1.Answer: (C) “With a pillow, apply pressure against the incision.” Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by coughing which causes tension on the incision that leads to pain.
2.Answer: (C) experience reduced sensory perception Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data.
3.Answer: (C) This is normal side-effect of AtSO4 Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.
4.Answer: (D) Administer Demerol 50mg IM q4h Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse.
5.Answer: (D) "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow’s surgery?" The client is showing signs of anxiety reaction to a stressful event. Recognizing the client’s anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns.
6.Answer: (C) Check the patency of the nasogastric tube for any obstruction. Nausea is one of the common complaints of a patient after receiving general anesthesia. But this complaint could be aggravated by gastric distention especially in a patient who has undergone abdominal surgery. Insertion of the NGT helps relieve the problem. Checking on the patency of the NGT for any obstruction will help the nurse determine the cause of the problem and institute the necessary intervention.
7.Answer: (C) Handle him gently when assisting with required care Patients with cancer and bone metastasis experience severe pain especially when moving. Bone tumors weaken the bone to appoint at which normal activities and even position changes can lead to fracture. During nursing care, the patient needs to be supported and handled gently.
8.Answer: (B) Take his vital signs again in 15 minutes. Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. Complications can occur during this period as a result of the surgery or the anesthesia or both. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring.
9.Answer: (C) Bleeding from ears The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation
10.Answer: (D) “I smoke 1 1/2 packs of cigarettes per day.” Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. Exercise and maintaining normal serum cholesterol levels help in its prevention.
11.Answer: (B) The positive inotropic effect will decrease urine output Inotropic effect of drugs on the heart causes increase force of its contraction. This increases cardiac output that improves renal perfusion resulting in an improved urine output.
12.Answer: (A) Use of stool softeners. Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver.
13.Answer: (D) may engage in contact sports The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.
14.Answer: (D) “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved. Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 – 5 mins. If the chest pain is unrelieved, after three tablets, there is a possibility of acute coronary occlusion that requires immediate medical attention.
15.Answer: (B) Canned sardines Canned foods are generally rich in sodium content as salt is used as the main preservative.
16.Answer: (C) Instruct the client about the need for bed rest. In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism.
17.Answer: (B) It prevents conversion of factors that are needed in the formation of clots. Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.
18.Answer: (D) Cough or change in a chronic cough Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. The irritation causes the cough which initially maybe dry, persistent and unproductive. As the tumor enlarges, obstruction of the airways occurs and the cough may become productive due to infection.
19.Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the clientoxygen in low concentrations will maintain the client’s hypoxic drive.
20.Answer: (C) Suction until the client indicates to stop or no longer than 20 second One hazard encountered when suctioning a client is the development of hypoxia. Suctioning sucks not only the secretions but also the gases found in the airways. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning.
21.Answer: (D) Delay resistance and increase the tuberculostatic effect Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. Using drugs in combination can delay the drug resistance.
22.Answer: (B) Facilitate ventilation of the left lung. Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.
23.Answer: (D) Slowly breath out through the mouth with pursed lips after inhaling the drug. If the client breathes out through the mouth with pursed lips, this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness.
24.Answer: (A) Food and fluids will be withheld for at least 2 hours. Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.
25.Answer: (C) Lower the oxygen rate. The client with COPD is suffering from chronic CO2 retention. The hypoxic drive is his chief stimulus for breathing. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR.
26.Answer: (C) Impaired gas exchange. Pneumonia, which is an infection, causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. Because the patient would require adequate hydration, this makes him prone to fluid volume excess.
27.Answer: (D) posterior neck fat pad and thin extremities “Buffalo hump” is the accumulation of fat pads over the upper back and neck. Fat may also accumulate on the face. There is truncal obesity but the extremities are thin. All these are noted in a client with Cushing’s syndrome.
28.Answer: (B) “I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.” The possible side effects of steroid administration are hypokalemia, increase tendency to infection and poor wound healing. Clients on the drug must follow strictly the doctor’s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis
29.Answer: (C) Blood pressure Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.
30.Answer: (D) Give the guest a glass of orange juice In diabetic patients, the nurse should watch out for signs of hypoglycemia manifested by dizziness, tremors, weakness, pallor diaphoresis and tachycardia. When this occurs in a conscious client, he should be given immediately carbohydrates in the form of fruit juice, hard candy, honey or, if unconscious, glucagons or dextrose per IV.
31.Answer: (C) “The medication will block the cardiovascular symptoms of Grave’s disease.” Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave’s disease.
32.Answer: (A) Checking the back and sides of the operative dressing Following surgery of the thyroid gland, bleeding is a potential complication. This can best be assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry and clear of drainage.
33.Answer: (C) Progressive weight gain Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.
34.Answer: (C) Lipodystrophic areas can result, causing erratic insulin absorption rates from these Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions.
35.Answer: (C) Keep legs elevated on 2 pillows while sleeping The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.
36.Answer: (B) Assess gag reflex prior to administration of fluids The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration.
37.Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake Duodenal ulcer is related to an increase in the secretion of HCl. This can be buffered by food intake thus the relief of the pain that is brought about by food intake.
38.Answer: (B) Notify the MD of your findings The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention.
39.Answer: (A) Sit upright for at least 30 minutes after meals The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying, causing distention of the duodenum or jejunum produced by a bolus of food. To delay the emptying, the client has to lie down after meals. Sitting up after meals will promote the dumping syndrome.
40.Answer: (A) Treatment will include Ranitidine and Antibiotics One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to ulcer.
41.Answer: (B) Empty bladder before procedure Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure.
42.Answer: (A) “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.” The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. A protein-restricted diet will therefore decrease ammonia production.
43.Answer: (C) Meperidine Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.
44.Answer: (B) encouraging the client to cough and deep breathe Cholecystectomy requires a subcostal incision. To minimize pain, clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent such complications.
45.Answer: (A) Deflate the esophageal balloon When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction
46.Answer: (B) Ulcerative colitis Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem.
47.Answer: (A) Give laxative the night before and a cleansing enema in the morning before the test Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema.
48.Answer: (D) “I will include more fresh fruits and vegetables in my diet.” Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer.
49.Answer: (A) Cover the wound with sterile, moist saline dressing Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process.
50.Answer: (B) Ambulate. Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination.