. SGPT (Vitamin B12) IM. Available is a vial
A. Increase her lean body B. LDH of the drug labeled 1 ml= 100 mcg.
mass C. CK-MB The nurse should administer:
B. Lower her metabolic D. AST A. 0.5 ml
rate 11. An early finding in the EKG of a B. 1.0 ml
C. Decrease her appetite client with an infarcted mycardium C. 1.5 ml
D. Raise her heart rate would be: D. 2.0 ml
5. The physician orders non-weight A. Disappearance of Q 17. Health teachings to be given to
bearing with crutches for Joy, who waves a client with Pernicious Anemia
had surgery for a fractured hip. The B. Elevated ST segments regarding her therapeutic regimen
most important activity to facilitate C. Absence of P wave concerning Vit. B12 will include:
walking with crutches before D. Flattened T waves A. Oral tablets of Vitamin
ambulation begun is: 12. Jose, who had a myocardial B12 will control her symptoms
A. Exercising the triceps, infarction 2 days earlier, has been B. IM injections are
finger flexors, and elbow complaining to the nurse about required for daily control
extensors issues related to his hospital stay. C. IM injections once a
B. Sitting up at the edge of The best initial nursing response month will maintain control
the bed to help strengthen would be to: D. Weekly Z-track
back muscles A. Allow him to release his injections provide needed
C. Doing isometric feelings and then leave him control
exercises on the unaffected leg alone to allow him to regain his 18. The nurse knows that a client
D. Using the trapeze composure with Pernicious Anemia
frequently for pull-ups to B. Refocus the understands the teaching regarding
strengthen the biceps muscles conversation on his fears, the vitamin B12 injections when she
6. The nurse recognizes that a frustrations and anger about states that she must take it:
client understood the demonstration his condition A. When she feels fatigued
of crutch walking when she places B. During exacerbations of
her weight on: anemia
C. Until her symptoms
subside
D. For the rest of her life
19. Arthur Cruz, a 45 year old artist,
has recently had an
abdominoperineal resection and
colostomy. Mr. Cruz accuses the
nurse of being uncomfortable during
a dressing change, because his
wound looks terrible. The nurse
recognizes that the client is using
the defense mechanism known as:
A. Reaction Formation
B. Sublimation
C. Intellectualization
D. Projection
20. When preparing to teach a client
with colostomy how to irrigate his
colostomy, the nurse should plan to
perform the procedure:
A. When the client would
have normally had a bowel
movement
B. After the client accepts
he had a bowel movement
C. Before breakfast and
morning care
D. At least 2 hours before
visitors arrive
21. When observing an ostomate do
a return demonstration of the
colostomy irrigation, the nurse notes
that he needs more teaching if he:
A. Stops the flow of fluid
when he feels uncomfortable
B. Lubricates the tip of the
catheter before inserting it into
the stoma
C. Hangs the bag on a
clothes hook on the bathroom
door during fluid insertion
D. Discontinues the
insertion of fluid after only 500
ml of fluid has been instilled
22. When doing colostomy irrigation
at home, a client with colostomy
should be instructed to report to his
physician :
A. Abdominal cramps
during fluid inflow
B. Difficulty in inserting the
irrigating tube
C. Passage of flatus during
expulsion of feces
D. Inability to complete
the procedure in half an hour
23. A client with colostomy refuses
to allow his wife to see the incision
or stoma and ignores most of his
dietary instructions. The nurse on
assessing this data, can assume
that the client is experiencing:
A. A reaction formation to
his recent altered body image.
B. A difficult time
accepting reality and is in a
state of denial.
C. Impotency due to the
surgery and needs sexual
counseling
D. Suicide thoughts and
should be seen by psychiatrist
24. The nurse would know that
dietary teaching had been effective
for a client with colostomy when he
states that he will eat:
A. Food low in fiber so that
there is less stool
B. Everything he ate before
the operation but will avoid
those foods that cause gas
C. Bland foods so that his
intestines do not become
irritated
D. Soft foods that are more
easily digested and absorbed
by the large intestines
25. Eddie, 40 years old, is brought
to the emergency room after the
crash of his private plane. He has
suffered multiple crushing wounds
of the chest, abdomen and legs. It is
feared his leg may have to be
amputated. When Eddie arrives in
the emergency room, the
assessment that assume the
greatest priority are:
A. Level of consciousness
and pupil size
B. Abdominal contusions
and other wounds
C. Pain, Respiratory rate
and blood pressure
D. Quality of respirations
and presence of pulsesQuality
of respirations and presence of
pulses
26. Eddie, a plane crash victim,
undergoes endotracheal intubation
and positive pressure ventilation.
The most immediate nursing
intervention for him at this time
would be to:
A. Facilitate his verbal
communication
B. Maintain sterility of the
ventilation system
C. Assess his response to
the equipment
D. Prepare him for
emergency surgery
27. A chest tube with water seal
drainage is inserted to a client
following a multiple chest injury. A
few hours later, the clients chest
tube seems to be obstructed. The
most appropriate nursing action
would be to
A. Prepare for chest tube
removal
B. Milk the tube toward the
collection container as ordered
C. Arrange for a stat Chest
x-ray film.
D. Clam the tube
immediately
28. The observation that indicates a
desired response to thoracostomy
drainage of a client with chest injury
is:
A. Increased breath sounds
B. Constant bubbling in the
drainage chamber
C. Crepitus detected on
palpation of chest
D. Increased respiratory
rate
29. In the evaluation of a clients
response to fluid replacement
therapy, the observation that
indicates adequate tissue perfusion
to vital organs is:
A. Urinary output is 30 ml
in an hour
B. Central venous pressure
reading of 2 cm H2O
C. Pulse rates of 120 and
110 in a 15 minute period
D. Blood pressure readings
of 50/30 and 70/40 within 30
minutes
30. A client with multiple injury
following a vehicular accident is
transferred to the critical care unit.
He begins to complain of increased
abdominal pain in the left upper
quadrant. A ruptured spleen is
diagnosed and he is scheduled for
emergency splenectomy. In
preparing the client for surgery, the
nurse should emphasize in his
teaching plan the:
A. Complete safety of the
procedure
B. Expectation of
postoperative bleeding
C. Risk of the procedure
with his other injuries
D. Presence of abdominal
drains for several days after
surgery
31. To promote continued
improvement in the respiratory
status of a client following chest
tube removal after a chest surgery
for multiple rib fracture, the nurse
should:
A. Encourage bed rest with
active and passive range of
motion exercises
B. Encourage frequent
coughing and deep breathing
C. Turn him from side to
side at least every 2 hours
D. Continue observing for
dyspnea and crepitus
32. A client undergoes below the
knee amputation following a
vehicular accident. Three days
postoperatively, the client is refusing
to eat, talk or perform any
rehabilitative activities. The best
initial nursing approach would be to:
A. Give him explanations of
why there is a need to quickly
increase his activity
B. Emphasize repeatedly
that with as prosthesis, he will
be able to return to his normal
lifestyle
C. Appear cheerful and
non-critical regardless of his
response to attempts at
intervention
D. Accept and
acknowledge that his
withdrawal is an initially normal
and necessary part of grieving
33. The key factor in accurately
assessing how body image changes
will be dealt with by the client is the:
A. Extent of body change
present
B. Suddenness of the
change
C. Obviousness of the
change
D. Clients perception of
the change
34. Larry is diagnosed as having
myelocytic leukemia and is admitted
to the hospital for chemotherapy.
Larry discusses his recent diagnosis
of leukemia by referring to statistical
 facts and figures. The nurse A. Distal tubule aware that this pattern will alter his
recognizes that Larry is using the B. Collecting duct arterial blood gases by:
defense mechanism known as: C. Glomerulus of the A. Increasing HCO3
A. Reaction formation nephron B. Decreasing PCO2
B. Sublimation D. Ascending limb of the C. Decreasing pH
C. Intellectualization loop of Henle D. Decreasing PO2
D. Projection 42. Mr. Ong weighs 210 lbs on 49. Routine postoperative IV fluids
35. The laboratory results of the admission to the hospital. After 2 are designed to supply hydration
client with leukemia indicate bone days of diuretic therapy he weighs and electrolyte and only limited
marrow depression. The nurse 205.5 lbs. The nurse could estimate energy. Because 1 L of a 5%
should encourage the client to: that the amount of fluid he has lost dextrose solution contains 50 g of
A. Increase his activity is: sugar, 3 L per day would apply
level and ambulate frequently A. 0.5 L approximately:
B. Sleep with the head of B. 1.0 L A. 400 Kilocalories
his bed slightly elevated C. 2.0 L B. 600 Kilocalories
C. Drink citrus juices D. 3.5 L C. 800 Kilocalories
frequently for nourishment 43. Mr. Ong, a client with CHF, has D. 1000 Kilocalories
D. Use a soft toothbrush been receiving a cardiac glycoside, 50. Thrombus formation is a danger
and electric razor a diuretic, and a vasodilator drug. for all postoperative clients. The
36. Dennis receives a blood His apical pulse rate is 44 and he is nurse should act independently to
transfusion and develops flank pain, on bed rest. The nurse concludes prevent this complication by:
chills, fever and hematuria. The that his pulse rate is most likely the A. Encouraging adequate
nurse recognizes that Dennis is result of the: fluids
probably experiencing: A. Diuretic B. Applying elastic
A. An anaphylactic B. Vasodilator stockings
transfusion reaction C. Bed-rest regimen C. Massaging gently the
B. An allergic transfusion D. Cardiac glycoside legs with lotion
reaction 44. The diet ordered for a client with D. Performing active-
C. A hemolytic transfusion CHF permits him to have a 190 g of assistive leg exercises
reaction carbohydrates, 90 g of fat and 100 g 51. An unconscious client is
D. A pyrogenic transfusion of protein. The nurse understands admitted to the ICU, IV fluids are
reaction that this diet contains started and a Foley catheter is
37. A client jokes about his leukemia approximately: inserted. With an indwelling
even though he is becoming sicker A. 2200 calories catheter, urinary infection is a
and weaker. The nurses most B. 2000 calories potential danger. The nurse can
therapeutic response would be: C. 2800 calories best plan to avoid this problem by:
A. Your laugher is a cover D. 1600 calories A. Emptying the drainage
for your fear. 45. After the acute phase of bag frequently
B. He who laughs on the congestive heart failure, the nurse B. Collecting a weekly
outside, cries on the inside. should expect the dietary urine specimen
C. Why are you always management of the client to include C. Maintaining the ordered
laughing? the restriction of: hydration
D. Does it help you to A. Magnesium D. Assessing urine specific
joke about your illness? B. Sodium gravity
38. In dealing with a dying client C. Potassium 52. The nurse performs full range of
who is in the denial stage of grief, D. Calcium motion on a bedridden clients
the best nursing approach is to: 46. Jude develops GI bleeding and extremities. When putting his ankle
A. Agree with and is admitted to the hospital. An through range of motion, the nurse
encourage the clients denial important etiologic clue for the must perform:
B. Reassure the client that nurse to explore while taking his A. Flexion, extension and
everything will be okay history would be: left and right rotation
C. Allow the denial but be A. The medications he has B. Abduction, flexion,
available to discuss death been taking adduction and extension
D. Leave the client alone to B. Any recent foreign travel C. Pronation, supination,
discuss the loss C. His usual dietary pattern rotation, and extension
39. During and 8 hour shift, Mario D. His working patterns D. Dorsiflexion, plantar
drinks two 6 oz. cups of tea and 47. The meal pattern that would flexion, eversion and inversion
vomits 125 ml of fluid. During this 8 probably be most appropriate for a 53. A client has been in a coma for
hour period, his fluid balance would client recovering from GI bleeding 2 months. The nurse understands
be: is: that to prevent the effects of
A. +55 ml A. Three large meals large shearing force on the skin, the head
B. +137 ml enough to supply adequate of the bed should be at an angle of:
C. +235 ml energy. A. 30 degrees
D. +485 ml B. Regular meals and B. 45 degrees
40. Mr. Ong is admitted to the snacks to limit gastric C. 60 degrees
hospital with a diagnosis of Left- discomfort D. 90 degrees
sided CHF. In the assessment, the C. Limited food and fluid 54. Rene, age 62, is scheduled for a
nurse should expect to find: intake when he has pain TURP after being diagnosed with a
A. Crushing chest pain D. A flexible plan according Benign Prostatic Hyperplasia
B. Dyspnea on exertion to his appetite (BPH). As part of the preoperative
C. Extensive peripheral 48. A client with a history of teaching, the nurse should tell the
edema recurrent GI bleeding is admitted to client that after surgery:
D. Jugular vein distention the hospital for a gastrectomy. A. Urinary control may be
41. The physician orders on a client Following surgery, the client has a permanently lost to some
with CHF a cardiac glycoside, a nasogastric tube to low continuous degree
vasodilator, and furosemide (Lasix). suction. He begins to B. Urinary drainage will be
The nurse understands Lasix exerts hyperventilate. The nurse should be dependent on a urethral
is effects in the: catheter for 24 hours
C. Frequency and burning In planning for the clients return percent of Claras body surface that
on urination will last while the from the OR, the nurse would is burned is:
cystotomy tube is in place consider that in a subtotal A. 4.5%
D. His ability to perform thyroidectomy: B. 9%
sexually will be permanently A. The entire thyroid gland C. 18 %
impaired is removed D. 22.5%
55. The transurethral resection of B. A small part of the gland 67. The nurse applies mafenide
the prostate is performed on a client is left intact acetate (Sulfamylon cream) to
with BPH. Following surgery, C. One parathyroid gland is Clara, who has second and third
nursing care should include: also removed degree burns on the right upper and
A. Changing the abdominal D. A portion of the thyroid lower extremities, as ordered by the
dressing and four parathyroids are physician. This medication will:
B. Maintaining patency of removed A. Inhibit bacterial growth
the cystotomy tube 62. Before a post- thyroidectomy B. Relieve pain from the
C. Maintaining patency of a client returns to her room from the burn
three-way Foley catheter for OR, the nurse plans to set up C. Prevent scar tissue
cystoclysis emergency equipment, which formation
D. Observing for should include: D. Provide chemical
hemorrhage and wound A. A crash cart with bed debridement
infection board 68. Forty-eight hours after a burn
56. In the early postoperative period B. A tracheostomy set and injury, the physician orders for the
following a transurethral surgery, oxygen client 2 liters of IV fluid to be
the most common complication the C. An airway and administered q12 h. The drop factor
nurse should observe for is: rebreathing mask of the tubing is 10 gtt/ml. The nurse
A. Sepsis D. Two ampules of sodium should set the flow to provide:
B. Hemorrhage bicarbonate A. 18 gtt/min
C. Leakage around the 63. When a post-thyroidectomy B. 28 gtt/min
catheter client returns from surgery the nurse C. 32 gtt/min
D. Urinary retention with assesses her for unilateral injury of D. 36 gtt/min
overflow the laryngeal nerve every 30 to 60 69. Clara, a burn client, receives a
57. Following prostate surgery, the minutes by: temporary heterograft (pig skin) on
retention catheter is secured to the A. Observing for signs of some of her burns. These grafts
clients leg causing slight traction of tetany will:
the inflatable balloon against the B. Checking her throat for A. Debride necrotic
prostatic fossa. This is done to: swelling epithelium
A. Limit discomfort C. Asking her to state her B. Be sutured in place for
B. Provide hemostasis name out loud better adherence
C. Reduce bladder spasms D. Palpating the side of her C. Relieve pain and
D. Promote urinary neck for blood seepage promote rapid epithelialization
drainage 64. On a post-thyroidectomy clients D. Frequently be used
58. Twenty-four hours after TURP discharge, the nurse teaches her to concurrently with topical
surgery, the client tells the nurse he observe for signs of surgically antimicrobials.
has lower abdominal discomfort. induced hypothyroidism. The nurse 70. A client with burns on the chest
The nurse notes that the catheter would know that the client has periodic episodes of dyspnea.
drainage has stopped. The nurses understands the teaching when she The position that would provide for
initial action should be to: states she should notify the the greatest respiratory capacity
A. Irrigate the catheter physician if she develops: would be the:
with saline A. Intolerance to heat A. Semi-fowlers position
B. Milk the catheter tubing B. Dry skin and fatigue B. Sims position
C. Remove the catheter C. Progressive weight loss C. Orthopneic position
D. Notify the physician D. Insomnia and D. Supine position
59. The nurse would know that a excitability 71. Jane, a 20- year old college
post-TURP client understood his 65. A clients exopthalmos continues student is admiited to the hospital
discharge teaching when he says I inspite of thyroidectomy for Graves with a tentative diagnosis of
should: Disease. The nurse teaches her myasthenia gravis. She is
A. Get out of bed into a how to reduce discomfort and scheduled to have a series of
chair for several hours daily prevent corneal ulceration. The diagnostic studies for myasthenia
B. Call the physician if my nurse recognizes that the client gravis, including a Tensilon test. In
urinary stream decreases understands the teaching when she preparing her for this procedure, the
C. Attempt to void every 3 says: I should: nurse explains that her response to
hours when Im awake A. Elevate the head of my the medication will confirm the
D. Avoid vigorous exercise bed at night diagnosis if Tensilon produces:
for 6 months after surgery B. Avoid moving my extra- A. Brief exaggeration of
60. Lucy is admitted to the surgical ocular muscles symptoms
unit for a subtotal thyroidectomy. C. Avoid using a sleeping B. Prolonged symptomatic
She is diagnosed with Graves mask at night improvement
Disease. When assessing Lucy, the D. Avoid excessive C. Rapid but brief
nurse would expect to find: blinking symptomatic improvement
A. Lethargy, weight gain, 66. Clara is a 37-year old cook. She D. Symptomatic
and forgetfulness is admitted for treatment of partial improvement of just the ptosis
B. Weight loss, protruding and full-thickness burns of her 72. The initial nursing goal for a
eyeballs, and lethargy entire right lower extremity and the client with myasthenia gravis during
C. Weight loss, anterior portion of her right upper the diagnostic phase of her
exopthalmos and restlessness extremity. Her respiratory status is hospitalization would be to:
D. Constipation, dry skin, compromised, and she is in pain A. Develop a teaching plan
and weight gain and anxious. Performing an B. Facilitate psychologic
61. Lucy undergoes Subtotal immediate appraisal, using the rule adjustment
Thyroidectomy for Graves Disease. of nines, the nurse estimates the
C. Maintain the present 74. Helen is diagnosed with 75. Helen, a client with myasthenia
muscle strength myasthenia gravis and gravis, begins to experience
D. Prepare for the pyridostigmine bromide (Mestinon) increased difficulty in swallowing. To
appearance of myasthenic therapy is started. The Mestinon prevent aspiration of food, the
crisis dosage is frequently changed nursing action that would be most
73. The most significant initial during the first week. While the effective would be to:
nursing observations that need to dosage is being adjusted, the A. Change her diet order
be made about a client with nurses priority intervention is to: from soft foods to clear liquids
myasthenia include: A. Administer the B. Place an emergency
A. Ability to chew and medication exactly on time tracheostomy set in her room
speak distinctly B. Administer the C. Assess her respiratory
B. Degree of anxiety about medication with food or mild status before and after meals
her diagnosis C. Evaluate the clients D. Coordinate her meal
C. Ability to smile an to muscle strength hourly after schedule with the peak effect
close her eyelids medication of her medication, Mestinon
D. Respiratory exchange D. Evaluate the clients
and ability to swallow emotional side effects between
doses
2. Answer: (A) 25 gtt/min . To get the
correct flow rate: multiply the amount to be
infused (50 ml) by the drop factor (10) and divide
the result by the amount of time in minutes (20)
3. Answer: (B) Eating habits are
altered . For weight reduction to occur and be
maintained, a new dietary program, with a balance
of foods from the basic four food groups, must be
established and continued
4. Answer: (A) Increase her lean body
mass . Increased exercise builds skeletal muscle
mass and reduces excess fatty tissue.
5. Answer: (A) Exercising the triceps,
finger flexors, and elbow extensors . These
sets of muscles are used when walking with
crutches and therefore need strengthening prior to
ambulation.
6. Answer: (C) The palms of her
hands .The palms should bear the clients weight
to avoid damage to the nerves in the axilla
(brachial plexus)
7. Answer: (C) 12 minims . Using ratio and
proportion 8 mg/10 mg = X minims/15 minims 10
X= 120 X = 12 minims The nurse will administer
12 minims intravenously equivalent to 8mg
Morphine Sulfate
8. Answer: (B) Relieves pain and
decreases level of anxiety. Morphine is a
specific central nervous system depressant used to
relieve the pain associated with myocardial
infarction. It also decreases anxiety and
apprehension and prevents cardiogenic shock by
decreasing myocardial oxygen demand.
9. Answer: (C) Supports combustion. The
nurse should know that Oxygen is necessary to
produce fire, thus precautionary measures are
important regarding its use.
10. Answer: (C) CK-MB. The cardiac marker,
Creatinine phosphokinase (CPK) isoenzyme levels,
especially the MB sub-unit which is cardio-specific,
begin to rise in 3-6 hours, peak in 12-18 hours and
are elevated 48 hours after the occurrence of the
infarct. They are therefore most reliable in
assisting with early diagnosis. The cardiac markers
elevate as a result of myocardial tissue damage.
11. Answer: (B) Elevated STsegments . This
is a typical early finding after a myocardial infarct
because of the altered contractility of the heart.
The other choices are not typical of MI.
12. Answer: (B) Refocus the conversation
on his fears, frustrations and anger about his
condition . This provides the opportunity for the
Answers and Rationales client to verbalize feelings underlying behavior and
1. Answer: (B) protecting the client from helpful in relieving anxiety. Anxiety can be a
infection. Immunodeficiency is an absent or stressor which can activate the sympathoadrenal
depressed immune response that increases response causing the release of catecholamines
susceptibility to infection. So it is the nurses that can increase cardiac contractility and
primary responsibility to protect the patient from workload that can further increase myocardial
infection. oxygen demand.
13. Answer: (D) Increased pulse
rate . Fever causes an increase in the bodys
metabolism, which results in an increase in oxygen
consumption and demand. This need for oxygen
increases the heart rate, which is reflected in the
increased pulse rate. Increased BP, chest pain and
shortness of breath are not typically noted in fever.
14. Answer: (C) Avoid giving him direct
information and help him explore his feelings
. To help the patient verbalize and explore his
feelings, the nurse must reflect and analyze the
feelings that are implied in the clients question.
The focus should be on collecting data to minister
to the clients psychosocial needs.
15. Answer: (C) Absorb vitamin
B12 . Pernicious anemia is caused by the inability
to absorb vitamin B12 in the stomach due to a lack
of intrinsic factor in the gastric juices. In the
Schilling test, radioactive vitamin B12 is
administered and its absorption and excretion can
be ascertained through the urine.
16. Answer: (D) 2.0 ml . First convert
milligrams to micrograms and then use ratio and
proportion (0.2 mg= 200 mcg) 200 mcg : 100
mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml.
to give 0.2 mg of Cyanocobalamin.
17. Answer: (C) IM injections once a month
will maintain control . Deep IM injections bypass
B12 absorption defect in the stomach due to lack
of intrinsic factor, the transport carrier component
of gastric juices. A monthly dose is usually
sufficient since it is stored in active body tissues
such as the liver, kidney, heart, muscles, blood and
bone marrow
18. Answer: (D) For the rest of her
life . Since the intrinsic factor does not return to
gastric secretions even with therapy, B12
injections will be required for the remainder of the
clients life.
19. Answer: (D) Projection. Projection is the
attribution of unacceptable feelings and emotions
to others which may indicate the patients
nonacceptance of his condition.
20. Answer: (A) When the client would
have normally had a bowel
movement . Irrigation should be performed at the
time the client normally defecated before the
colostomy to maintain continuity in lifestyle and
usual bowel function/habit.
21. Answer: (C) Hangs the bag on a
clothes hook on the bathroom door during
fluid insertion . The irrigation bag should be
hung 12-18 inches above the level of the stoma; a
clothes hook is too high which can create increase
pressure and sudden intestinal distention and
cause abdominal discomfort to the patient.
22. Answer: (B) Difficulty in inserting the
irrigating tube . Difficulty of inserting the
irrigating tube indicates stenosis of the stoma and
should be reported to the physician. Abdominal
cramps and passage of flatus can be expected
during colostomy irrigations. The procedure may
take longer than half an hour.
23. Answer: (B) A difficult time accepting
reality and is in a state of denial. As long as no
one else confirms the presence of the stoma and
the client does not need to adhere to a prescribed
regimen, the clients denial is supported
24. Answer: (B) Everything he ate before
the operation but will avoid those foods that
cause gas . There is no special diets for clients
with colostomy. These clients can eat a regular
diet. Only gas-forming foods that cause distention
and discomfort should be avoided.
25. Answer: (D) Quality of respirations and
presence of pulsesQuality of respirations and
presence of pulses . Respiratory and
cardiovascular functions are essential for
oxygenation. These are top priorities to trauma
management. Basic life functions must be
maintained or reestablished
26. Answer: (C) Assess his response to the
equipment . It is a primary nursing responsibility
to evaluate effect of interventions done to the
client. Nothing is achieved if the equipment is
working and the client is not responding
27. Answer: (B) Milk the tube toward the
collection container as ordered . This assists in
moving blood, fluid or air, which may be
obstructing drainage, toward the collection
chamber
28. Answer: (A) Increased breath
sounds . The chest tube normalizes intrathoracic
pressure and restores negative intra-pleural
pressure, drains fluid and air from the pleural
space, and improves pulmonary function
29. Answer: (A) Urinary output is 30 ml in
an hour . A rate of 30 ml/hr is considered
adequate for perfusion of kidney, heart and brain.
30. Answer: (D) Presence of abdominal
drains for several days after surgery . Drains
are usually inserted into the splenic bed to
facilitate removal of fluid in the area that could
lead to abscess formation.
31. Answer: (B) Encourage frequent
coughing and deep breathing . This nursing
action prevents atelectasis and collection of
respiratory secretions and promotes adequate
ventilation and gas exchange.
32. Answer: (D) Accept and acknowledge
that his withdrawal is an initially normal and
necessary part of grieving . The withdrawal
provides time for the client to assimilate what has
occurred and integrate the change in the body
image. Acceptance of the clients behavior is an
important factor in the nurses intervention.
33. Answer: (D) Clients perception of the
change . It is not reality, but the clients feeling
about the change that is the most important
determinant of the ability to cope. The client
should be encouraged to his feelings.
34. Answer: (C) Intellectualization . People
use defense mechanisms to cope with stressful
events. Intellectualization is the use of reasoning
and thought processes to avoid the emotional
upsets.
35. Answer: (D) Use a soft toothbrush and
electric razor . Suppression of red bone marrow
increases bleeding susceptibility associated with
thrombocytopenia, decreased platelets. Anemia
and leucopenia are the two other problems noted
with bone marrow depression.
36. Answer: (C) A hemolytic transfusion
reaction . This results from a recipients
antibodies that are incompatible with transfused
RBCs; also called type II hypersensitivity; these
signs result from RBC hemolysis, agglutination, and
capillary plugging that can damage renal function,
thus the flank pain and hematuria and the other
manifestations.
37. Answer: (D) Does it help you to joke
about your illness? . This non-judgmentally on
the part of the nurse points out the clients
behavior.
38. Answer: (C) Allow the denial but be
available to discuss death . This does not take
away the clients only way of coping, and it permits
future movement through the grieving process
when the client is ready. Dying clients move
through the different stages of grieving and the
nurse must be ready to intervene in all these
stages.
39. Answer: (C) +235 ml . The clients intake
was 360 ml (6oz x 30 ml) and loss was 125 ml of
fluid; loss is subtracted from intake
40. Answer: (B) Dyspnea on
exertion . Pulmonary congestion and edema
occur because of fluid extravasation from the
pulmonary capillary bed, resulting in difficult
breathing. Left-sided heart failure creates a
backward effect on the pulmonary system that
leads to pulmonary congestion.
41. Answer: (D) Ascending limb of the loop
of Henle . This is the site of action of Lasix being a
potent loop diuretic.
42. Answer: (C) 2.0 L . One liter of fluid
weighs approximately 2.2 lbs. Therefore a 4.5 lbs
weight loss equals approximately 2 Liters.
43. Answer: (D) Cardiac glycoside . A
cardiac glycoside such as digitalis increases force
of cardiac contraction, decreases the conduction
speed of impulses within the myocardium and
slows the heart rate.
44. Answer: (B) 2000 calories . There are 9
calories in each gram of fat and 4 calories in each
gram of carbohydrate and protein
45. Answer: (B) Sodium . Restriction of
sodium reduces the amount of water retention that
reduces the cardiac workload
46. Answer: (A) The medications he has
been taking . Some medications, such as aspirin
and prednisone, irritate the stomach lining and
may cause bleeding with prolonged use
47. Answer: (B) Regular meals and snacks
to limit gastric discomfort . Presence of food in
the stomach at regular intervals interacts with HCl
limiting acid mucosal irritation. Mucosal irritation
can lead to bleeding.
48. Answer: (B) Decreasing
PCO2 . Hyperventilation results in the increased
elimination of carbon dioxide from the blood that
can lead to respiratory alkalosis.
49. Answer: (B) 600
Kilocalories . Carbohydrates provide 4 kcal/
gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal;
only about a third of the basal energy need.
50. Answer: (D) Performing active-
assistive leg exercises . Inactivity causes
venous stasis, hypercoagulability, and external
pressure against the veins, all of which lead to
thrombus formation. Early ambulation or exercise
of the lower extremities reduces the occurrence of
this phenomenon
51. Answer: (C) Maintaining the ordered
hydration . Promoting hydration, maintains urine
production at a higher rate, which flushes the
bladder and prevents urinary stasis and possible
infection
52. Answer: (D) Dorsiflexion, plantar
flexion, eversion and inversion . These
movements include all possible range of motion for
the ankle joint
53. Answer: (A) 30 degrees . Shearing force
occurs when 2 surfaces move against each other;
when the bed is at an angle greater than 30
degrees, the torso tends to slide and causes this
phenomenon. Shearing forces are good
contributory factors of pressure sores.
54. Answer: (B) Urinary drainage will be
dependent on a urethral catheter for 24
hours . An indwelling urethral catheter is used,
because surgical trauma can cause urinary
retention leading to further complications such as
bleeding.
55. Answer: (C) Maintaining patency of a
three-way Foley catheter for
cystoclysis . Patency of the catheter promotes
bladder decompression, which prevents distention
and bleeding. Continuous flow of fluid through the
bladder limits clot formation and promotes
hemostasis
56. Answer: (B) Hemorrhage . After
transurethral surgery, hemorrhage is common
because of venous oozing and bleeding from many
small arteries in the prostatic bed.
57. Answer: (B) Provide hemostasis . The
pressure of the balloon against the small blood
vessels of the prostate creates a tampon-like effect
that causes them to constrict thereby preventing
bleeding.
58. Answer: (B) Milk the catheter
tubing . Milking the tubing will usually dislodge
the plug and will not harm the client. A physicians
order is not necessary for a nurse to check
catheter patency.
59. Answer: (B) Call the physician if my
urinary stream decreases . Urethral mucosa in
the prostatic area is destroyed during surgery and
strictures my form with healing that causes partial
or even complete ueinary obstruction.
60. Answer: (C) Weight loss, exopthalmos
and restlessness . Classic signs associated with
hyperthyroidism are weight loss and restlessness
because of increased basal metabolic rate.
Exopthalmos is due to peribulbar edema.
61. Answer: (B) A small part of the gland is
left intact . Remaining thyroid tissue may provide
enough hormone for normal function. Total
thyroidectomy is generally done in clients with
Thyroid Ca.
62. Answer: (B) A tracheostomy set and
oxygen . Acute respiratory obstruction in the post-
operative period can result from edema,
subcutaneous bleeding that presses on the
trachea, nerve damage, or tetany.
63. Answer: (C) Asking her to state her
name out loud . If the recurrent laryngeal nerve
is damaged during surgery, the client will be
hoarse and have difficult speaking.
64. Answer: (B) Dry skin and fatigue . Dry
skin is most likely caused by decreased glandular
function and fatigue caused by decreased
metabolic rate. Body functions and metabolism are
decreased in hypothyroidism.
65. Answer: (C) Avoid using a sleeping
mask at night . The mask may irritate or scratch
the eye if the client turns and lies on it during the
night.
66. Answer: (D) 22.5% . The entire right
lower extremity is 18% the anterior portion of the
right upper extremity is 4.5% giving a total of
22.5%
67. Answer: (A) Inhibit bacterial
growth . Sulfamylon is effective against a wide
variety of gram positive and gram negative
organisms including anaerobes
68. Answer: (B) 28 gtt/min . This is the
correct flow rate; multiply the amount to be
infused (2000 ml) by the drop factor (10) and
divide the result by the amount of time in minutes
(12 hours x 60 minutes)
69. Answer: (C) Relieve pain and promote
rapid epithelialization . The graft covers nerve
endings, which reduces pain and provides a
framework for granulation that promotes effective
healing.
70. Answer: (C) Orthopneic position . The
orthopneic position lowers the diaphragm and
provides for maximal thoracic expansion
71. Answer: (C) Rapid but brief
symptomatic improvement . Tensilon acts
systemically to increase muscle strength; with a
peak effect in 30 seconds, It lasts several minutes.
72. Answer: (C) Maintain the present
muscle strength . Until diagnosis is confirmed,
 primary goal should be to maintain adequate
activity and prevent muscle atrophy
73. Answer: (D) Respiratory exchange and
ability to swallow . Muscle weakness can lead to
respiratory failure that will require emergency
intervention and inability to swallow may lead to
aspiration
74. Answer: (C) Evaluate the clients
muscle strength hourly after medication
Peak response occurs 1 hour after
administration and lasts up to 8 hours; the
response will influence dosage levels.
75. Answer: (D) Coordinate her meal
schedule with the peak effect of her
medication, Mestinon . Dysphagia should be
minimized during peak effect of Mestinon, thereby
decreasing the probability of aspiration. Mestinon
can increase her muscle strength including her
ability to swallow.