1.Answer: (B) protecting the client from infection Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection.
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 client’s 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 client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.
13.Answer: (D) Increased pulse rate Fever causes an increase in the body’s 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 client’s question. The focus should be on collecting data to minister to the client’s 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 client’s 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 client’s 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 client’s behavior is an important factor in the nurse’s intervention.
33.Answer: (D) Client’s perception of the change It is not reality, but the client’s 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 recipient’s antibodies that are incompatible with transfused RBC’s; 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 client’s behavior.
38.Answer: (C) Allow the denial but be available to discuss death This does not take away the client’s 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 client’s 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 physician’s 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 client’s muscle strength hourly after medicationPeak 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.