MEDICAL SURGICAL NURSING 1.

Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurses best response would be: . !"ain will become less each day.# $. !This is a normal reaction after surgery.# %. !&ith a pillow, apply pressure against the incision.# '. !( will gi)e you the pain medication the physician ordered.# nswer: *%+ !&ith a pillow, apply pressure against the incision.# pplying 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. ,. The nurse needs to carefully assess the complaint of pain of the elderly because older people . are expected to experience chronic pain $. ha)e a decreased pain threshold %. experience reduced sensory perception '. ha)e altered mental function nswer: *%+ experience reduced sensory perception 'egenerati)e 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. -. Mary recei)ed tropine./0 as a pre-medication -1 minutes ago and is now complaining of dry mouth and her "2 is higher, than before the medication was administered. The nurses best . The patient is ha)ing an allergic reaction to the drug. $. The patient needs a higher dose of this drug %. This is normal side-effect of t./0 '. The patient is anxious about upcoming surgery nswer: *%+ This is normal side-effect of t./0 tropine sulfate is a )agolytic drug that decreases oropharyngeal secretions and increases the heart rate. 0. nas postoperati)e )ital signs are a blood pressure of 31451 mm 6g, a pulse of 101, and respirations of -,. .uspecting shoc7, which of the following orders would the nurse 8uestion9 . "ut the client in modified Trendelenberg:s position. $. dminister oxygen at 111;. %. Monitor urine output e)ery hour. '. dminister 'emerol 51mg (M 80h nswer: *'+ dminister 'emerol 51mg (M 80h dministering 'emerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not gi)en to a patient in shoc7. &hat is needed is promotion for ade8uate oxygenation and perfusion. ll the other inter)entions can be expected to be done by the nurse. 5. Mr. "ablo, diagnosed with $ladder %ancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. 6e is wringing his hands and pacing the floor when the nurse enters his room. &hat is the best approach9 . <=ood e)ening, Mr. "ablo. &asn:t it a pleasant day, today9< $. <Mr, "ablo, you must be so worried, (:ll lea)e you alone with your thoughts. %. !Mr. "ablo, you:ll wear out the hospital floors and yourself at this rate.< '. <Mr. "ablo, you appear anxious to me. 6ow are you

feeling about tomorrow:s surgery9< nswer: *'+ <Mr. "ablo, you appear anxious to me. 6ow are you feeling about tomorrow:s surgery9< The client is showing signs of anxiety reaction to a stressful e)ent. 2ecogni>ing the clients anxiety con)eys acceptance of his beha)ior and will allow for )erbali>ation of feelings and concerns. ?. fter surgery, =ina returns from the "ost-anesthesia %are @nit *2eco)ery 2oom+ with a nasogastric tube in place following a gall bladder surgery. .he continues to complain of nausea. &hich action would the nurse ta7e9 . %all the physician immediately. $. dminister the prescribed antiemetic. %. %hec7 the patency of the nasogastric tube for any obstruction. '. %hange the patients position. nswer: *%+ %hec7 the patency of the nasogastric tube for any obstruction. Aausea is one of the common complaints of a patient after recei)ing general anesthesia. $ut this complaint could be aggra)ated by gastric distention especially in a patient who has undergone abdominal surgery. (nsertion of the A=T helps relie)e the problem. %hec7ing on the patency of the A=T for any obstruction will help the nurse determine the cause of the problem and institute the necessary inter)ention. B. Mr. "ere> is in continuous pain from cancer that has metastasi>ed to the bone. "ain medication pro)ides little relief and he refuses to mo)e. The nurse should plan to: . 2eassure him that the nurses will not hurt him $. Cet him perform his own acti)ities of daily li)ing %. 6andle him gently when assisting with re8uired care '. %omplete .M. care 8uic7ly as possible when necessary nswer: *%+ 6andle him gently when assisting with re8uired care "atients with cancer and bone metastasis experience se)ere pain especially when mo)ing. $one tumors wea7en the bone to appoint at which normal acti)ities and e)en position changes can lead to fracture. 'uring nursing care, the patient needs to be supported and handled gently. 3. client returns from the reco)ery room at D M alert and oriented, with an (E infusing. 6is pulse is 3,, blood pressure is 1,1431, respirations are ,1, and all are within normal range. t 11 am and at 11 am, his )ital signs are stable. t noon, howe)er, his pulse rate is D0, blood pressure is 11?4B0, and respirations are ,0. &hat nursing action is most appropriate9 . Aotify his physician. $. Ta7e his )ital signs again in 15 minutes. %. Ta7e his )ital signs again in an hour. '. "lace the patient in shoc7 position. nswer: *$+ Ta7e his )ital signs again in 15 minutes. Monitoring the clients )ital signs following surgery gi)es the nurse a sound information about the clients condition. %omplications can occur during this period as a result of the surgery or the anesthesia or both. Feeping close trac7 of changes in the E. and )alidating them will help the nurse initiate inter)entions to pre)ent complications from occurring. D. 5? year old construction wor7er is brought to the hospital unconscious after falling from a ,-story building.

&hen assessing the client, the nurse would be most concerned if the assessment re)ealed: . 2eacti)e pupils $. depressed fontanel %. $leeding from ears '. n ele)ated temperature nswer: *%+ $leeding from ears The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. $leeding from the ears occurs only with basal s7ull fractures that can easily contribute to increased intracranial pressure and brain herniation 11. &hich of the ff. statements by the client to the nurse indicates a ris7 factor for % '9 . !( exercise e)ery other day.# $. !My father died of Myasthenia =ra)is.# %. !My cholesterol is 131.# '. !( smo7e 1 14, pac7s of cigarettes per day.# nswer: *'+ !( smo7e 1 14, pac7s of cigarettes per day.# .mo7ing has been considered as one of the maGor modifiable ris7 factors for coronary artery disease. Hxercise and maintaining normal serum cholesterol le)els help in its pre)ention. 11. Mr. $raga was ordered 'igoxin 1.,5 mg. /'. &hich is poor 7nowledge regarding this drug9 . (t has positi)e inotropic and negati)e chronotropic effects $. The positi)e inotropic effect will decrease urine output %. Toxixity can occur more easily in the presence of hypo7alemia, li)er and renal problems '. 'o not gi)e the drug if the apical rate is less than ?1 beats per minute. nswer: *$+ The positi)e inotropic effect will decrease urine output (notropic effect of drugs on the heart causes increase force of its contraction. This increases cardiac output that impro)es renal perfusion resulting in an impro)ed urine output. 1,. Ealsal)a maneu)er can result in bradycardia. &hich of the following acti)ities will not stimulate Ealsal)a:s maneu)er9 . @se of stool softeners. $. Hnema administration %. =agging while toothbrushing. '. Cifting hea)y obGects nswer: * + @se of stool softeners. .training or bearing down acti)ities can cause )agal stimulation that leads to bradycardia. @se of stool softeners promote easy bowel e)acuation that pre)ents straining or the )alsal)a maneu)er. 1-. The nurse is teaching the patient regarding his permanent artificial pacema7er. &hich information gi)en by the nurse shows her 7nowledge deficit about the artificial cardiac pacema7er9 . ta7e the pulse rate once a day, in the morning upon awa7ening $. may be allowed to use electrical appliances %. ha)e regular follow up care '. may engage in contact sports nswer: *'+ may engage in contact sports

The client should be ad)ised by the nurse to a)oid contact sports. This will pre)ent trauma to the area of the pacema7er generator. 10. patient with angina pectoris is being discharged home with nitroglycerine tablets. &hich of the following instructions does the nurse include in the teaching9 . !&hen your chest pain begins, lie down, and place one tablet under your tongue. (f the pain continues, ta7e another tablet in 5 minutes.# $. !"lace one tablet under your tongue. (f the pain is not relie)ed in 15 minutes, go to the hospital.# %. !%ontinue your acti)ity, and if the pain does not go away in 11 minutes, begin ta7ing the nitro tablets one e)ery 5 minutes for 15 minutes, then go lie down.# '. !"lace one Aitroglycerine tablet under the tongue e)ery fi)e minutes for three doses. =o to the hospital if the pain is unrelie)ed. nswer: *'+ !"lace one Aitroglycerine tablet under the tongue e)ery fi)e minutes for three doses. =o to the hospital if the pain is unrelie)ed. ngina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. =i)ing nitroglycerine will produce coronary )asodilation that impro)es the coronary blood flow in - I 5 mins. (f the chest pain is unrelie)ed, after three tablets, there is a possibility of acute coronary occlusion that re8uires immediate medical attention. 15. client with chronic heart failure has been placed on a diet restricted to ,111mg. of sodium per day. The client demonstrates ade8uate 7nowledge if beha)iors are e)ident such as not salting food and a)oidance of which food9 . &hole mil7 $. %anned sardines %. "lain nuts '. Hggs nswer: *$+ %anned sardines %anned foods are generally rich in sodium content as salt is used as the main preser)ati)e. 1?. student nurse is assigned to a client who has a diagnosis of thrombophlebitis. &hich action by this team member is most appropriate9 . pply a heating pad to the in)ol)ed site. $. Hle)ate the client:s legs D1 degrees. %. (nstruct the client about the need for bed rest. '. "ro)ide acti)e range-of-motion exercises to both legs at least twice e)ery shift. nswer: *%+ (nstruct the client about the need for bed rest. (n a client with thrombophlebitis, bedrest will pre)ent the dislodgment of the clot in the extremity which can lead to pulmonary embolism. 1B. client recei)ing heparin sodium as7s the nurse how the drug wor7s. &hich of the following points would the nurse include in the explanation to the client9 . (t dissol)es existing thrombi. $. (t pre)ents con)ersion of factors that are needed in the formation of clots. %. (t inacti)ates thrombin that forms and dissol)es existing thrombi. '. (t interferes with )itamin F absorption. nswer: *$+ (t pre)ents con)ersion of factors that are needed in the formation of clots.

6eparin is an anticoagulant. (t pre)ents the con)ersion of prothrombin to thrombin. (t does not dissol)e a clot. 13. The nurse is conducting an education session for a group of smo7ers in a !stop smo7ing# class. &hich finding would the nurse state as a common symptom of lung cancer9 : . 'yspnea on exertion $. Foamy, blood-tinged sputum %. &hee>ing sound on inspiration '. %ough or change in a chronic cough nswer: *'+ %ough or change in a chronic cough %igarette smo7e is a carcinogen that irritates and damages the respiratory epithelium. The irritation causes the cough which initially maybe dry, persistent and unproducti)e. s the tumor enlarges, obstruction of the airways occurs and the cough may become producti)e due to infection. 1D. &hich is the most rele)ant 7nowledge about oxygen administration to a client with %/"'9 . /xygen at 1-,C4min is gi)en to maintain the hypoxic stimulus for breathing. $. 6ypoxia stimulates the central chemoreceptors in the medulla that ma7es the client breath. %. /xygen is administered best using a non-rebreathing mas7 '. $lood gases are monitored using a pulse oximeter. nswer: * + /xygen at 1-,C4min is gi)en to maintain the hypoxic stimulus for breathing. %/"' causes a chronic %/, retention that renders the medulla insensiti)e to the %/, stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. =i)ing the clientoxygen in low concentrations will maintain the clients hypoxic dri)e. ,1. &hen suctioning mucus from a client:s lungs, which nursing action would be least appropriate9 . Cubricate the catheter tip with sterile saline before insertion. $. @se sterile techni8ue with a two-glo)ed approach %. .uction until the client indicates to stop or no longer than ,1 second '. 6yperoxygenate the client before and after suctioning nswer: *%+ .uction until the client indicates to stop or no longer than ,1 second /ne ha>ard encountered when suctioning a client is the de)elopment of hypoxia. .uctioning suc7s not only the secretions but also the gases found in the airways. This can be pre)ented by suctioning the client for an a)erage time of 5-11 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning. ,1. 'r. .antos prescribes oral rifampin *2imactane+ and isonia>id *(A6+ for a client with a positi)e Tuberculin s7in test. &hen informing the client of this decision, the nurse 7nows that the purpose of this choice of treatment is to . %ause less irritation to the gastrointestinal tract $. 'estroy resistant organisms and promote proper blood le)els of the drugs %. =ain a more rapid systemic effect '. 'elay resistance and increase the tuberculostatic effect nswer: *'+ 'elay resistance and increase the tuberculostatic effect "ulmonary T$ is treated primarily with chemotherapeutic agents for ?-1, mons. prolonged treatment duration is

necessary to ensure eradication of the organisms and to pre)ent relapse. The increasing pre)alence of drug resistance points to the need to begin the treatment with drugs in combination. @sing drugs in combination can delay the drug resistance. ,,. Mario undergoes a left thoracotomy and a partial pneumonectomy. %hest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. (n the postanesthesia care unit Mario is placed in Fowler:s position on either his right side or on his bac7 to . 2educe incisional pain. $. Facilitate )entilation of the left lung. %. H8uali>e pressure in the pleural space. '. (ncrease )enous return nswer: *$+ Facilitate )entilation of the left lung. .ince only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Ceft lung by positioning the client on the opposite unoperated side. ,-. client with %/"' is being prepared for discharge. The following are rele)ant instructions to the client regarding the use of an oral inhaler HJ%H"T . $reath in and out as fully as possible before placing the mouthpiece inside the mouth. $. (nhale slowly through the mouth as the canister is pressed down %. 6old his breath for about 11 seconds before exhaling '. .lowly breath out through the mouth with pursed lips after inhaling the drug. nswer: *'+ .lowly breath out through the mouth with pursed lips after inhaling the drug. (f the client breathes out through the mouth with pursed lips, this can easily force the Gust inhaled drug out of the respiratory tract that will lessen its effecti)eness. ,0. client is scheduled for a bronchoscopy. &hen teaching the client what to expect afterward, the nurse:s highest priority of information would be . Food and fluids will be withheld for at least , hours. $. &arm saline gargles will be done 8 ,h. %. %oughing and deep-breathing exercises will be done 8,h. '. /nly ice chips and cold li8uids will be allowed initially. nswer: * + Food and fluids will be withheld for at least , hours. "rior to bronchoscopy, the doctors sprays the bac7 of the throat with anesthetic to minimi>e the gag reflex and thus facilitate the insertion of the bronchoscope. =i)ing the client food and drin7 after the procedure without chec7ing on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours. ,5. The nurse enters the room of a client with chronic obstructi)e pulmonary disease. The client:s nasal cannula oxygen is running at a rate of ? C per minute, the s7in color is pin7, and the respirations are D per minute and shallow. &hat is the nurses best initial action9 . Ta7e heart rate and blood pressure. $. %all the physician. %. Cower the oxygen rate. '. "osition the client in a Fowler:s position. nswer: *%+ Cower the oxygen rate. The client with %/"' is suffering from chronic %/,

retention. The hypoxic dri)e is his chief stimulus for breathing. =i)ing /, inhalation at a rate that is more than ,-C4min can ma7e the client lose his hypoxic dri)e which can be assessed as decreasing 22. ,?. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. &hich is the most appropriate nursing diagnosis for this patient9 . Fluid )olume deficit $. 'ecreased tissue perfusion. %. (mpaired gas exchange. '. 2is7 for infection nswer: *%+ (mpaired gas exchange. "neumonia, which is an infection, causes lobar consolidation thus impairing gas exchange between the al)eoli and the blood. $ecause the patient would re8uire ade8uate hydration, this ma7es him prone to fluid )olume excess. ,B. nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded face. &hich additional assessment finding would lead the nurse to suspect that the client has %ushings syndrome rather than obesity9 . large thighs and upper arms $. pendulous abdomen and large hips %. abdominal striae and an7le enlargement '. posterior nec7 fat pad and thin extremities nswer: *'+ posterior nec7 fat pad and thin extremities !$uffalo hump# is the accumulation of fat pads o)er the upper bac7 and nec7. Fat may also accumulate on the face. There is truncal obesity but the extremities are thin. ll these are noted in a client with %ushings syndrome. ,3. &hich statement by the client indicates understanding of the possible side effects of "rednisone therapy9 . !( should limit my potassium inta7e because hyper7alemia is a side-effect of this drug.# $. !( must ta7e this medicine exactly as my doctor ordered it. ( shouldnt s7ip doses.# %. !This medicine will protect me from getting any colds or infection.# '. !My incision will heal much faster because of this drug.# nswer: *$+ !( must ta7e this medicine exactly as my doctor ordered it. ( shouldnt s7ip doses.# The possible side effects of steroid administration are hypo7alemia, increase tendency to infection and poor wound healing. %lients on the drug must follow strictly the doctors order since s7ipping the drug can lower the drug le)el in the blood that can trigger acute adrenal insufficiency or ddisonian %risis ,D. client, who is suspected of ha)ing "heochromocytoma, complains of sweating, palpitation and headache. &hich assessment is essential for the nurse to ma7e first9 . "upil reaction $. 6and grips %. $lood pressure '. $lood glucose nswer: *%+ $lood pressure "heochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can ele)ate the blood pressure. -1. The nurse is attending a bridal shower for a friend when another guest, who happens to be a diabetic, starts to tremble and complains of di>>iness. The next best action for the nurse to ta7e is to:

. Hncourage the guest to eat some ba7ed macaroni $. %all the guests personal physician %. /ffer the guest a cup of coffee '. =i)e the guest a glass of orange Guice nswer: *'+ =i)e the guest a glass of orange Guice (n diabetic patients, the nurse should watch out for signs of hypoglycemia manifested by di>>iness, tremors, wea7ness, pallor diaphoresis and tachycardia. &hen this occurs in a conscious client, he should be gi)en immediately carbohydrates in the form of fruit Guice, hard candy, honey or, if unconscious, glucagons or dextrose per (E. -1. n adult, who is newly diagnosed with =ra)es disease, as7s the nurse, !&hy do ( need to ta7e "ropanolol *(nderal+9# $ased on the nurses understanding of the medication and =ra)es disease, the best response would be: . !The medication will limit thyroid hormone secretion.# $. !The medication limit synthesis of the thyroid hormones.# %. !The medication will bloc7 the cardio)ascular symptoms of =ra)es disease.# '. !The medication will increase the synthesis of thyroid hormones.# nswer: *%+ !The medication will bloc7 the cardio)ascular symptoms of =ra)es disease.# "ropranolol *(nderal+ is a beta-adrenergic bloc7er that controls the cardio)ascular manifestations brought about by increased secretion of the thyroid hormone in =ra)es disease. -,. 'uring the first ,0 hours after thyroid surgery, the nurse should include in her care: . %hec7ing the bac7 and sides of the operati)e dressing $. .upporting the head during mild range of motion exercise %. Hncouraging the client to )entilate her feelings about the surgery '. d)ising the client that she can resume her normal acti)ities immediately nswer: * + %hec7ing the bac7 and sides of the operati)e dressing Following surgery of the thyroid gland, bleeding is a potential complication. This can best be assessed by chec7ing the bac7 and the sides of the operati)e dressing as the blood may flow towards the side and bac7 lea)ing the front dry and clear of drainage. --. /n discharge, the nurse teaches the patient to obser)e for signs of surgically induced hypothyroidism. The nurse would 7now that the patient understands the teaching when she states she should notify the M' if she de)elops: . (ntolerance to heat $. 'ry s7in and fatigue %. "rogressi)e weight gain '. (nsomnia and excitability nswer: *%+ "rogressi)e weight gain 6ypothyroidism, a decrease in thyroid hormone production, is characteri>ed by hypometabolism that manifests itself with weight gain. -0. &hat is the best reason for the nurse in instructing the client to rotate inGection sites for insulin9 . Cipodystrophy can result and is extremely painful $. "oor rotation techni8ue can cause superficial

hemorrhaging %. Cipodystrophic areas can result, causing erratic insulin absorption rates from these '. (nGection sites can ne)er be reused nswer: *%+ Cipodystrophic areas can result, causing erratic insulin absorption rates from these Cipodystrophy is the de)elopment of fibrofatty masses at the inGection site caused by repeated use of an inGection site. (nGecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions. -5. &hich of the following would be inappropriate to include in a diabetic teaching plan9 . %hange position hourly to increase circulation $. (nspect feet and legs daily for any changes %. Feep legs ele)ated on , pillows while sleeping '. Feep the insulin not in use in the refrigerator nswer: *%+ Feep legs ele)ated on , pillows while sleeping The client with 'M has decreased peripheral circulation caused by microangiopathy. Feeping the legs ele)ated during sleep will further cause circulatory impairment. -?. (ncluded in the plan of care for the immediate postgastroscopy period will be: . Maintain A=T to intermittent suction $. ssess gag reflex prior to administration of fluids %. ssess for pain and medicate as ordered '. Measure abdominal girth e)ery 0 hours nswer: *$+ ssess 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. =i)ing fluids and food at this time can lead to aspiration. -?. (ncluded in the plan of care for the immediate postgastroscopy period will be: . Maintain A=T to intermittent suction $. ssess gag reflex prior to administration of fluids %. ssess for pain and medicate as ordered '. Measure abdominal girth e)ery 0 hours nswer: *$+ ssess 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. =i)ing fluids and food at this time can lead to aspiration. -B. &hich description of pain would be most characteristic of a duodenal ulcer9 . =nawing, dull, aching, hungerli7e pain in the epigastric area that is relie)ed by food inta7e $. 2@K pain that increases after meal %. .harp pain in the epigastric area that radiates to the right shoulder '. sensation of painful pressure in the midsternal area nswer: * + =nawing, dull, aching, hungerli7e pain in the epigastric area that is relie)ed by food inta7e 'uodenal ulcer is related to an increase in the secretion of 6%l. This can be buffered by food inta7e thus the relief of the pain that is brought about by food inta7e. -3. The client underwent $illroth surgery for gastric ulcer. "ost-operati)ely, the drainage from his A=T is thic7 and the )olume of secretions has dramatically reduced in the last ,

hours and the client feels li7e )omiting. The most appropriate nursing action is to: . 2eposition the A=T by ad)ancing it gently A.. $. Aotify the M' of your findings %. (rrigate the A=T with 51 cc of sterile '. 'iscontinue the low-intermittent suction nswer: *$+ Aotify the M' of your findings The clients feeling of )omiting and the reduction in the )olume of A=T drainage that is thic7 are signs of possible abdominal distention caused by obstruction of the A=T. This should be reported immediately to the M' to pre)ent tension and rupture on the site of anastomosis caused by gastric distention. -D. fter $illroth (( .urgery, the client de)eloped dumping syndrome. &hich of the following should the nurse exclude in the plan of care9 . .it upright for at least -1 minutes after meals $. Ta7e only sips of 6,/ between bites of solid food %. Hat small meals e)ery ,-- hours '. 2educe the amount of simple carbohydrate in the diet nswer: * + .it upright for at least -1 minutes after meals The dumping syndrome occurs within -1 mins after a meal due to rapid gastric emptying, causing distention of the duodenum or GeGunum produced by a bolus of food. To delay the emptying, the client has to lie down after meals. .itting up after meals will promote the dumping syndrome. 01. The laboratory of a male patient with "eptic ulcer re)ealed an ele)ated titer of 6elicobacter pylori. &hich of the following statements indicate an understanding of this data9 . Treatment will include 2anitidine and ntibiotics $. Ao treatment is necessary at this time %. This result indicates gastric cancer caused by the organism '. .urgical treatment is necessary nswer: * + Treatment will include 2anitidine and ntibiotics /ne of the causes of peptic ulcer is 6. "ylori infection. (t releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epitheliums resistance to acid digestion. =i)ing antibiotics will control the infection and 2anitidine, which is a histamine-, bloc7er, will reduce acid secretion that can lead to ulcer. 01. &hat instructions should the client be gi)en before undergoing a paracentesis9 . A"/ 1, hours before procedure $. Hmpty bladder before procedure %. .trict bed rest following procedure '. Hmpty bowel before procedure nswer: *$+ Hmpty bladder before procedure "aracentesis in)ol)es the remo)al of ascitic fluid from the peritoneal ca)ity through a puncture made below the umbilicus. The client needs to )oid before the procedure to pre)ent accidental puncture of a distended bladder during the procedure. 0,. The husband of a client as7s the nurse about the proteinrestricted diet ordered because of ad)anced li)er disease. &hat statement by the nurse would best explain the purpose of the diet9

. !The li)er cannot rid the body of ammonia that is made by the brea7down of protein in the digesti)e system.# $. !The li)er heals better with a high carbohydrates diet rather than protein.# %. !Most people ha)e too much protein in their diets. The amount of this diet is better for li)er healing.# '. !$ecause of portal hyperemesis, the blood flows around the li)er and ammonia made from protein collects in the brain causing hallucinations.# nswer: * + !The li)er cannot rid the body of ammonia that is made by the brea7down of protein in the digesti)e system.# The largest source of ammonia is the en>ymatic and bacterial digestion of dietary and blood proteins in the =( tract. protein-restricted diet will therefore decrease ammonia production. 0-. &hich of the drug of choice for pain controls the patient with acute pancreatitis9 . Morphine $. A. ('. %. Meperidine '. %odeine nswer: *%+ Meperidine "ain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. 'emerol is the drug of choice because it is less li7ely to cause spasm of the .phincter of /ddi unli7e Morphine which is spasmogenic. 00. (mmediately after cholecystectomy, the nursing action that should assume the highest priority is: . encouraging the client to ta7e ade8uate deep breaths by mouth $. encouraging the client to cough and deep breathe %. changing the dressing at least $(' '. irrigate the T-tube fre8uently nswer: *$+ encouraging the client to cough and deep breathe %holecystectomy re8uires a subcostal incision. To minimi>e pain, clients ha)e a tendency to ta7e shallow breaths which can lead to respiratory complications li7e pneumonia and atelectasis. 'eep breathing and coughing exercises can help pre)ent such complications. 05. .engsta7en-$la7emore tube is inserted in the effort to stop the bleeding esophageal )arices in a patient with complicated li)er cirrhosis. @pon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to: . 'eflate the esophageal balloon $. Monitor E. %. Hncourage him to ta7e deep breaths '. Aotify the M' nswer: * + 'eflate the esophageal balloon &hen a client with a .engsta7en-$la7emore tube de)elops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction 0?. The client presents with se)ere rectal bleeding, 1? diarrheal stools a day, se)ere abdominal pain, tenesmus and dehydration. $ecause of these symptoms the nurse should be alert for other problems associated with what disease9

. %hrons disease $. @lcerati)e colitis %. 'i)erticulitis '. "eritonitis nswer: *$+ @lcerati)e colitis @lcerati)e colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. @lcerations lead to sloughing that causes stools as many as 11-,1 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem. 0B. client is being e)aluated for cancer of the colon. (n preparing the client for barium enema, the nurse should: . =i)e laxati)e the night before and a cleansing enema in the morning before the test $. 2ender an oil retention enema and gi)e laxati)e the night before %. (nstruct the client to swallow ? radiopa8ue tablets the e)ening before the study '. "lace the client on %$2 a day before the study nswer: * + =i)e laxati)e the night before and a cleansing enema in the morning before the test $arium enema is the radiologic )isuali>ation 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 laxati)e and enema. 03. The client has a good understanding of the means to reduce the chances of colon cancer when he states: . !( will exercise daily.# $. !( will include more red meat in my diet.# %. !( will ha)e an annual chest x-ray.# '. !( will include more fresh fruits and )egetables in my diet.# nswer: *'+ !( will include more fresh fruits and )egetables in my diet.# Aumerous aspects of diet and nutrition may contribute to the de)elopment of cancer. low-fiber diet, such as when fresh fruits and )egetables are minimal or lac7ing in the diet, slows transport of materials through the gut which has been lin7ed to colorectal cancer. 0D. 'ays after abdominal surgery, the clients wound dehisces. The safest nursing inter)ention when this occurs is to . %o)er the wound with sterile, moist saline dressing $. pproximate the wound edges with tapes %. (rrigate the wound with sterile saline '. 6old the abdominal contents in place with a sterile glo)ed hand nswer: * + %o)er the wound with sterile, moist saline dressing 'ehiscence is the partial or complete separation of the surgical wound edges. &hen this occurs, the client is placed in low Fowlers position and instructed to lie 8uietly. The wound should be co)ered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to pre)ent the dressing from stic7ing to the wound which can disturb the healing process.

51. n intra)enous pyelogram re)eals that "aulo, age -5, has a renal calculus. 6e is belie)ed to ha)e a small stone that will pass spontaneously. To increase the chance of the stone passing, the nurse would instruct the client to force fluids and to . .train all urine. $. mbulate. %. 2emain on bed rest. '. s7 for medications to relax him. nswer: *$+ mbulate. Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobili>e the stone and by increased fluid inta7e which will flush out the stone during urination. 51. female client is admitted with a diagnosis of acute renal failure. .he is awa7e, alert, oriented, and complaining of se)ere bac7 pain, nausea and )omiting and abdominal cramps. 6er )ital signs are blood pressure 1114B1 mm 6g, pulse 111, respirations -1, and oral temperature 111.0LF *-3L%+. 6er electrolytes are sodium 1,1 mH84C, potassium 5., mH84CM her urinary output for the first 3 hours is 51 ml. The client is displaying signs of which electrolyte imbalance9 . 6yponatremia $. 6yper7alemia %. 6yperphosphatemia '. 6ypercalcemia nswer: * + 6yponatremia The normal serum sodium le)el is 1-5 I 105 mH84C. The clients serum sodium is below normal. 6yponatremia also manifests itself with abdominal cramps and nausea and )omiting 5,. ssessing the laboratory findings, which result would the nurse most li7ely expect to find in a client with chronic renal failure9 . $@A 11 to -1 mg4dl, potassium 0.1 mH84C, creatinine 1.5 to 1.5 mg4dl $. 'ecreased serum calcium, blood p6 B.,, potassium ?.5 mH84C %. $@A 15 mg4dl, increased serum calcium, creatinine l.1 mg4dl '. $@A -5 to 01 mg4dl, potassium -.5 mH84C, p6 B.-5, decreased serum calcium nswer: *$+ 'ecreased serum calcium, blood p6 B.,, potassium ?.5 mH84C %hronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. &ith the loss of renal function, the 7idneys ability to regulate fluid and electrolyte and acid base balance results. The serum %a decreases as the 7idneys fail to excrete phosphate, potassium and hydrogen ions are retained. 5-. Treatment with hemodialysis is ordered for a client and an external shunt is created. &hich nursing action would be of highest priority with regard to the external shunt9 . 6eparini>e it daily. $. )oid ta7ing blood pressure measurements or blood samples from the affected arm. %. %hange the .ilastic tube daily. '. (nstruct the client not to use the affected arm. nswer: *$+ )oid ta7ing blood pressure measurements or

blood samples from the affected arm. (n the client with an external shunt, dont use the arm with the )ascular access site to ta7e blood pressure readings, draw blood, insert (E lines, or gi)e inGections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt. 50. 2omeo 'ia>, age B3, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia *$"6+. 6e is scheduled for a transurethral resection of the prostate *T@2"+. (t would be inappropriate to include which of the following points in the preoperati)e teaching9 . T@2" is the most common operation for $"6. $. Hxplain the purpose and function of a two-way irrigation system. %. Hxpect bloody urine, which will clear as healing ta7es place. '. 6e will be pain free. nswer: *'+ 6e will be pain free. .urgical inter)entions in)ol)e an experience of pain for the client which can come in )arying degrees. Telling the pain that he will be pain free is gi)ing him false reassurance. 55. 2oxy is admitted to the hospital with a possible diagnosis of appendicitis. /n physical examination, the nurse should be loo7ing for tenderness on palpation at Mc$urneys point, which is located in the . left lower 8uadrant $. left upper 8uadrant %. right lower 8uadrant '. right upper 8uadrant nswer: *%+ right lower 8uadrant To be exact, the appendix is anatomically located at the Mc $urneys point at the right iliac area of the right lower 8uadrant. 5?. Mr. Ealde> has undergone surgical repair of his inguinal hernia. 'ischarge teaching should include . telling him to a)oid hea)y lifting for 0 to ? wee7s $. instructing him to ha)e a soft bland diet for two wee7s %. telling him to resume his pre)ious daily acti)ities without limitations '. recommending him to drin7 eight glasses of water daily nswer: * + telling him to a)oid hea)y lifting for 0 to ? wee7s The client should a)oid lifting hea)y obGects and any strenuous acti)ity for 0-? wee7s after surgery to pre)ent stress on the inguinal area. There is no special diet re8uired. The fluid inta7e of eight glasses a day is good ad)ice but is not a priority in this case. 5B. -1-year-old homema7er fell asleep while smo7ing a cigarette. .he sustained se)ere burns of the face,nec7, anterior chest, and both arms and hands. @sing the rule of nines, which is the best estimate of total body-surface area burned9 . 13; $. ,,; %. -1; '. 01; nswer: *%+ -1; @sing the 2ule of Aine in the estimation of total body surface burned, we allot the following: D; - headM D; - each upper extremityM 13;- front chest and abdomenM 13; - entire bac7M

13; - each lower extremity and 1; - perineum. 53. Aursing care planning is based on the 7nowledge that the first ,0-03 hours post-burn are characteri>ed by: . n increase in the total )olume of intracranial plasma $. Hxcessi)e renal perfusion with diuresis %. Fluid shift from interstitial space '. Fluid shift from intra)ascular space to the interstitial space nswer: *'+ Fluid shift from intra)ascular space to the interstitial space This period is the burn shoc7 stage or the hypo)olemic phase. Tissue inGury causes )asodilation that results in increase capillary permeability ma7ing fluids shift from the intra)ascular to the interstitial space. This can lead to a decrease in circulating blood )olume or hypo)olemia which decreases renal perfusion and urine output. 5D. (f a client has se)ere bums on the upper torso, which item would be a primary concern9 . 'ebriding and co)ering the wounds $. dministering antibiotics %. Fre8uently obser)ing for hoarseness, stridor, and dyspnea '. Hstablishing a patent (E line for fluid replacement nswer: *%+ Fre8uently obser)ing for hoarseness, stridor, and dyspnea $urns located in the upper torso, especially resulting from thermal inGury related to fires can lead to inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a patent airway is a primary concern. ?1. %ontractures are among the most serious long-term complications of se)ere burns. (f a burn is located on the upper torso, which nursing measure would be least effecti)e to help pre)ent contractures9 . %hanging the location of the bed or the TE set, or both, daily $. Hncouraging the client to chew gum and blow up balloons %. )oiding the use of a pillow for sleep, or placing the head in a position of hyperextension '. 6elping the client to rest in the position of maximal comfort nswer: *'+ 6elping the client to rest in the position of maximal comfort Mobility and placing the burned areas in their functional position can help pre)ent contracture deformities related to burns. "ain can immobili>e a client as he see7s the position where he finds less pain and pro)ides maximal comfort. $ut this approach can lead to contracture deformities and other complications. ?1. n adult is recei)ing Total "arenteral Autrition *T"A+. &hich of the following assessment is essential9 . e)aluation of the peripheral (E site $. confirmation that the tube is in the stomach %. assess the bowel sound '. fluid and electrolyte monitoring nswer: *'+ fluid and electrolyte monitoring Total parenteral nutrition is a method of pro)iding nutrients to the body by an (E route. The admixture is made up of proteins, carbohydrates, fats, electrolytes, )itamins, trace minerals and sterile water based on indi)idual client needs. (t is intended to impro)e the clients nutritional status. $ecause

of its composition, it is important to monitor the clients fluid inta7e and output including electrolytes, blood glucose and weight. ?,. &hich drug would be least effecti)e in lowering a client:s serum potassium le)el9 . =lucose and insulin $. "olystyrene sulfonate *Fayexalate+ %. %alcium glucomite '. luminum hydroxide nswer: *'+ luminum hydroxide luminum hydroxide binds dietary phosphorus in the =( tract and helps treat hyperphosphatemia. ll the other medications mentioned help treat hyper7alemia and its effects. ?-. nurse is directed to administer a hypotonic intra)enous solution. Coo7ing at the following labeled solutions, she should choose . 1.05; Aa%l $. 1.D; Aa%l %. '5& '. '5A.. nswer: * + 1.05; Aa%l 6ypotonic solutions li7e 1.05; Aa%l has a lower tonicity that the bloodM 1.D; Aa%l and '5& are isotonic solutions with same tonicity as the bloodM and '5A.. is hypertonic with a higher tonicity thab the blood. ?0. patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypo)olemia would cause all of the following symptoms HJ%H"T . hypertension $. oliguria %. tachycardia '. tachypnea nswer: * + hypertension (n hypo)olemia, one of the compenasatory mechanisms is acti)ation of the sympathetic ner)ous system that increases the 22 N "2 and helps restore the $" to maintain tissue perfusion but not cause a hypertension. The .A. stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration and increases sodium N water reabsorption that leads to oliguria. ?5. Maria .ison, 01 years old, single, was admitted to the hospital with a diagnosis of $reast %ancer. .he was scheduled for radical mastectomy. Aursing care during the preoperati)e period should consist of . assuring Maria that she will be cured of cancer $. assessing Maria:s expectations and doubts %. maintaining a cheerful and optimistic en)ironment '. 7eeping Maria:s )isitors to a minimum so she can ha)e time for herself nswer: *$+ assessing Maria:s expectations and doubts ssessing the clients expectations and doubts will help lessen her fears and anxieties. The nurse needs to encourage the client to )erbali>e and to listen and correctly pro)ide explanations when needed. ??. Maria refuses to ac7nowledge that her breast was remo)ed. .he belie)es that her breast is intact under the dressing. The nurse should

. call the M' to change the dressing so Fathy can see the incision $. recogni>e that Fathy is experiencing denial, a normal stage of the grie)ing process %. reinforce Fathys belief for se)eral days until her body can adGust to stress of surgery. '. remind Fathy that she needs to accept her diagnosis so that she can begin rehabilitation exercises. nswer: *$+ recogni>e that Fathy is experiencing denial, a normal stage of the grie)ing process person grie)es to a loss of a significant obGect. The initial stage in the grie)ing process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patients feelings and encourage )erbali>ation. ?B. chemotherapeutic agent 5F@ is ordered as an adGunct measure to surgery. &hich of the ff. statements about chemotherapy is true9 . it is a local treatment affecting only tumor cells $. it affects both normal and tumor cells %. it has been pro)en as a complete cure for cancer '. it is often used as a palliati)e measure. nswer: *$+ it affects both normal and tumor cells %hemotherapeutic agents are gi)en to destroy the acti)ely proliferating cancer cells. $ut these agents cannot differentiate the abnormal acti)ely proliferating cancer cells from those that are acti)ely proliferating normal cells li7e the cells of the bone marrow, thus the effect of bone marrow depression. ?3. &hich is an incorrect statement pertaining to the following procedures for cancer diagnostics9 . $iopsy is the remo)al of suspicious tissue and the only definiti)e method to diagnose cancer $. @ltrasonography detects tissue density changes difficult to obser)e by J-ray )ia sound wa)es. %. %T scanning uses magnetic fields and radio fre8uencies to pro)ide cross-sectional )iew of tumor '. Hndoscopy pro)ides direct )iew of a body ca)ity to detect abnormality. nswer: *%+ %T scanning uses magnetic fields and radio fre8uencies to pro)ide cross-sectional )iew of tumor %T scan uses narrow beam x-ray to pro)ide cross-sectional )iew. M2( uses magnetic fields and radio fre8uencies to detect tumors. ?D. post-operati)e complication of mastectomy is lymphedema. This can be pre)ented by . ensuring patency of wound drainage tube $. placing the arm on the affected side in a dependent position %. restricting mo)ement of the affected arm '. fre8uently ele)ating the arm of the affected side abo)e the le)el of the heart. nswer: *'+ fre8uently ele)ating the arm of the affected side abo)e the le)el of the heart. Hle)ating the arm abo)e the le)el of the heart promotes good )enous return to the heart and good lymphatic drainage thus pre)enting swelling. B1. &hich statement by the client indicates to the nurse that the patient understands precautions necessary during internal radiation therapy for cancer of the cer)ix9 . !( should get out of bed and wal7 around in my room.#

$. !My B year old twins should not come to )isit me while (m recei)ing treatment.# %. !( will try not to cough, because the force might ma7e me expel the application.# '. !( 7now that my primary nurse has to wear one of those badges li7e the people in the x-ray department, but they are not necessary for anyone else who comes in here.# nswer: *$+ !My B year old twins should not come to )isit me while (m recei)ing treatment.# %hildren ha)e cells that are normally acti)ely di)iding in the process of growth. 2adiation acts not only against the abnormally acti)ely di)iding cells of cancer but also on the normally di)iding cells thus affecting the growth and de)elopment of the child and e)en causing cancer itself. B1. 6igh uric acid le)els may de)elop in clients who are recei)ing chemotherapy. This is caused by: . The inability of the 7idneys to excrete the drug metabolites $. 2apid cell catabolism %. Toxic effect of the antibiotic that are gi)en concurrently '. The altered blood ph from the acid medium of the drugs nswer: *$+ 2apid cell catabolism /ne of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction of large number of tumor cells. . (ntracellular contents are released, including potassium and purines, into the bloodstream faster than the body can eliminate them. The purines are con)erted in the li)er to uric acid and released into the blood causing hyperuricemia. They can precipitate in the 7idneys and bloc7 the tubules causing acute renal failure. B,. &hich of the following inter)entions would be included in the care of plan in a client with cer)ical implant9 . Fre8uent ambulation $. @nlimited )isitors %. Cow residue diet '. Eaginal irrigation e)ery shift nswer: *%+ Cow residue diet (t is important for the nurse to remember that the implant be 7ept intact in the cer)ix during therapy. Mobility and )aginal irrigations are not done. low residue diet will pre)ent bowel mo)ement that could lead to dislodgement of the implant. "atient is also strictly isolated to protect other people from the radiation emissions B-. &hich nursing measure would a)oid constriction on the affected arm immediately after mastectomy9 . )oid $" measurement and constricting clothing on the affected arm $. cti)e range of motion exercises of the arms once a day. %. 'iscourage feeding, washing or combing with the affected arm '. "lace the affected arm in a dependent position, below the le)el of the heart nswer: * + )oid $" measurement and constricting clothing on the affected arm $" cuff constricts the blood )essels where it is applied. $" measurements should be done on the unaffected arm to ensure ade8uate circulation and )enous and lymph drainage in the affected arm

B0. client suffering from acute renal failure has an unexpected increase in urinary output to 151ml4hr. The nurse assesses that the client has entered the second phase of acute renal failure. Aursing actions throughout this phase include obser)ation for signs and symptoms of . 6yper)olemia, hypo7alemia, and hypernatremia. $. 6yper)olemia, hyper7alemia, and hypernatremia. %. 6ypo)olemia, wide fluctuations in serum sodium and potassium le)els. '. 6ypo)olemia, no fluctuation in serum sodium and potassium le)els. nswer: *%+ 6ypo)olemia, wide fluctuations in serum sodium and potassium le)els. The second phase of 2F is the diuretic phase or high output phase. The diuresis can result in an output of up to 11C4day of dilute urine. Coss of fluids and electrolytes occur. B5. n adult has Gust been brought in by ambulance after a motor )ehicle accident. &hen assessing the client, the nurse would expect which of the following manifestations could ha)e resulted from sympathetic ner)ous system stimulation9 . rapid pulse and increased 22 $. 'ecreased physiologic functioning %. 2igid posture and altered perceptual focus '. (ncreased awareness and attention nswer: * + rapid pulse and increased 22 The fight or flight reaction of the sympathetic ner)ous system occurs during stress li7e in a motor )ehicular accident. This is manifested by increased in cardio)ascular function and 22 to pro)ide the immediate needs of the body for sur)i)al. B?. Ms. .y undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. &hen she arri)es in the 22 she is still in shoc7. The nurse:s priority should be . placing her in a trendeleburg position $. putting se)eral warm blan7ets on her %. monitoring her hourly urine output '. assessing her E. especially her 22 nswer: *'+ assessing her E. especially her 22 .hoc7 is characteri>ed by reduced tissue and organ perfusion and e)entual organ dysfunction and failure. %hec7ing on the E. especially the 22, which detects need for oxygenation, is a priority to help detect its progress and pro)ide for prompt management before the occurrence of complications. BB. maGor goal for the client during the first 03 hours after a se)ere bum is to pre)ent hypo)olemic shoc7. The best indicator of ade8uate fluid balance during this period is . Hle)ated hematocrit le)els. $. @rine output of -1 to 51 ml4hr. %. %hange in le)el of consciousness. '. Hstimate of fluid loss through the burn eschar. nswer: *$+ @rine output of -1 to 51 ml4hr. 6ypo)olemia is a decreased in circulatory )olume. This causes a decrease in tissue perfusion to the different organs of the body. Measuring the hourly urine output is the most 8uantifiable way of measuring tissue perfusion to the organs. Aormal renal perfusion should produce 1ml47g of $&4min. n output of -1-51 ml4hr is considered ade8uate and

indicates good fluid balance. B3. thoracentesis is performed on a chest-inGured client, and no fluid or air is found. $lood and fluids is administered intra)enously *(E+, but the client:s )ital signs do not impro)e. central )enous pressure line is inserted, and the initial reading is ,1 cm 6O/. The most li7ely cause of these findings is which of the following9 . .pontaneous pneumothorax $. 2uptured diaphragm %. 6emothorax '. "ericardial tamponade nswer: *'+ "ericardial tamponade "ericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the )entricles causing a decrease in )entricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and )enous congestion manifested by a %E" reading abo)e normal. BD. (nter)ention for a pt. who has swallowed a Muriatic cid includes all of the following except . administering an irritant that will stimulate )omiting $. aspirating secretions from the pharynx if respirations are affected %. neutrali>ing the chemical '. washing the esophagus with large )olumes of water )ia gastric la)age nswer: * + administering an irritant that will stimulate )omiting .wallowing of corrosi)e substances causes se)ere irritation and tissue destruction of the mucous membrane of the =( tract. Measures are ta7en to immediately remo)e the toxin or reduce its absorption. For corrosi)e poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric la)age and the administration of acti)ated charcoal to absorb the poison. dministering an irritant with the concomitant )omiting to remo)e the swallowed poison will further cause irritation and damage to the mucosal lining of the digesti)e tract. Eomiting is only indicated when non-corrosi)e poison is swallowed. 31. &hich initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest9 . .7in warm and dry $. "upils e8ual and react to light %. "alpable carotid pulse '. "ositi)e $abins7i:s reflex nswer: *%+ "alpable carotid pulse "resence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of %"2. "ulsations in arteries indicates blood flowing in the blood )essels with each cardiac contraction. .igns of effecti)e tissue perfusion will be noted after. 31. %hemical burn of the eye are treated with . local anesthetics and antibacterial drops for ,0 I -? hrs. $. hot compresses applied at 15-minute inter)als %. Flushing of the lids, conGuncti)a and cornea with tap or preferably sterile water '. cleansing the conGuncti)a with a small cotton-tipped applicator

nswer: *%+ Flushing of the lids, conGuncti)a and cornea with tap or preferably sterile water "rompt treatment of ocular chemical burns is important to pre)ent further damage. (mmediate tap-water eye irrigation should be started on site e)en before transporting the patient to the nearest hospital facility. (n the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done. 3,. The 6eimlich maneu)er *abdominal thrust+, for acute airway obstruction, attempts to: . Force air out of the lungs $. (ncrease systemic circulation %. (nduce emptying of the stomach '. "ut pressure on the apex of the heart nswer: * + Force air out of the lungs The 6eimlich maneu)er is used to assist a person cho7ing on a foreign obGect. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material. 3-. Pohn, 1? years old, is brought to the H2 after a )ehicular accident. 6e is pronounced dead on arri)al. &hen his parents arri)e at the hospital, the nurse should: . as7 them to stay in the waiting area until she can spend time alone with them $. spea7 to both parents together and encourage them to support each other and express their emotions freely %. .pea7 to one parent at a time so that each can )entilate feelings of loss without upsetting the other '. as7 the M' to medicate the parents so they can stay calm to deal with their sons death. nswer: *$+ spea7 to both parents together and encourage them to support each other and express their emotions freely .udden death of a family member creates a state of shoc7 on the family. They go into a stage of denial and anger in their grie)ing. ssisting them with information they need to 7now, answering their 8uestions and listening to them will pro)ide the needed support for them to mo)e on and be of support to one another. 30. n emergency treatment for an acute asthmatic attac7 is drenaline 1:1111 gi)en hypodermically. This is gi)en to: . increase $" $. decrease mucosal swelling %. relax the bronchial smooth muscle '. decrease bronchial secretions nswer: *%+ relax the bronchial smooth muscle cute asthmatic attac7 is characteri>ed by se)ere bronchospasm which can be relie)ed by the immediate administration of bronchodilators. drenaline or Hpinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles. 35. nurse is performing %"2 on an adult patient. &hen performing chest compressions, the nurse understands the correct hand placement is located o)er the . upper half of the sternum $. upper third of the sternum %. lower half of the sternum '. lower third of the sternum nswer: *%+ lower half of the sternum The exact and safe location to do cardiac compression is the lower half of the sternum. 'oing it at the lower third of the

sternum may cause gastric compression which can lead to a possible aspiration. 3?. The nurse is performing an eye examination on an elderly client. The client states QMy )ision is blurred, and ( dont easily see clearly when ( get into a dar7 room.# The nurse best response is: . !Rou should be grateful you are not blind.# $. ! s one ages, )isual changes are noted as part of degenerati)e changes. This is normal.# %. !Rou should rest your eyes fre8uently.# '. !Rou maybe able to impro)e you )ision if you mo)e slowly.# nswer: *$+ ! s one ages, )isual changes are noted as part of degenerati)e changes. This is normal.# ging causes less elasticity of the lens affecting accommodation leading to blurred )ision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it ta7es the older person to adGust when going to and from light and dar7 en)ironment and needs brighter light for close )ision. 3B. &hich of the following acti)ities is not encouraged in a patient after an eye surgery9 . snee>ing, coughing and blowing the nose $. straining to ha)e a bowel mo)ement %. wearing tight shirt collars '. sexual intercourse nswer: *'+ sexual intercourse To reduce increases in (/", teach the client and family about acti)ity restrictions. .exual intercourse can cause a sudden rise in (/". 33. &hich of the following indicates poor practice in communicating with a hearing-impaired client9 . @se appropriate hand motions $. Feep hands and other obGects away from your mouth when tal7ing to the client %. .pea7 clearly in a loud )oice or shout to be heard '. %on)erse in a 8uiet room with minimal distractions nswer: *%+ .pea7 clearly in a loud )oice or shout to be heard .houting raises the fre8uency of the sound and often ma7es understanding the spo7en words difficult. (t is enough for the nurse to spea7 clearly and slowly. 3D. client is to undergo lumbar puncture. &hich is least important information about C"9 . .pecimens obtained should be labeled in their proper se8uence. $. (t may be used to inGect air, dye or drugs into the spinal canal. %. ssess mo)ements and sensation in the lower extremities after the '. Force fluids before and after the procedure. nswer: *'+ Force fluids before and after the procedure. C" in)ol)es the remo)al of some amount of spinal fluid. To facilitate %.F production, the client is instructed to increase fluid inta7e to -C, unless contraindicated, for ,0 to 03 hrs after the procedure. D1. client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Aursing care of the client includes the following HJ%H"T

. (nform the client that a warm, flushed feeling and a salty taste may be $. Maintain pressure dressing o)er the site of puncture and chec7 for %. %hec7 pulse, color and temperature of the extremity distal to the site of '. Fept the extremity used as puncture site flexed to pre)ent bleeding. nswer: *'+ Fept the extremity used as puncture site flexed to pre)ent bleeding. ngiography in)ol)es the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood )essel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be 7ept straight and immobili>ed during the duration of the bedrest after the procedure. (ce bag can be applied intermittently to the puncture site. D1. &hich is considered as the earliest sign of increased (%" that the nurse should closely obser)ed for9 . abnormal respiratory pattern $. rising systolic and widening pulse pressure %. contralateral hemiparesis and ipsilateral dilation of the pupils '. progression from restlessness to confusion and disorientation to lethargy nswer: *'+ progression from restlessness to confusion and disorientation to lethargy The first maGor effect of increasing (%" is a decrease in cerebral perfusion causing hypoxia that produces a progressi)e alteration in the C/%. This is initially manifested by restlessness. D,. &hich is irrele)ant in the pharmacologic management of a client with %E 9 . /smotic diuretics and corticosteroids are gi)en to decrease cerebral edema $. nticon)ulsants are gi)en to pre)ent sei>ures %. Thrombolytics are most useful within three hours of an occlusi)e %E '. spirin is used in the acute management of a completed stro7e. nswer: *'+ spirin is used in the acute management of a completed stro7e. The primary goal in the management of %E is to impro)e cerebral tissue perfusion. spirin is a platelet deaggregator used in the pre)ention of recurrent or embolic stro7e but is not used in the acute management of a completed stro7e as it may lead to bleeding. D-. &hat would be the M/.T therapeutic nursing action when a clients expressi)e aphasia is se)ere9 . nticipate the client wishes so she will not need to tal7 $. %ommunicate by means of 8uestions that can be answered by the client sha7ing the head %. Feep us a steady flow ran7 to minimi>e silence '. Hncourage the client to spea7 at e)ery possible opportunity. nswer: *'+ Hncourage the client to spea7 at e)ery possible opportunity. Hxpressi)e or motor aphasia is a result of damage in the

$rocas area of the frontal lobe. (t is amotor speech problem in which the client generally understands what is said but is unable to communicate )erbally. The patient can best he helped therefore by encouraging him to communicate and reinforce this beha)ior positi)ely. D0. client with head inGury is confused, drowsy and has une8ual pupils. &hich of the following nursing diagnosis is most important at this time9 . altered le)el of cogniti)e function $. high ris7 for inGury %. altered cerebral tissue perfusion '. sensory perceptual alteration nswer: *%+ altered cerebral tissue perfusion The obser)ations made by the nurse clearly indicate a problem of decrease cerebral perfusion. 2estoring cerebral perfusion is most important to maintain cerebral functioning and pre)ent further brain damage. D5. &hich nursing diagnosis is of the highest priority when caring for a client with myasthenia gra)is9 . "ain $. 6igh ris7 for inGury related to muscle wea7ness %. (neffecti)e coping related to illness '. (neffecti)e airway clearance related to muscle wea7ness nswer: *'+ (neffecti)e airway clearance related to muscle wea7ness Myasthenia gra)is causes a failure in the transmission of ner)e impulses at the neuromuscular Gunction which may be due to a wea7ening or decrease in acetylcholine receptor sites. This leads to sporadic, progressi)e wea7ness or abnormal fatigability of striated muscles that e)entually causes loss of function. The respiratory muscles can become wea7 with decreased tidal )olume and )ital capacity ma7ing breathing and clearing the airway through coughing difficult. The respiratory muscle wea7ness may be se)ere enough to re8uire and emergency airway and mechanical )entilation. D?. The client has clear drainage from the nose and ears after a head inGury. 6ow can the nurse determine if the drainage is %.F9 . Measure the ph of the fluid $. Measure the specific gra)ity of the fluid %. Test for glucose '. Test for chlorides nswer: *%+ Test for glucose The %.F contains a large amount of glucose which can be detected by using glucostix. positi)e result with the drainage indicate %.F lea7age. DB. The nurse includes the important measures for stump care in the teaching plan for a client with an amputation. &hich measure would be excluded from the teaching plan9 . &ash, dry, and inspect the stump daily. $. Treat superficial abrasions and blisters promptly. %. pply a <shrin7er< bandage with tighter arms around the proximal end of the affected limb. '. Toughen the stump by pushing it against a progressi)ely harder substance *e.g., pillow on a foot-stool+. nswer: *%+ pply a <shrin7er< bandage with tighter arms around the proximal end of the affected limb. The !shrin7er# bandage is applied to pre)ent swelling of the stump. (t should be applied with the distal end with the tighter arms. pplying the tighter arms at the proximal end

will impair circulation and cause swelling by reducing )enous flow. D3. B1-year-old female comes to the clinic for a routine chec7up. .he is 5 feet 0 inches tall and weighs 131 pounds. 6er maGor complaint is pain in her Goints. .he is retired and has had to gi)e up her )olunteer wor7 because of her discomfort. .he was told her diagnosis was osteoarthritis about 5 years ago. &hich would be excluded from the clinical pathway for this client9 . 'ecrease the calorie count of her daily diet. $. Ta7e warm baths when arising. %. .lide items across the floor rather than lift them. '. "lace items so that it is necessary to bend or stretch to reach them. nswer: *'+ "lace items so that it is necessary to bend or stretch to reach them. "atients with osteoarthritis ha)e decreased mobility caused by Goint pain. /)er-reaching and stretching to get an obGect are to be a)oided as this can cause more pain and can e)en lead to falls. The nurse should see to it therefore that obGects are within easy reach of the patient. DD. client is admitted from the emergency department with se)ere-pain and edema in the right foot. 6is diagnosis is gouty arthritis. &hen de)eloping a plan of care, which action would ha)e the highest priority9 . pply hot compresses to the affected Goints. $. .tress the importance of maintaining good posture to pre)ent deformities. %. dminister salicylates to minimi>e the inflammatory reaction. '. Hnsure an inta7e of at least -111 ml of fluid per day. nswer: *'+ Hnsure an inta7e of at least -111 ml of fluid per day. =outy arthritis is a metabolic disease mar7ed by urate deposits that cause painful arthritic Goints. The patient should be urged to increase his fluid inta7e to pre)ent the de)elopment of urinary uric acid stones. 111. client had a laminectomy and spinal fusion yesterday. &hich statement is to be excluded from your plan of care9 . $efore log rolling, place a pillow under the client:s head and a pillow between the client:s legs. $. $efore log rolling, remo)e the pillow from under the client:s head and use no pillows between the client:s legs. %. Feep the 7nees slightly flexed while the client is lying in a semi-Fowler:s position in bed. '. Feep a pillow under the client:s head as needed for comfort. nswer: *$+ $efore log rolling, remo)e the pillow from under the client:s head and use no pillows between the client:s legs. Following a laminectomy and spinal fusion, it is important that the bac7 of the patient be maintained in straight alignment and to support the entire )ertebral column to promote complete healing. 111. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the ff. as a priority in the plan of care9 . pro)iding emotional support to decrease fear $. protecting the client from infection

%. encouraging discussion about lifestyle changes '. identifying factors that decreased the immune function nswer: *$+ protecting the client from infection (mmunodeficiency is an absent or depressed immune response that increases susceptibility to infection. .o it is the nurses primary responsibility to protect the patient from infection. 11,. Poy, an obese -, year old, is admitted to the hospital after an automobile accident. .he has a fractured hip and is brought to the /2 for surgery. fter surgery Poy is to recei)e a piggy-bac7 of %lindamycin phosphate *%leocin+ -11 mg in 51 ml of '5&. The piggybac7 is to infuse in ,1 minutes. The drop factor of the (E set is 11 gtt4ml. The nurse should set the piggybac7 to flow at: . ,5 gtt4min $. -1 gtt4min %. -5 gtt4min '. 05 gtt4min nswer: * + ,5 gtt4min To get the correct flow rate: multiply the amount to be infused *51 ml+ by the drop factor *11+ and di)ide the result by the amount of time in minutes *,1+ 11-. The day after her surgery Poy as7s the nurse how she might lose weight. $efore answering her 8uestion, the nurse should bear in mind that long-term weight loss best occurs when: . Fats are controlled in the diet $. Hating habits are altered %. %arbohydrates are regulated '. Hxercise is part of the program nswer: *$+ Hating 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 110. The nurse teaches Poy, an obese client, the )alue of aerobic exercises in her weight reduction program. The nurse would 7now that this teaching was effecti)e when Poy says that exercise will: . (ncrease her lean body mass $. Cower her metabolic rate %. 'ecrease her appetite '. 2aise her heart rate nswer: * + (ncrease her lean body mass (ncreased exercise builds s7eletal muscle mass and reduces excess fatty tissue. 115. The physician orders non-weight bearing with crutches for Poy, who had surgery for a fractured hip. The most important acti)ity to facilitate wal7ing with crutches before ambulation begun is: . Hxercising the triceps, finger flexors, and elbow extensors $. .itting up at the edge of the bed to help strengthen bac7 muscles %. 'oing isometric exercises on the unaffected leg '. @sing the trape>e fre8uently for pull-ups to strengthen the biceps muscles

nswer: * + Hxercising the triceps, finger flexors, and elbow extensors These sets of muscles are used when wal7ing with crutches and therefore need strengthening prior to ambulation. 11?. The nurse recogni>es that a client understood the demonstration of crutch wal7ing when she places her weight on: . The palms and axillary regions $. $oth feet placed wide apart %. The palms of her hands '. 6er axillary regions nswer: *%+ The palms of her hands The palms should bear the clients weight to a)oid damage to the ner)es in the axilla *brachial plexus+ 11B. Poey is a 0? year-old radio technician who is admitted because of mild chest pain. 6e is 5 feet, 3 inches tall and weighs 1D1 pounds. 6e is diagnosed with a myocardial infarct. Morphine sulfate, 'ia>epam *Ealium+ and Cidocaine are prescribed. The physician orders 3 mg of Morphine .ulfate to be gi)en (E. The )ial on hand is labeled 1 ml4 11 mg. The nurse should administer: . 3 minims $. 11 minims %. 1, minims '. 15 minims nswer: *%+ 1, minims @sing ratio and proportion 3 mg411 mg S J minims415 minims 11 JS 1,1 J S 1, minims The nurse will administer 1, minims intra)enously e8ui)alent to 3mg Morphine .ulfate 113. Poey as7s the nurse why he is recei)ing the inGection of Morphine after he was hospitali>ed for se)ere anginal pain. The nurse replies that it: . &ill help pre)ent erratic heart beats $. 2elie)es pain and decreases le)el of anxiety %. 'ecreases anxiety '. 'ilates coronary blood )essels nswer: *$+ 2elie)es pain and decreases le)el of anxiety Morphine is a specific central ner)ous system depressant used to relie)e the pain associated with myocardial infarction. (t also decreases anxiety and apprehension and pre)ents cardiogenic shoc7 by decreasing myocardial oxygen demand. 11D. /xygen -C4min by nasal cannula is prescribed for Poey who is admitted to the hospital for chest pain. The nurse institutes safety precautions in the room because oxygen: . %on)erts to an alternate form of matter $. 6as unstable properties %. .upports combustion '. (s flammable nswer: *%+ .upports combustion The nurse should 7now that /xygen is necessary to produce fire, thus precautionary measures are important regarding its use. 111. Myra is ordered laboratory tests after she is admitted to the hospital for angina. The isoen>yme test that is the most

reliable early indicator of myocardial insult is: . .="T $. C'6 %. %F-M$ '. .T nswer: *%+ %F-M$ The cardiac mar7er, %reatinine phospho7inase *%"F+ isoen>yme le)els, especially the M$ sub-unit which is cardio-specific, begin to rise in --? hours, pea7 in 1,-13 hours and are ele)ated 03 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac mar7ers ele)ate as a result of myocardial tissue damage. 111. n early finding in the HF= of a client with an infarcted mycardium would be: . 'isappearance of K wa)es $. Hle)ated .T segments %. bsence of " wa)e '. Flattened T wa)es nswer: *$+ Hle)ated .T segments 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 M(. 11,. Pose, who had a myocardial infarction , days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to: . llow him to release his feelings and then lea)e him alone to allow him to regain his composure $. 2efocus the con)ersation on his fears, frustrations and anger about his condition %. Hxplain how his being upset dangerously disturbs his need for rest '. ttempt to explain the purpose of different hospital routines nswer: *$+ 2efocus the con)ersation on his fears, frustrations and anger about his condition This pro)ides the opportunity for the client to )erbali>e feelings underlying beha)ior and helpful in relie)ing anxiety. nxiety can be a stressor which can acti)ate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and wor7load that can further increase myocardial oxygen demand. 11-. Twenty four hours after admission for an cute M(, Poses temperature is noted at -D.- %. The nurse monitors him for other adaptations related to the pyrexia, including: . .hortness of breath $. %hest pain %. Hle)ated blood pressure '. (ncreased pulse rate nswer: *'+ (ncreased pulse rate Fe)er 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. (ncreased $", chest pain and shortness of breath are not typically noted in fe)er.

110. Pose, who is admitted to the hospital for chest pain, as7s the nurse, !(s it still possible for me to ha)e another heart attac7 if ( watch my diet religiously and a)oid stress9# The most appropriate initial response would be for the nurse to: . .uggest he discuss his feelings of )ulnerability with his physician. $. Tell him that he certainly needs to be especially careful about his diet and lifestyle. %. )oid gi)ing him direct information and help him explore his feelings '. 2ecogni>e that he is frightened and suggest he tal7 with the psychiatrist or counselor. nswer: *%+ )oid gi)ing him direct information and help him explore his feelings To help the patient )erbali>e and explore his feelings, the nurse must reflect and analy>e the feelings that are implied in the clients 8uestion. The focus should be on collecting data to minister to the clients psychosocial needs. 115. na, 55 years old, is admitted to the hospital to rule out pernicious anemia. .chilling test is ordered for na. The nurse recogni>es that the primary purpose of the .chilling test is to determine the clients ability to: . .tore )itamin $1, $. 'igest )itamin $1, %. bsorb )itamin $1, '. "roduce )itamin $1, nswer: *%+ bsorb )itamin $1, "ernicious anemia is caused by the inability to absorb )itamin $1, in the stomach due to a lac7 of intrinsic factor in the gastric Guices. (n the .chilling test, radioacti)e )itamin $1, is administered and its absorption and excretion can be ascertained through the urine. 11?. na is diagnosed to ha)e "ernicious anemia. The physician orders 1., mg of %yanocobalamin *Eitamin $1,+ (M. )ailable is a )ial of the drug labeled 1 mlS 111 mcg. The nurse should administer: . 1.5 ml $. 1.1 ml %. 1.5 ml '. ,.1 ml nswer: *'+ ,.1 ml First con)ert milligrams to micrograms and then use ratio and proportion *1., mgS ,11 mcg+ ,11 mcg : 111 mcgS J ml : ml 111 JS ,11 J S , ml. (nGect , ml. to gi)e 1., mg of %yanocobalamin. 11B. 6ealth teachings to be gi)en to a client with "ernicious nemia regarding her therapeutic regimen concerning Eit. $1, will include: . /ral tablets of Eitamin $1, will control her symptoms $. (M inGections are re8uired for daily control %. (M inGections once a month will maintain control '. &ee7ly T-trac7 inGections pro)ide needed control nswer: *%+ (M inGections once a month will maintain control 'eep (M inGections bypass $1, absorption defect in the stomach due to lac7 of intrinsic factor, the transport carrier component of gastric Guices. monthly dose is usually sufficient since it is stored in acti)e body tissues such as the li)er, 7idney, heart, muscles, blood and bone marrow

113. The nurse 7nows that a client with "ernicious nemia understands the teaching regarding the )itamin $1, inGections when she states that she must ta7e it: . &hen she feels fatigued $. 'uring exacerbations of anemia %. @ntil her symptoms subside '. For the rest of her life nswer: *'+ For the rest of her life .ince the intrinsic factor does not return to gastric secretions e)en with therapy, $1, inGections will be re8uired for the remainder of the clients life. 11D. rthur %ru>, a 05 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. %ru> accuses the nurse of being uncomfortable during a dressing change, because his !wound loo7s terrible.# The nurse recogni>es that the client is using the defense mechanism 7nown as: . 2eaction Formation $. .ublimation %. (ntellectuali>ation '. "roGection nswer: *'+ "roGection "roGection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition. 1,1. &hen preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure: . &hen the client would ha)e normally had a bowel mo)ement $. fter the client accepts he had a bowel mo)ement %. $efore brea7fast and morning care '. t least , hours before )isitors arri)e nswer: * + &hen the client would ha)e normally had a bowel mo)ement (rrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function4habit. 1,1. &hen obser)ing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he: . .tops the flow of fluid when he feels uncomfortable $. Cubricates the tip of the catheter before inserting it into the stoma %. 6angs the bag on a clothes hoo7 on the bathroom door during fluid insertion '. 'iscontinues the insertion of fluid after only 511 ml of fluid has been instilled nswer: *%+ 6angs the bag on a clothes hoo7 on the bathroom door during fluid insertion The irrigation bag should be hung 1,-13 inches abo)e the le)el of the stomaM a clothes hoo7 is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient. 1,,. &hen doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician : . bdominal cramps during fluid inflow $. 'ifficulty in inserting the irrigating tube %. "assage of flatus during expulsion of feces

'. (nability to complete the procedure in half an hour nswer: *$+ 'ifficulty in inserting the irrigating tube 'ifficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. bdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may ta7e longer than half an hour. 1,-. 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: . $. reaction formation to his recent altered body image. difficult time accepting reality and is in a state of denial.

%. ssess his response to the e8uipment '. "repare him for emergency surgery nswer: *%+ ssess his response to the e8uipment (t is a primary nursing responsibility to e)aluate effect of inter)entions done to the client. Aothing is achie)ed if the e8uipment is wor7ing and the client is not responding 1,B. chest tube with water seal drainage is inserted to a client following a multiple chest inGury. few hours later, the clients chest tube seems to be obstructed. The most appropriate nursing action would be to . "repare for chest tube remo)al $. Mil7 the tube toward the collection container as ordered %. rrange for a stat %hest x-ray film. '. %lam the tube immediately nswer: *$+ Mil7 the tube toward the collection container as ordered This assists in mo)ing blood, fluid or air, which may be obstructing drainage, toward the collection chamber 1,3. The obser)ation that indicates a desired response to thoracostomy drainage of a client with chest inGury is: . (ncreased breath sounds $. %onstant bubbling in the drainage chamber %. %repitus detected on palpation of chest '. (ncreased respiratory rate nswer: * + (ncreased breath sounds The chest tube normali>es intrathoracic pressure and restores negati)e intra-pleural pressure, drains fluid and air from the pleural space, and impro)es pulmonary function 1,D. (n the e)aluation of a clients response to fluid replacement therapy, the obser)ation that indicates ade8uate tissue perfusion to )ital organs is: . @rinary output is -1 ml in an hour $. %entral )enous pressure reading of , cm 6,/ %. "ulse rates of 1,1 and 111 in a 15 minute period '. $lood pressure readings of 514-1 and B1401 within -1 minutes nswer: * + @rinary output is -1 ml in an hour rate of -1 ml4hr is considered ade8uate for perfusion of 7idney, heart and brain. 1-1. client with multiple inGury following a )ehicular accident is transferred to the critical care unit. 6e begins to complain of increased abdominal pain in the left upper 8uadrant. ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. (n preparing the client for surgery, the nurse should emphasi>e in his teaching plan the: . %omplete safety of the procedure $. Hxpectation of postoperati)e bleeding %. 2is7 of the procedure with his other inGuries '. "resence of abdominal drains for se)eral days after surgery nswer: *'+ "resence of abdominal drains for se)eral days after surgery 'rains are usually inserted into the splenic bed to facilitate remo)al of fluid in the area that could lead to abscess formation.

%. (mpotency due to the surgery and needs sexual counseling '. .uicide thoughts and should be seen by psychiatrist nswer: *$+ difficult time accepting reality and is in a state of denial. s 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 1,0. The nurse would 7now that dietary teaching had been effecti)e for a client with colostomy when he states that he will eat: . Food low in fiber so that there is less stool $. H)erything he ate before the operation but will a)oid those foods that cause gas %. $land foods so that his intestines do not become irritated '. .oft foods that are more easily digested and absorbed by the large intestines nswer: *$+ H)erything he ate before the operation but will a)oid those foods that cause gas There is no special diets for clients with colostomy. These clients can eat a regular diet. /nly gas-forming foods that cause distention and discomfort should be a)oided. 1,5. Hddie, 01 years old, is brought to the emergency room after the crash of his pri)ate plane. 6e has suffered multiple crushing wounds of the chest, abdomen and legs. (t is feared his leg may ha)e to be amputated. &hen Hddie arri)es in the emergency room, the assessment that assume the greatest priority are: . Ce)el of consciousness and pupil si>e $. bdominal contusions and other wounds %. "ain, 2espiratory rate and blood pressure '. Kuality of respirations and presence of pulsesKuality of respirations and presence of pulses nswer: *'+ Kuality of respirations and presence of pulsesKuality of respirations and presence of pulses 2espiratory and cardio)ascular functions are essential for oxygenation. These are top priorities to trauma management. $asic life functions must be maintained or reestablished 1,?. Hddie, a plane crash )ictim, undergoes endotracheal intubation and positi)e pressure )entilation. The most immediate nursing inter)ention for him at this time would be to: . Facilitate his )erbal communication $. Maintain sterility of the )entilation system

1-1. To promote continued impro)ement in the respiratory status of a client following chest tube remo)al after a chest surgery for multiple rib fracture, the nurse should: . Hncourage bed rest with acti)e and passi)e range of motion exercises $. Hncourage fre8uent coughing and deep breathing %. Turn him from side to side at least e)ery , hours '. %ontinue obser)ing for dyspnea and crepitus nswer: *$+ Hncourage fre8uent coughing and deep breathing This nursing action pre)ents atelectasis and collection of respiratory secretions and promotes ade8uate )entilation and gas exchange. 1-,. client undergoes below the 7nee amputation following a )ehicular accident. Three days postoperati)ely, the client is refusing to eat, tal7 or perform any rehabilitati)e acti)ities. The best initial nursing approach would be to: . =i)e him explanations of why there is a need to 8uic7ly increase his acti)ity $. Hmphasi>e repeatedly that with as prosthesis, he will be able to return to his normal lifestyle %. ppear cheerful and non-critical regardless of his response to attempts at inter)ention '. ccept and ac7nowledge that his withdrawal is an initially normal and necessary part of grie)ing nswer: *'+ ccept and ac7nowledge that his withdrawal is an initially normal and necessary part of grie)ing The withdrawal pro)ides time for the client to assimilate what has occurred and integrate the change in the body image. cceptance of the clients beha)ior is an important factor in the nurses inter)ention. 1--. The 7ey factor in accurately assessing how body image changes will be dealt with by the client is the: . Hxtent of body change present $. .uddenness of the change %. /b)iousness of the change '. %lients perception of the change nswer: *'+ %lients perception of the change (t 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. 1-0. Carry is diagnosed as ha)ing myelocytic leu7emia and is admitted to the hospital for chemotherapy. Carry discusses his recent diagnosis of leu7emia by referring to statistical facts and figures. The nurse recogni>es that Carry is using the defense mechanism 7nown as: . 2eaction formation $. .ublimation %. (ntellectuali>ation '. "roGection nswer: *%+ (ntellectuali>ation "eople use defense mechanisms to cope with stressful e)ents. (ntellectuali>ation is the use of reasoning and thought processes to a)oid the emotional upsets. 1-5. The laboratory results of the client with leu7emia indicate bone marrow depression. The nurse should encourage the client to:

. (ncrease his acti)ity le)el and ambulate fre8uently $. .leep with the head of his bed slightly ele)ated %. 'rin7 citrus Guices fre8uently for nourishment '. @se a soft toothbrush and electric ra>or nswer: *'+ @se a soft toothbrush and electric ra>or .uppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. nemia and leucopenia are the two other problems noted with bone marrow depression. 1-?. 'ennis recei)es a blood transfusion and de)elops flan7 pain, chills, fe)er and hematuria. The nurse recogni>es that 'ennis is probably experiencing: . n anaphylactic transfusion reaction $. n allergic transfusion reaction %. hemolytic transfusion reaction '. pyrogenic transfusion reaction nswer: *%+ hemolytic transfusion reaction This results from a recipients antibodies that are incompatible with transfused 2$%sM also called type (( hypersensiti)ityM these signs result from 2$% hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flan7 pain and hematuria and the other manifestations. 1-B. client Go7es about his leu7emia e)en though he is becoming sic7er and wea7er. The nurses most therapeutic response would be: . !Rour laugher is a co)er for your fear.# $. !6e who laughs on the outside, cries on the inside.# %. !&hy are you always laughing9# '. !'oes it help you to Go7e about your illness9# nswer: *'+ !'oes it help you to Go7e about your illness9# This non-Gudgmentally on the part of the nurse points out the clients beha)ior. 1-3. (n dealing with a dying client who is in the denial stage of grief, the best nursing approach is to: . gree with and encourage the clients denial $. 2eassure the client that e)erything will be o7ay %. llow the denial but be a)ailable to discuss death '. Cea)e the client alone to discuss the loss nswer: *%+ llow the denial but be a)ailable to discuss death This does not ta7e away the clients only way of coping, and it permits future mo)ement through the grie)ing process when the client is ready. 'ying clients mo)e through the different stages of grie)ing and the nurse must be ready to inter)ene in all these stages. 1-D. 'uring and 3 hour shift, Mario drin7s two ? o>. cups of tea and )omits 1,5 ml of fluid. 'uring this 3 hour period, his fluid balance would be: . U55 ml $. U1-B ml %. U,-5 ml '. U035 ml nswer: *%+ U,-5 ml The clients inta7e was -?1 ml *?o> x -1 ml+ and loss was 1,5 ml of fluidM loss is subtracted from inta7e

101. Mr. /ng is admitted to the hospital with a diagnosis of Ceft-sided %6F. (n the assessment, the nurse should expect to find: . %rushing chest pain $. 'yspnea on exertion %. Hxtensi)e peripheral edema '. Pugular )ein distention nswer: *$+ 'yspnea on exertion "ulmonary congestion and edema occur because of fluid extra)asation from the pulmonary capillary bed, resulting in difficult breathing. Ceft-sided heart failure creates a bac7ward effect on the pulmonary system that leads to pulmonary congestion. 101. The physician orders on a client with %6F a cardiac glycoside, a )asodilator, and furosemide *Casix+. The nurse understands Casix exerts is effects in the: . 'istal tubule $. %ollecting duct %. =lomerulus of the nephron '. scending limb of the loop of 6enle nswer: *'+ scending limb of the loop of 6enle This is the site of action of Casix being a potent loop diuretic. 10,. Mr. /ng weighs ,11 lbs on admission to the hospital. fter , days of diuretic therapy he weighs ,15.5 lbs. The nurse could estimate that the amount of fluid he has lost is: . 1.5 C $. 1.1 C %. ,.1 C '. -.5 C nswer: *%+ ,.1 C /ne liter of fluid weighs approximately ,., lbs. Therefore a 0.5 lbs weight loss e8uals approximately , Citers. 10-. Mr. /ng, a client with %6F, has been recei)ing a cardiac glycoside, a diuretic, and a )asodilator drug. 6is apical pulse rate is 00 and he is on bed rest. The nurse concludes that his pulse rate is most li7ely the result of the: . 'iuretic $. Easodilator %. $ed-rest regimen '. %ardiac glycoside nswer: *'+ %ardiac glycoside cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate. 100. The diet ordered for a client with %6F permits him to ha)e a 1D1 g of carbohydrates, D1 g of fat and 111 g of protein. The nurse understands that this diet contains approximately: . ,,11 calories $. ,111 calories %. ,311 calories '. 1?11 calories nswer: *$+ ,111 calories There are D calories in each gram of fat and 0 calories in each gram of carbohydrate and protein

105. fter the acute phase of congesti)e heart failure, the nurse should expect the dietary management of the client to include the restriction of: . Magnesium $. .odium %. "otassium '. %alcium nswer: *$+ .odium 2estriction of sodium reduces the amount of water retention that reduces the cardiac wor7load 10?. Pude de)elops =( bleeding and is admitted to the hospital. n important etiologic clue for the nurse to explore while ta7ing his history would be: . The medications he has been ta7ing $. ny recent foreign tra)el %. 6is usual dietary pattern '. 6is wor7ing patterns nswer: * + The medications he has been ta7ing .ome medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use 10B. The meal pattern that would probably be most appropriate for a client reco)ering from =( bleeding is: . Three large meals large enough to supply ade8uate energy. $. 2egular meals and snac7s to limit gastric discomfort %. Cimited food and fluid inta7e when he has pain '. flexible plan according to his appetite nswer: *$+ 2egular meals and snac7s to limit gastric discomfort "resence of food in the stomach at regular inter)als interacts with 6%l limiting acid mucosal irritation. Mucosal irritation can lead to bleeding. 103. client with a history of recurrent =( bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. 6e begins to hyper)entilate. The nurse should be aware that this pattern will alter his arterial blood gases by: . (ncreasing 6%/$. 'ecreasing "%/, %. 'ecreasing p6 '. 'ecreasing "/, nswer: *$+ 'ecreasing "%/, 6yper)entilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory al7alosis. 10D. 2outine postoperati)e (E fluids are designed to supply hydration and electrolyte and only limited energy. $ecause 1 C of a 5; dextrose solution contains 51 g of sugar, - C per day would apply approximately: . 011 Filocalories $. ?11 Filocalories %. 311 Filocalories '. 1111 Filocalories nswer: *$+ ?11 Filocalories %arbohydrates pro)ide 0 7cal4 gramM therefore -C x 51 g4C x 0 7cal4g S ?11 7calM only about a third of the basal energy

need. 151. Thrombus formation is a danger for all postoperati)e clients. The nurse should act independently to pre)ent this complication by: . Hncouraging ade8uate fluids $. pplying elastic stoc7ings %. Massaging gently the legs with lotion '. "erforming acti)e-assisti)e leg exercises nswer: *'+ "erforming acti)e-assisti)e leg exercises (nacti)ity causes )enous stasis, hypercoagulability, and external pressure against the )eins, all of which lead to thrombus formation. Harly ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon 151. n unconscious client is admitted to the (%@, (E fluids are started and a Foley catheter is inserted. &ith an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to a)oid this problem by: . Hmptying the drainage bag fre8uently $. %ollecting a wee7ly urine specimen %. Maintaining the ordered hydration '. ssessing urine specific gra)ity nswer: *%+ Maintaining the ordered hydration "romoting hydration, maintains urine production at a higher rate, which flushes the bladder and pre)ents urinary stasis and possible infection 15,. The nurse performs full range of motion on a bedridden clients extremities. &hen putting his an7le through range of motion, the nurse must perform: . Flexion, extension and left and right rotation $. bduction, flexion, adduction and extension %. "ronation, supination, rotation, and extension '. 'orsiflexion, plantar flexion, e)ersion and in)ersion nswer: *'+ 'orsiflexion, plantar flexion, e)ersion and in)ersion These mo)ements include all possible range of motion for the an7le Goint 15-. client has been in a coma for , months. The nurse understands that to pre)ent the effects of shearing force on the s7in, the head of the bed should be at an angle of: . -1 degrees $. 05 degrees %. ?1 degrees '. D1 degrees nswer: * + -1 degrees .hearing force occurs when , surfaces mo)e against each otherM when the bed is at an angle greater than -1 degrees, the torso tends to slide and causes this phenomenon. .hearing forces are good contributory factors of pressure sores. 150. 2ene, age ?,, is scheduled for a T@2" after being diagnosed with a $enign "rostatic 6yperplasia *$"6+. s part of the preoperati)e teaching, the nurse should tell the client that after surgery: . @rinary control may be permanently lost to some degree $. @rinary drainage will be dependent on a urethral catheter for ,0 hours %. Fre8uency and burning on urination will last while the

cystotomy tube is in place '. 6is ability to perform sexually will be permanently impaired nswer: *$+ @rinary drainage will be dependent on a urethral catheter for ,0 hours n indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding. 155. The transurethral resection of the prostate is performed on a client with $"6. Following surgery, nursing care should include: . %hanging the abdominal dressing $. Maintaining patency of the cystotomy tube %. Maintaining patency of a three-way Foley catheter for cystoclysis '. /bser)ing for hemorrhage and wound infection nswer: *%+ Maintaining patency of a three-way Foley catheter for cystoclysis "atency of the catheter promotes bladder decompression, which pre)ents distention and bleeding. %ontinuous flow of fluid through the bladder limits clot formation and promotes hemostasis 15?. (n the early postoperati)e period following a transurethral surgery, the most common complication the nurse should obser)e for is: . .epsis $. 6emorrhage %. Cea7age around the catheter '. @rinary retention with o)erflow nswer: *$+ 6emorrhage fter transurethral surgery, hemorrhage is common because of )enous oo>ing and bleeding from many small arteries in the prostatic bed. 15B. Following prostate surgery, the retention catheter is secured to the clients leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to: . Cimit discomfort $. "ro)ide hemostasis %. 2educe bladder spasms '. "romote urinary drainage nswer: *$+ "ro)ide hemostasis The pressure of the balloon against the small blood )essels of the prostate creates a tampon-li7e effect that causes them to constrict thereby pre)enting bleeding. 153. Twenty-four hours after T@2" surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurses initial action should be to: . (rrigate the catheter with saline $. Mil7 the catheter tubing %. 2emo)e the catheter '. Aotify the physician nswer: *$+ Mil7 the catheter tubing Mil7ing the tubing will usually dislodge the plug and will not harm the client. physicians order is not necessary for a nurse to chec7 catheter patency.

15D. The nurse would 7now that a post-T@2" client understood his discharge teaching when he says !( should:# . =et out of bed into a chair for se)eral hours daily $. %all the physician if my urinary stream decreases %. ttempt to )oid e)ery - hours when (m awa7e '. )oid )igorous exercise for ? months after surgery nswer: *$+ %all the physician if my urinary stream decreases @rethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or e)en complete ueinary obstruction. 1?1. Cucy is admitted to the surgical unit for a subtotal thyroidectomy. .he is diagnosed with =ra)es 'isease. &hen assessing Cucy, the nurse would expect to find: . Cethargy, weight gain, and forgetfulness $. &eight loss, protruding eyeballs, and lethargy %. &eight loss, exopthalmos and restlessness '. %onstipation, dry s7in, and weight gain nswer: *%+ &eight loss, exopthalmos and restlessness %lassic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Hxopthalmos is due to peribulbar edema. 1?1. Cucy undergoes .ubtotal Thyroidectomy for =ra)es 'isease. (n planning for the clients return from the /2, the nurse would consider that in a subtotal thyroidectomy: . The entire thyroid gland is remo)ed $. small part of the gland is left intact %. /ne parathyroid gland is also remo)ed '. portion of the thyroid and four parathyroids are remo)ed nswer: *$+ small part of the gland is left intact 2emaining thyroid tissue may pro)ide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid %a. 1?,. $efore a post- thyroidectomy client returns to her room from the /2, the nurse plans to set up emergency e8uipment, which should include: . crash cart with bed board $. tracheostomy set and oxygen %. n airway and rebreathing mas7 '. Two ampules of sodium bicarbonate nswer: *$+ tracheostomy set and oxygen cute respiratory obstruction in the post-operati)e period can result from edema, subcutaneous bleeding that presses on the trachea, ner)e damage, or tetany. 1?-. &hen a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral inGury of the laryngeal ner)e e)ery -1 to ?1 minutes by: . /bser)ing for signs of tetany $. %hec7ing her throat for swelling %. s7ing her to state her name out loud '. "alpating the side of her nec7 for blood seepage nswer: *%+ s7ing her to state her name out loud (f the recurrent laryngeal ner)e is damaged during surgery, the client will be hoarse and ha)e difficult spea7ing. 1?0. /n a post-thyroidectomy clients discharge, the nurse

teaches her to obser)e for signs of surgically induced hypothyroidism. The nurse would 7now that the client understands the teaching when she states she should notify the physician if she de)elops: . (ntolerance to heat $. 'ry s7in and fatigue %. "rogressi)e weight loss '. (nsomnia and excitability nswer: *$+ 'ry s7in and fatigue 'ry s7in is most li7ely caused by decreased glandular function and fatigue caused by decreased metabolic rate. $ody functions and metabolism are decreased in hypothyroidism. 1?5. clients exopthalmos continues inspite of thyroidectomy for =ra)es 'isease. The nurse teaches her how to reduce discomfort and pre)ent corneal ulceration. The nurse recogni>es that the client understands the teaching when she says: !( should: . Hle)ate the head of my bed at night $. )oid mo)ing my extra-ocular muscles %. )oid using a sleeping mas7 at night '. )oid excessi)e blin7ing nswer: *%+ )oid using a sleeping mas7 at night The mas7 may irritate or scratch the eye if the client turns and lies on it during the night. 1??. %lara is a -B-year old coo7. .he is admitted for treatment of partial and full-thic7ness burns of her entire right lower extremity and the anterior portion of her right upper extremity. 6er respiratory status is compromised, and she is in pain and anxious. "erforming an immediate appraisal, using the rule of nines, the nurse estimates the percent of %laras body surface that is burned is: . 0.5; $. D; %. 13 ; '. ,,.5; nswer: *'+ ,,.5; The entire right lower extremity is 13; the anterior portion of the right upper extremity is 0.5; gi)ing a total of ,,.5; 1?B. The nurse applies mafenide acetate *.ulfamylon cream+ to %lara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will: . (nhibit bacterial growth $. 2elie)e pain from the burn %. "re)ent scar tissue formation '. "ro)ide chemical debridement nswer: * + (nhibit bacterial growth .ulfamylon is effecti)e against a wide )ariety of gram positi)e and gram negati)e organisms including anaerobes 1?3. Forty-eight hours after a burn inGury, the physician orders for the client , liters of (E fluid to be administered 81, h. The drop factor of the tubing is 11 gtt4ml. The nurse should set the flow to pro)ide: . 13 gtt4min

$. ,3 gtt4min %. -, gtt4min '. -? gtt4min nswer: *$+ ,3 gtt4min This is the correct flow rateM multiply the amount to be infused *,111 ml+ by the drop factor *11+ and di)ide the result by the amount of time in minutes *1, hours x ?1 minutes+ 1?D. %lara, a burn client, recei)es a temporary heterograft *pig s7in+ on some of her burns. These grafts will: . 'ebride necrotic epithelium $. $e sutured in place for better adherence %. 2elie)e pain and promote rapid epitheliali>ation '. Fre8uently be used concurrently with topical antimicrobials. nswer: *%+ 2elie)e pain and promote rapid epitheliali>ation The graft co)ers ner)e endings, which reduces pain and pro)ides a framewor7 for granulation that promotes effecti)e healing. 1B1. client with burns on the chest has periodic episodes of dyspnea. The position that would pro)ide for the greatest respiratory capacity would be the: . .emi-fowlers position $. .ims position %. /rthopneic position '. .upine position nswer: *%+ /rthopneic position The orthopneic position lowers the diaphragm and pro)ides for maximal thoracic expansion 1B1. Pane, a ,1- year old college student is admiited to the hospital with a tentati)e diagnosis of myasthenia gra)is. .he is scheduled to ha)e a series of diagnostic studies for myasthenia gra)is, including a Tensilon test. (n preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces: . $rief exaggeration of symptoms $. "rolonged symptomatic impro)ement %. 2apid but brief symptomatic impro)ement '. .ymptomatic impro)ement of Gust the ptosis nswer: *%+ 2apid but brief symptomatic impro)ement Tensilon acts systemically to increase muscle strengthM with a pea7 effect in -1 seconds, (t lasts se)eral minutes. 1B,. The initial nursing goal for a client with myasthenia gra)is during the diagnostic phase of her hospitali>ation would be to: . 'e)elop a teaching plan $. Facilitate psychologic adGustment %. Maintain the present muscle strength '. "repare for the appearance of myasthenic crisis nswer: *%+ Maintain the present muscle strength @ntil diagnosis is confirmed, primary goal should be to maintain ade8uate acti)ity and pre)ent muscle atrophy 1B-. The most significant initial nursing obser)ations that need to be made about a client with myasthenia include: . bility to chew and spea7 distinctly $. 'egree of anxiety about her diagnosis

%. bility to smile an to close her eyelids '. 2espiratory exchange and ability to swallow nswer: *'+ 2espiratory exchange and ability to swallow Muscle wea7ness can lead to respiratory failure that will re8uire emergency inter)ention and inability to swallow may lead to aspiration 1B0. 6elen is diagnosed with myasthenia gra)is and pyridostigmine bromide *Mestinon+ therapy is started. The Mestinon dosage is fre8uently changed during the first wee7. &hile the dosage is being adGusted, the nurses priority inter)ention is to: . dminister the medication exactly on time $. dminister the medication with food or mild %. H)aluate the clients muscle strength hourly after medication '. H)aluate the clients emotional side effects between doses nswer: *%+ H)aluate the clients muscle strength hourly after medication "ea7 response occurs 1 hour after administration and lasts up to 3 hoursM the response will influence dosage le)els. 1B5. 6elen, a client with myasthenia gra)is, begins to experience increased difficulty in swallowing. To pre)ent aspiration of food, the nursing action that would be most effecti)e would be to: . %hange her diet order from soft foods to clear li8uids $. "lace an emergency tracheostomy set in her room %. ssess her respiratory status before and after meals '. %oordinate her meal schedule with the pea7 effect of her medication, Mestinon nswer: *'+ %oordinate her meal schedule with the pea7 effect of her medication, Mestinon 'ysphagia should be minimi>ed during pea7 effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.