Text Mode – Text version of the exam. 1. Nurse Linda is caring for a client who has sustained a head injury and is exhibiting decerebrate posturing. She knows that understanding the characteristics of this type of posturing is crucial for accurate monitoring and intervention. Which of the following is a characteristic of decerebrate posturing? A. Flexion of the upper extremities while the lower extremities are extended. 2. Nurse Betty is caring for a female client who is taking Cascara Sagrada as part of her medication regimen. Nurse Betty knows it’s important to educate the client about potential side effects. Which of the following may be experienced as side effects of taking Cascara Sagrada? A. Development of a partial bowel obstruction. 3. Nurse Michelle is caring for a client who is suffering from a myocardial infarction. Dr. Marquez has ordered a continuous intravenous nitroglycerin infusion for the client. What is the most essential nursing action for Nurse Michelle to take in this situation? A. Monitor the client’s blood pressure every 4 hours. 4. Nurse Andrew is caring for a client who is on the second day of hospitalization following a Myocardial Infarction. He is focused on evaluating the client’s progress and planning the next steps in care. Which of the following is an expected outcome for this client on the second day of hospitalization? A. Experiencing severe chest pain. 5. Nurse Emily is caring for a 68-year-old client who has been diagnosed with a right-sided brain attack (stroke) and is admitted to the hospital. In planning care for this client, what should Nurse Emily prioritize? A. Perform passive range of motion exercises to maintain joint flexibility. 6. Nurse Jennifer is caring for Jude, a patient who has been hospitalized following a myocardial infarction. Jude is curious about why he is being administered morphine. What should Nurse Jennifer explain as the primary reason for administering morphine in his case? A. Morphine works to dilate the coronary blood vessels. 7. Nurse Hanna is responsible for caring for a client who has just returned to the nursing unit after undergoing a left nephrectomy (surgical removal of the left kidney). In prioritizing her care for this client, what would be Nurse Hanna’s highest priority? A. Monitoring the client’s temperature. 8. A 64-year-old male client has an extensive medical history involving cardiovascular issues, including hypertension and angina. He is slated to undergo a cardiac catheterization procedure soon. Nurse Cherry is responsible for educating the client before the procedure. What should she inform the client is the primary aim of undergoing cardiac catheterization? A) To assess the efficiency of the heart valves in opening and closing. 9. Nurse Karen is caring for a client who has recently undergone a cardiac catheterization. During the first several hours post-procedure, what would be the most essential action for Nurse Karen to take? A. Monitor the client’s temperature on an hourly basis. 10. Nurse Olivia is caring for Cassy, who has recently undergone a mitral valve replacement. During the postoperative period, Cassy suddenly experiences continuous bleeding from the surgical incision. Which of the following pharmaceutical agents should Nurse Olivia prepare to administer to Cassy to address this issue? A. Vitamin C 11. Nurse Emily is developing a teaching plan for a client with mitral stenosis to reduce the risk of endocarditis through good dental care. What should Nurse Emily include in the teaching plan as the proper tool for dental hygiene in this client? A) A medium-bristle toothbrush. 12. Nurse Thomas is educating a client about the potential side effects of digitalis, a medication used to treat heart conditions. What should Nurse Thomas teach the client as a sign of digitalis toxicity? A. Experiencing visual disturbances, such as seeing yellow spots or halos. 13. Nurse Karen is assessing a client suspected of having mitral regurgitation, a condition where the mitral valve doesn’t close tightly, allowing blood to flow backward in the heart. Among the following signs and symptoms, which one would most likely be present in a client with mitral regurgitation? A. Experiencing chest pain or discomfort. 14. Nurse Jenny is caring for Krissa, who has a history of chronic infection of the urinary system and is now complaining of urinary frequency and a burning sensation. To determine whether the current problem originates in the kidneys, Nurse Jenny should assess whether the client has discomfort or pain in which of the following areas? A. Right or left costovertebral angle. 15. John suddenly experiences a seizure while under the care of Nurse Gina. During the episode, John exhibits uncontrollable jerking movements. Nurse Gina needs to document the occurrence accurately. Which type of seizure did John most likely experience? A. Absence seizure 16. Nurse Jade is caring for a client with Buerger’s disease, a condition associated with tobacco use that causes blood vessels to become inflamed and clotted. Understanding that smoking cessation is a critical strategy for managing this disease, Nurse Jade anticipates that the male client will be discharged with a prescription for which medication? A. Nicotine (Nicotrol) 17. Nurse Trisha is educating a client with heart failure about taking oral Furosemide, a diuretic medication. She instructs the client to take the medication in the morning. What is the primary reason for this timing? A. To help excrete excessive fluids that may have accumulated overnight. 18. Nurse Allison is caring for a client diagnosed with Raynaud’s disease. Although the exact cause of this condition remains unclear, she recognizes that Raynaud’s disease is specifically characterized by what? A. An episodic vasospastic disorder affecting the small arteries in extremities. 19. Nurse Hector is educating male clients with diabetes about the importance of self-monitoring blood glucose levels as opposed to urine glucose testing. What should Nurse Hector explain as the primary reason why self-monitoring of blood glucose is preferred? A. Blood glucose testing is not influenced by medications. 20. Anna, who weighed 210 pounds upon admission to the hospital, has been receiving diuretic therapy. After 2 days, her weight is 205.5 pounds. Nurse Emily wants to estimate the amount of fluid Anna has lost. How should she calculate this? A. 3.5 L of fluid loss. 21. Nurse Olivia is administering intravenous albumin to a patient and understands that the shift of body fluids associated with this treatment occurs through which physiological process? A. Diffusion, the movement of molecules from an area of high concentration to low concentration. 22. Emma, a 52-year-old client with a fractured left tibia, has a long leg cast and is using crutches to ambulate. Nurse Sophia is monitoring Emma for potential complications associated with crutch walking. What sign or symptom should Nurse Sophia specifically assess for that indicates a complication related to crutch use? A. Spasm in the triceps muscle. 23. Nurse Ethan is caring for a client with pulmonary edema and heart failure. Understanding the underlying conditions, what would be the primary goal of therapy for this client? A. Decrease peripheral edema. 24. Nurse Maya is educating a neutropenic client and his family about care practices to avoid. Neutropenia is a condition characterized by a low number of neutrophils, increasing the risk of infection. Which of the following statements should Nurse Maya teach the client and his family to avoid? A. Performing perineal hygiene after each bowel movement. 25. A female client diagnosed with a perforated peptic ulcer is experiencing a painful and rigid abdomen. With surgery scheduled and a nasogastric tube inserted, Nurse Emily is determining the best position for the client before surgery. Which position should the client be placed in? A. Dorsal recumbent position 26. Post-surgery, Nurse Jackson is focused on ensuring adequate ventilatory exchange for the client. Which nursing intervention is most appropriate to achieve this goal? A. Maintain humidified oxygen via nasal cannula as needed. 27. Leo has undergone thoracic surgery and has a chest tube connected to a water-seal drainage system attached to suction. Nurse Karen notices the presence of excessive bubbling in the water-seal chamber. What should be the nurse’s immediate action? A. Thoroughly check the system for any potential air leaks. 28. Nurse Luke is evaluating the renal function of a male client. After carefully documenting urine volume and characteristics, he wants to assess the best indicator of renal function. Which of the following signs should Nurse Luke consider as the best indicator of renal function? A. Level of consciousness. 29. A client diagnosed with hypertension is receiving education from Nurse Emma on restricting sodium intake. Nurse Emma would know that the teachings are effective if the client states which of the following? A) “I will use sea salt instead of regular table salt, as it’s healthier.” 30. Nurse Thompson is caring for a male client with a history of cirrhosis and alcoholism who has been admitted with severe dyspnea leading to ascites. The client’s condition requires an immediate understanding of the underlying cause of the ascites. Nurse Thompson should be aware that the ascites is most likely the result of a heightened level of what? A) Bile salts being secreted. 31. Nurse Martin is attending to a newly admitted client diagnosed with Hodgkin’s disease who has just undergone an excisional cervical lymph node biopsy under local anesthesia. As part of post-procedure care, what is the first aspect Nurse Martin should assess? A) Consciousness level of the patient. 32. Nurse Johnson is caring for a client who has suffered a 15% blood loss due to an accident. She is vigilant for signs of hypovolemic shock, a condition that might occur with significant blood loss. Which of the following nursing assessment findings would best indicate the client is experiencing hypovolemic shock? A) An extremely slow respiratory rate, measuring 4 breaths per minute. 33. Nurse Hazel is preparing to give preoperative instructions to a client who is scheduled to undergo rhinoplasty. As part of the instructions to ensure a successful surgery and recovery, which of the following pieces of information should Nurse Hazel include in her teaching? A) Expect nasal packing to remain in place for a duration of 8 to 10 days post-surgery. 34. Jeff is admitted to the hospital, and Nurse Mitchell is responsible for his care. He has been diagnosed with metabolic acidosis resulting from Diabetic Ketoacidosis (DKA). As Nurse Mitchell prepares the initial treatment for this condition, which of the following medications should she prioritize? A) A supplement of potassium. 35. Dr. Jackson advises a client to improve skin health by increasing the intake of foods rich in Vitamin E and beta-carotene. Nurse Rivera follows up on this advice by teaching the client about the food sources of these nutrients. Which of the following does Nurse Rivera identify as excellent food sources of both Vitamin E and beta-carotene? A) Citrus fruits such as oranges and grapefruit. 36. Nurse Allen is caring for a client diagnosed with Gastroesophageal Reflux Disease (GERD). To manage symptoms and prevent discomfort after meals, Nurse Allen should teach the client that after every meal, it’s advisable to… A) Lie down flat immediately to aid in digestion. 37. Nurse Taylor is closely monitoring a patient who has just undergone a gastroscopy. In the post-procedure assessment, she knows that a major complication to watch for that may indicate a serious problem would be: A) Excessive thirst and dry mouth. 38. A client has just undergone a cholecystectomy and inquires about dietary restrictions. Nurse Aria provides dietary guidance, and she would recognize that the teaching was well understood when the client informs a family member: A) “For the rest of my life, I must steer clear of fatty foods.” 39. Nurse Olivia is educating a client who has been recently diagnosed with hepatitis A about the concerning signs and symptoms related to this condition. She emphasizes that the client must report one specific symptom immediately to the physician. Which one is it? A) Persistent nausea. 40. Nurse Jackson is educating a patient about the treatment of tuberculosis and discusses the potential side effects of various antituberculosis drugs. The patient expresses concern about potential damage to the 8th cranial nerve. Which drug should Nurse Jackson mention as one that can cause this specific damage? A) Streptomycin 41. A client, curious about the causes of peptic ulcers, asks Nurse Hanna for information. Nurse Hanna responds by explaining that recent research indicates peptic ulcers are primarily the result of which of the following? A) A diet that is excessively high in fats. 42. Mrs. Johnson, a 77-year-old client, is admitted under Nurse Emily’s care with a diagnosis of mild chronic heart failure. When Nurse Emily listens to Mrs. Johnson’s lungs to assess for signs indicative of chronic heart failure, she expects to hear: A) The presence of crackles. 43. Nurse Jessa is preparing postoperative care instructions for a client who has just undergone eye surgery. The client is anxious about what activities will be allowed during the recovery period. Nurse Jessa plans to teach the client that among the following, the best-recommended activity is: A) Bending over frequently. 44. A client arrives in the emergency room with Nurse Katherine after suffering a lower leg injury. The leg shows a prominent deformity, and the affected leg appears shorter than the other leg. It’s painful, swollen, and beginning to show signs of ecchymosis. Nurse Katherine interprets that the client is most likely experiencing: A) A muscular strain. 45. Nurse Chloe is preparing to instill an otic solution into an adult male client’s left ear. During the procedure, Nurse Chloe must be careful to avoid doing which of the following? A) Positioning the client in a side-lying position. 46. Nurse Grace is providing education to a male client with an ileostomy. She should instruct the client to report immediately which of the following symptoms? A. Occasional presence of undigested food in the ileostomy output. 47. Adam has been diagnosed with appendicitis and is now showing signs of fever, hypotension, and tachycardia. Nurse Olivia is concerned and suspects which of the following complications? A. Deficient fluid volume, leading to dehydration. 48. A client is diagnosed with acute pancreatitis, and Nurse Ethan is responsible for monitoring potential complications. Which of the following complications should the nurse carefully monitor for this client? A. Pneumonia 49. Nurse Thompson is caring for a patient in the icteric phase of viral hepatitis. The patient’s family members are concerned and have questions about what symptoms they can expect. Which of the following symptoms would Nurse Thompson expect the patient to manifest during the icteric phase of viral hepatitis? A. Presence of dark, tarry stool. 50. Roger, a patient who has just undergone a subtotal gastrectomy, is under the care of Nurse Anderson. The nurse is closely monitoring his nasogastric tube drainage as part of the postoperative care. What color should Nurse Anderson expect the nasogastric tube drainage to be for approximately 12 to 24 hours following the surgery? A. Bright red blood. 1. Correct answer: D. Extension of all extremities in response to a stimulus. Decerebrate posturing is a type of abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward. This posture is usually a sign of severe damage in the brain, specifically in the areas including the brain stem and the upper brain. It is often seen in response to painful stimuli and is considered a medical emergency requiring immediate intervention. In decerebrate posturing, the arms are extended by the sides, the palms are turned outward, and the legs are extended straight. This posture is indicative of dysfunction at the level of the brainstem, often between the superior and inferior colliculi. It is a more severe form of posturing compared to decorticate posturing and indicates more serious brain injury. Imagine the brain as the central computer of a highly sophisticated machine, which is your body. If the computer starts malfunctioning, the machine may go into a “safe mode” where it only performs basic functions. Decerebrate posturing is like the body’s “error message,” signaling that something is critically wrong with the brain, specifically the brainstem, which controls basic life functions like breathing and heart rate. Incorrect answer options: A. Flexion of the upper extremities while the lower extremities are extended. This describes decorticate posturing, not decerebrate posturing. Decorticate posturing is characterized by flexion of the arms, wrists, and fingers with adduction in upper extremities. The legs are extended and internally rotated. It is usually a sign of problems with areas including the cerebral hemispheres, the internal capsule, or the thalamus. B. Flexion of all extremities in response to a stimulus. This does not describe either decerebrate or decorticate posturing. Flexion of all extremities might be a reflexive response to pain but is not characteristic of the posturing seen in severe brain injury. C. Flexion of both the upper and lower extremities. This also does not describe decerebrate posturing. Flexion of both the upper and lower extremities is not typical for any form of abnormal posturing related to brain injury. 2. Correct answer: D. Occurrence of abdominal cramps. Cascara Sagrada is a natural laxative made from the bark of the buckthorn tree. It is often used to treat constipation. One of the common side effects of taking Cascara Sagrada is abdominal cramping. The active compounds in Cascara Sagrada stimulate peristalsis, the series of muscle contractions in the intestines that move stool through the digestive tract. While this is effective for relieving constipation, it can also lead to abdominal cramps as the muscles may contract more vigorously or irregularly. Think of your digestive system as a conveyor belt in a factory. Normally, the belt moves at a steady pace to get the job done. Cascara Sagrada is like hitting the “speed up” button on the conveyor belt. While it does make the belt move faster, helping to relieve constipation, it can also cause some “turbulence” (abdominal cramps) due to the sudden change in speed. Incorrect answer options: A. Development of a partial bowel obstruction. Cascara Sagrada is used to treat constipation and promote bowel movements; it is not associated with causing bowel obstructions. In fact, it may help prevent obstruction by facilitating the passage of stool. B. Onset of peptic ulcer disease. Cascara Sagrada acts on the lower digestive tract to stimulate bowel movements and does not affect the stomach lining or cause peptic ulcers. It is not an NSAID or a corticosteroid, which are classes of medications more commonly associated with peptic ulcers. C. Gastrointestinal bleeding. Cascara Sagrada is not known to cause gastrointestinal bleeding. It acts as a stimulant laxative and its primary side effects are related to the digestive process, such as cramps or diarrhea, but not bleeding. 3. Correct answer: C. Ensure that an infusion pump is available for administering the medication. In the case of a myocardial infarction (heart attack), nitroglycerin is often administered intravenously to dilate the coronary arteries and improve blood flow to the heart muscle. The most essential nursing action when administering a continuous intravenous nitroglycerin infusion is to ensure that an infusion pump is available. This is crucial because nitroglycerin is a potent vasodilator, and even a slight overdose can lead to significant hypotension (low blood pressure). An infusion pump allows for precise control of the medication’s flow rate, ensuring that the patient receives the correct dosage. Imagine you’re watering a delicate plant with a hose. If you turn the water pressure too high, you could damage the plant. An infusion pump is like having a specialized nozzle on the hose that lets you control the water flow precisely, ensuring you give the plant just the right amount of water it needs to thrive, without causing any harm. Incorrect answer options: A. Monitor the client’s blood pressure every 4 hours. While it’s important to monitor the client’s blood pressure, doing so every 4 hours may not be frequent enough, especially when administering a potent medication like nitroglycerin that can rapidly affect blood pressure. More frequent monitoring would likely be necessary. B. Obtain daily serum potassium levels for the client. Monitoring serum potassium levels is generally not directly related to the administration of nitroglycerin. While electrolyte balance is important in cardiac care, it is not the most essential nursing action in this specific situation. D. Frequently monitor the client’s urine output. While monitoring urine output is important in assessing renal function and fluid balance, it is not the most critical action when administering a continuous intravenous nitroglycerin infusion. The priority is to ensure accurate and safe medication administration. 4. Correct answer: D. Able to engage in self-care activities without experiencing pain. By the second day of hospitalization following a Myocardial Infarction (MI), the immediate crisis has usually been managed, and the focus shifts to stabilization and recovery. One of the expected outcomes for a client in this stage is the ability to engage in self-care activities without experiencing pain. This is a crucial indicator that the heart muscle is getting sufficient oxygen and that the treatment plan is effective. It also suggests that the patient is well on their way to recovery and can start participating more actively in their own care, which is essential for long-term management of cardiac health. Imagine your heart as a car engine that has just been through a rough patch, causing it to stall (the MI). The mechanics (healthcare team) have done the immediate repairs, and now you’re testing it out on a quiet road (the hospital). If you can drive around without the engine making alarming noises (chest pain), it’s a good sign that the repairs were successful and you can gradually get back to driving on busier roads (more strenuous activities). Incorrect answer options: A. Experiencing severe chest pain. Experiencing severe chest pain on the second day of hospitalization would not be an expected outcome and would be a cause for immediate concern. This could indicate that the initial treatment was not fully effective, or that there is ongoing ischemia or another complication. Severe chest pain could signify that the heart muscle is still not getting enough oxygen, which could lead to further damage. B. Ability to recognize the risk factors associated with Myocardial Infarction. While education about risk factors is an important part of long-term management and prevention of another MI, it is not the primary expected outcome on the second day of hospitalization. The immediate focus is more on medical stabilization and symptom management rather than patient education, although the latter is certainly important in the overall care plan. C. Capability to participate in cardiac rehabilitation walking programs. While cardiac rehabilitation is an important part of recovery after an MI, it is generally not initiated on the second day of hospitalization. The immediate post-MI period is focused on stabilization, monitoring for complications, and initiation of medications. Cardiac rehabilitation usually starts after the acute phase has been managed and the patient is medically stable, often not until after discharge from the hospital. 5. Correct answer: D. Place a hand roll and extend the left upper extremity on a pillow to prevent muscle contractions. In a right-sided brain attack (stroke), the left side of the body is often affected due to the contralateral (opposite side) control of the brain over the body. One of the primary concerns in this situation is the prevention of muscle contractions and maintenance of functional limb positioning. Placing a hand roll in the client’s hand and extending the left upper extremity on a pillow can help maintain the natural arch of the hand and prevent contractures. This positioning aids in preserving muscle and joint integrity, which is crucial for future rehabilitation and the overall quality of life for the patient. Contractures can lead to permanent shortening of the muscles, making it difficult to regain full range of motion even after the acute phase of the stroke has passed. Therefore, preventive measures like proper positioning are essential from the early stages of care. Think of the affected limb as a piece of clay. If you leave clay in an awkward position for too long, it hardens that way, making it difficult to reshape later. Similarly, if the affected limb is not properly positioned, the muscles and joints can “set” in uncomfortable and functionally limiting positions. Using a hand roll and a pillow is like using a mold to keep the clay in its proper shape while it hardens, ensuring it remains functional for future use. Incorrect answer options: A. Perform passive range of motion exercises to maintain joint flexibility. While passive range of motion exercises are important in maintaining joint flexibility, they are not the highest priority in the immediate care of a patient with a right-sided brain attack. The immediate concern is to prevent muscle contractions and maintain functional limb positioning, which is best achieved through proper positioning. B. Apply elastic stockings to prevent muscle flaccidity. Elastic stockings are generally used to prevent deep vein thrombosis (DVT) and not specifically to prevent muscle flaccidity. While preventing DVT is important in stroke patients, it is not the highest priority in terms of immediate limb care for a patient with a right-sided brain attack. C. Utilize a bed cradle to prevent dorsiflexion of the feet. A bed cradle is typically used to prevent pressure ulcers by keeping bed linens off sensitive areas of the body. It is not primarily used to prevent dorsiflexion of the feet or to manage issues related to muscle contractions in stroke patients. 6. Correct answer: B. Morphine is given to prevent shock and alleviate pain. Morphine is commonly administered to patients who have experienced a myocardial infarction (MI) primarily to alleviate pain and prevent the onset of shock. Pain relief is crucial because pain can trigger the release of stress hormones like adrenaline, which can increase the heart rate and oxygen demand of the heart, exacerbating the ischemia (lack of oxygen) to the heart muscle. By alleviating pain, morphine helps to reduce the workload on the heart, thereby decreasing oxygen consumption and aiding in the overall stabilization of the patient’s condition. Morphine also has a vasodilatory effect, which can help to lower blood pressure and reduce the risk of cardiogenic shock, a condition where the heart is unable to pump enough blood to meet the body’s needs. Preventing shock is vital in the management of MI as it can be a life-threatening complication. Think of the heart as a factory that’s working overtime due to a sudden large order (the pain from the MI). The factory’s machinery (the heart) is already strained, and pushing it to work even harder could lead to a breakdown. Morphine acts like a temporary reduction in the workload, allowing the factory to catch its breath and continue functioning more efficiently. It also acts like an emergency power generator, stepping in to make sure the factory doesn’t go into a complete shutdown (shock). Incorrect answer options: A. Morphine works to dilate the coronary blood vessels. While morphine does have some vasodilatory effects, its primary role in the management of MI is not to dilate the coronary vessels. Other medications like nitroglycerin are more commonly used for this specific purpose. C. Morphine helps in preventing fibrillation of the heart. Morphine is not primarily used to prevent fibrillation of the heart in the context of MI. Antiarrhythmic medications are more commonly used to manage heart rhythm disturbances following an MI. D. Morphine is used to decrease anxiety and restlessness. Although morphine can have a calming effect and may reduce anxiety and restlessness, this is not its primary purpose in the management of MI. The main goal is to alleviate pain and prevent shock, thereby reducing the heart’s workload and oxygen demand. 7. Correct answer: C. Keeping track of the client’s hourly urine output. After a nephrectomy, one of the most critical aspects to monitor is the client’s hourly urine output. The remaining kidney must take over the full function of filtering blood and excreting waste, and monitoring urine output is a direct way to assess how well the remaining kidney is functioning. A decrease in urine output could indicate that the remaining kidney is not adequately filtering blood, which could lead to fluid overload, electrolyte imbalances, and other complications. It could also be a sign of postoperative complications such as hemorrhage or renal failure. In the immediate postoperative period, the body is also at risk of fluid imbalances due to surgical stress and changes in vascular permeability. Accurate monitoring of urine output can provide early indications of such imbalances, allowing for timely interventions. It’s not just about the quantity of urine; the quality (color, consistency) also provides valuable information about renal function and hydration status. Think of the remaining kidney as a single lane on a two-lane highway that’s now handling all the traffic because the other lane is closed for repairs. If cars (waste products) are moving smoothly through the single lane, it indicates that the lane is managing the increased load well. But if you notice a traffic jam (reduced urine output), it’s a sign that there might be a problem that needs immediate attention, like a car breakdown (renal failure) or an accident (hemorrhage). Incorrect answer options: A. Monitoring the client’s temperature. While it’s important to monitor the client’s temperature to detect any signs of infection, it is not the highest priority immediately after a nephrectomy. Infection is a longer-term risk and would not typically manifest immediately postoperatively. B. Ensuring the client is able to turn from side to side. While mobility is important for preventing complications like pressure ulcers and deep vein thrombosis, it is not the highest priority in the immediate postoperative period after a nephrectomy. The focus is more on vital organ function, particularly the remaining kidney. D. Confirming that the client is able to sip clear liquids. While it’s important to assess the client’s ability to tolerate oral intake, this is not the highest priority immediately after a nephrectomy. The focus should be on vital signs and organ function, particularly renal function, before progressing to oral intake. 8. Correct answer: B) To obtain a visual representation of the disease affecting the coronary arteries. Cardiac catheterization is primarily used to obtain a visual representation of the coronary arteries, particularly when there is a history of cardiovascular issues like hypertension and angina. The procedure involves inserting a catheter into the coronary arteries and injecting a contrast dye. This allows for real-time imaging, typically through fluoroscopy, to visualize any blockages, narrowing, or other abnormalities in the coronary arteries. This is crucial for diagnosing conditions like Coronary Heart Disease (CHD) and planning subsequent interventions, which may include medications, angioplasty, or even coronary artery bypass grafting (CABG). Given the client’s extensive medical history involving cardiovascular issues, obtaining a visual representation of the coronary arteries is vital for accurate diagnosis and effective treatment planning. The procedure provides a detailed view of the coronary arteries, allowing healthcare providers to assess the severity and extent of any disease present. This is particularly important for individuals with multiple risk factors for CHD, as it provides a more comprehensive assessment than non-invasive tests alone. Imagine the coronary arteries as a series of underground tunnels that supply a city (the heart) with essential resources (oxygen and nutrients). If there’s a traffic jam or a collapsed section in one of these tunnels, the city could face a crisis. Cardiac catheterization is like sending a drone equipped with a camera into these tunnels. The drone captures live footage, allowing city planners (healthcare providers) to see exactly where the problem lies and how severe it is, enabling them to make informed decisions about repairs or rerouting traffic (medical interventions). Incorrect answer options: A) To assess the efficiency of the heart valves in opening and closing. While cardiac catheterization can provide information about heart valve function, it is not the primary aim of the procedure, especially for clients with a history of cardiovascular issues like hypertension and angina. The main focus is on assessing the coronary arteries for disease. C) To evaluate the electrical conduction system of the heart. Cardiac catheterization is not primarily used to evaluate the electrical conduction system of the heart. Tests like an electrocardiogram (ECG) are more suitable for this purpose. The main aim of cardiac catheterization in this context is to visualize the coronary arteries for disease assessment. D) To measure the volume of blood ejected by the left ventricle per minute (cardiac output). While cardiac catheterization can provide data on cardiac output, this is not its primary aim, especially in clients with a history of cardiovascular issues. The focus is on obtaining a visual representation of the coronary arteries to assess for disease. 9. Correct answer: B. Frequently assess the client’s apical pulse and blood pressure. In the immediate post-procedure period following cardiac catheterization, one of the most critical nursing actions is to frequently monitor the client’s apical pulse and blood pressure. This is essential for detecting any early signs of complications such as hemorrhage, arterial occlusion, or arrhythmias. A sudden change in blood pressure or pulse could indicate that the client is experiencing a complication that requires immediate intervention. For example, a drop in blood pressure and a rapid or irregular pulse could be signs of internal bleeding at the catheter insertion site. Additionally, the heart has just been “mapped” and potentially manipulated during the catheterization. This makes it more susceptible to changes in rhythm and rate, which can be detected by closely monitoring the apical pulse. Blood pressure monitoring is also crucial as fluctuations can indicate either hemorrhage or vascular complications, both of which require immediate attention. Think of the heart as a car engine that has just been inspected and tweaked by a mechanic (the catheterization procedure). After such an inspection, you’d want to keep a close eye on the car’s performance indicators like speed and oil pressure (apical pulse and blood pressure) to make sure everything is running smoothly. If you notice any sudden changes, it could mean that something wasn’t put back together properly or that a new issue has arisen, requiring immediate attention. Incorrect answer options: A. Monitor the client’s temperature on an hourly basis. While it’s important to monitor for signs of infection, temperature changes are usually not immediate complications of cardiac catheterization. Infection is a longer-term risk and would not typically manifest immediately post-procedure. C. Instruct the client to perform coughing and deep breathing exercises every 2 hours. While respiratory exercises are generally good for postoperative clients to prevent atelectasis and pneumonia, they are not the most immediate concern following cardiac catheterization. The focus should be on cardiovascular stability. D. Elevate the head of the client’s bed to a 45° angle. Elevating the head of the bed is generally not recommended immediately after cardiac catheterization, especially if the femoral artery was used for access, as this could put pressure on the insertion site and increase the risk of bleeding. 10. Correct answer: C. Protamine Sulfate. In the case of continuous bleeding following a mitral valve replacement, Protamine Sulfate is the pharmaceutical agent most likely to be administered. Protamine Sulfate is an antidote for heparin, an anticoagulant that is commonly used during cardiac surgeries to prevent blood clotting. If a patient experiences excessive bleeding postoperatively, Protamine Sulfate can be administered to neutralize the effects of heparin and facilitate clotting at the surgical site. This is crucial for stabilizing the patient and preventing further complications such as hemorrhagic shock or anemia. The administration of Protamine Sulfate is a delicate process that requires careful monitoring. The dosage must be calculated based on the amount of heparin administered during surgery, and the patient’s vital signs must be closely observed for any adverse reactions. It’s a time-sensitive intervention; the sooner it’s administered, the quicker the bleeding can be controlled. Imagine you’re painting a room and you’ve used a paint thinner to get the consistency you want. Suddenly, you realize the paint is too thin and is dripping everywhere, ruining the floor. Protamine Sulfate acts like a substance you’d add to the paint to thicken it back up, stopping the drips. Just like you’d need to know exactly how much thinner you used to know how much thickener to add, the dose of Protamine Sulfate needs to be calculated based on the amount of heparin used during the surgery. Incorrect answer options: A. Vitamin C. Vitamin C is not used to control bleeding in a postoperative setting. While it is essential for collagen synthesis and wound healing, it does not have the immediate clotting effect needed to control active bleeding. B. Quinidine Sulfate. Quinidine Sulfate is an antiarrhythmic medication and is not used to control bleeding. It is more commonly used to treat certain types of irregular heartbeats but would not be effective in stopping postoperative bleeding. D. Coumadin. Coumadin (Warfarin) is an anticoagulant and would exacerbate the problem of bleeding rather than solve it. It is used to prevent blood clots but is contraindicated in a situation where the patient is already experiencing excessive bleeding. 11. Correct answer: C. A soft-bristle toothbrush.For a client with mitral stenosis who is at risk for endocarditis, using a soft-bristle toothbrush is the most appropriate choice for dental hygiene. The soft bristles are less likely to cause gum irritation or bleeding, which can serve as entry points for bacteria to enter the bloodstream and potentially cause endocarditis. Mitral stenosis already places stress on the heart, and the presence of bacteria in the bloodstream can further exacerbate heart issues by causing infection of the heart valves. Good dental hygiene is crucial for this client, not just for oral health but also as a preventive measure against endocarditis. Regular brushing with a soft-bristle toothbrush, along with flossing and possibly using an antiseptic mouthwash, can help reduce the bacterial load in the mouth. This, in turn, minimizes the risk of bacteria entering the bloodstream through small cuts or sores in the mouth. Think of your gums as a garden and the soft-bristle toothbrush as a gentle rake. If you use a gentle rake, you can remove leaves and debris without damaging the plants or soil. A soft-bristle toothbrush works the same way; it cleans your teeth and gums without causing damage that could let harmful bacteria into your bloodstream, which is especially important when you already have a heart condition like mitral stenosis. Incorrect answer options: A. A medium-bristle toothbrush. A medium-bristle toothbrush may be too abrasive for someone with a heart condition like mitral stenosis, who is at higher risk for endocarditis. The stiff bristles could potentially cause gum irritation or minor bleeding, providing an entry point for bacteria. B. A hard-bristle toothbrush. A hard-bristle toothbrush is generally not recommended for anyone, especially not for someone at risk for endocarditis. The hard bristles can easily cause gum damage and bleeding, increasing the risk of bacterial infection that could lead to endocarditis. D. A dental pick. While dental picks can be effective for removing plaque and food particles, they also pose a risk of gum injury. For someone with mitral stenosis, any gum injury could be a potential entry point for bacteria that could lead to endocarditis. 12. Correct answer: A. Experiencing visual disturbances, such as seeing yellow spots or halos. Digitalis is a medication commonly used to treat various heart conditions, including heart failure and atrial fibrillation. While it is effective in strengthening heart contractions and regulating heart rate, it has a narrow therapeutic window, meaning the difference between a therapeutic and toxic dose is small. One of the hallmark signs of digitalis toxicity is experiencing visual disturbances, such as seeing yellow spots or halos around lights. This occurs because digitalis toxicity can affect the optic nerve, altering the way visual information is processed. If a client experiences these visual disturbances, it’s crucial to contact healthcare providers immediately for evaluation and possible adjustment of the medication. Digitalis toxicity can lead to severe complications, including life-threatening cardiac arrhythmias. Therefore, early recognition and intervention are vital to prevent further complications. Blood tests may be conducted to check the levels of digitalis, and other medications may be administered to counteract its effects. Think of your heart as a finely tuned musical instrument, like a violin, and digitalis as the rosin used on the bow to improve the sound quality (heart function). Too much rosin, however, can make the sound scratchy and unpleasant (digitalis toxicity). One of the first signs that you’ve used too much rosin might be that the violin starts producing distorted sounds (visual disturbances like yellow spots or halos). This is a warning sign that you need to adjust the amount of rosin you’re using to prevent further damage to the instrument (your heart). Incorrect answer options: B. Developing a skin rash across the chest and back areas. While skin rashes can be a side effect of many medications, they are not typically associated with digitalis toxicity. A rash would more likely indicate an allergic reaction to the medication rather than toxicity. If a rash occurs, it’s essential to consult healthcare providers for a differential diagnosis, as it could be related to other medications or underlying conditions. However, it should not be considered a hallmark sign of digitalis toxicity. C. Noticing an elevation in blood pressure levels. Digitalis primarily affects the heart and does not typically cause a significant elevation in blood pressure levels. Elevated blood pressure is not a recognized sign of digitalis toxicity. In fact, digitalis often has the opposite effect, potentially leading to lower blood pressure due to its action on the heart. If a patient notices a significant change in blood pressure, it’s crucial to consult healthcare providers, but this symptom is not directly related to digitalis toxicity. D. Feeling an unusual increase in appetite. Digitalis toxicity is more likely to cause loss of appetite or nausea rather than an increase in appetite. An unusual increase in appetite is not a sign of digitalis toxicity and could be related to other medical conditions or medications. For instance, medications like corticosteroids or certain antipsychotics can lead to increased appetite. Therefore, if a patient on digitalis experiences a sudden increase in appetite, it would be prudent to explore other potential causes rather than attributing it to digitalis toxicity. 13. Correct answer: C. Exhibiting exceptional dyspnea or difficulty breathing. Mitral regurgitation is a condition where the mitral valve in the heart doesn’t close tightly, allowing blood to flow backward into the left atrium. This backward flow can lead to a decrease in blood flow to the rest of the body and can cause symptoms like dyspnea or difficulty breathing. The reason for this is that the inefficient pumping can lead to fluid buildup in the lungs, making it hard for the individual to breathe. Dyspnea, particularly when lying down or during physical exertion, is a common symptom and often one of the first signs that prompt medical evaluation. In mitral regurgitation, the heart has to work harder to pump the same amount of blood, which can eventually lead to heart failure if not managed. The symptom of dyspnea is a direct result of this increased workload and the heart’s decreasing efficiency. It’s a red flag that should prompt immediate medical attention for diagnosis and treatment planning. Imagine your heart as a water pump and the mitral valve as a one-way flap that ensures water flows in only one direction. If the flap doesn’t close properly, some water will flow back, making the pump work harder to move the same amount of water. Now, think of your lungs as a garden that gets waterlogged if too much water flows back. When the garden is waterlogged (fluid buildup in the lungs), it’s hard to walk through it (difficulty breathing). Incorrect answer options: A. Experiencing chest pain or discomfort. While chest pain can be a symptom of various heart conditions, it is not typically the most prominent symptom in mitral regurgitation. The primary issue here is the backflow of blood leading to fluid in the lungs, which manifests more as difficulty breathing rather than chest pain. B. Showing an increase in creatine phosphokinase concentration. An increase in creatine phosphokinase is more indicative of muscle damage and is often seen in conditions like myocardial infarction. It is not a primary symptom or sign of mitral regurgitation, which primarily affects valve function and leads to symptoms like dyspnea. D. Having an altered level of consciousness. An altered level of consciousness is a severe symptom that could be indicative of multiple medical emergencies but is not typically associated with mitral regurgitation. Conditions like stroke or severe hypoxia are more likely to cause changes in consciousness. 14. Correct answer: A. Right or left costovertebral angle. The costovertebral angle (CVA) is the anatomical space formed by the vertebral column and the downward curve of the last rib. Pain or discomfort in the CVA is a classic sign of kidney problems, such as pyelonephritis (kidney infection) or kidney stones. The kidneys are retroperitoneal organs located in this area. When a patient has a urinary tract infection that has ascended to the kidneys, tapping lightly on the costovertebral angle can produce pain, known as CVA tenderness. This is a significant clinical finding and often leads to further diagnostic tests like urine cultures and imaging studies. Imagine your urinary system is like a home plumbing system. The kidneys are like the main water filter system, located in the basement or utility area (CVA). If there’s a problem with the main water filter, you’ll likely have to go to the basement to diagnose the issue. Similarly, if there’s a problem originating in the kidneys, signs will most likely be felt in the CVA area. Incorrect answer options: B. Labium, or the folds around the vulva. Pain or discomfort in the labium or vulva is more indicative of a lower urinary tract infection or a sexually transmitted infection rather than a kidney issue. This area is like the “faucet” in our plumbing analogy; issues here don’t usually signify a problem with the main water filter (kidneys). C. Urinary meatus, or the opening of the urethra. Discomfort at the urinary meatus is usually associated with lower urinary tract infections, urethritis, or trauma. It is not a specific indicator of kidney problems. In our plumbing analogy, this would be like having an issue with the nozzle of the hose; it doesn’t necessarily mean the main water filter (kidneys) is compromised. D. Suprapubic area, or the region just above the pubic bone. Pain in the suprapubic area is often associated with bladder issues, such as cystitis, rather than kidney problems. The bladder is like the “storage tank” in our plumbing analogy. If you have issues here, it’s more likely a problem with storing water (urine) rather than filtering it (kidney function). 15. Correct answer: B. Clonic seizure. Clonic seizures are characterized by repetitive, rhythmic jerking movements of the muscles. These are usually the result of abnormal electrical activity in the brain, specifically in the motor cortex, which controls muscle movements. The jerking is generally most prominent in the arms and legs but can involve the entire body. Clonic seizures are often part of a larger seizure episode that may include other seizure types, such as tonic seizures. The jerking movements are uncontrollable and can be violent, posing a risk for injury. Immediate medical attention is required to manage the symptoms and underlying causes. Think of the brain as a computer’s central processing unit (CPU). Normally, the CPU sends out organized, well-timed signals to execute functions (like moving a mouse cursor). But during a clonic seizure, it’s as if the CPU starts sending out chaotic, rapid-fire signals. This results in the jerking movements, similar to how a computer mouse would erratically move all over the screen if the CPU malfunctioned. The brain’s neurons usually fire in a coordinated manner, but during a seizure, there’s a burst of electrical activity that disrupts this harmony. In a clonic seizure, this disorganized electrical activity primarily affects the motor cortex. The result is uncontrolled muscle contractions that manifest as jerking movements. Antiseizure medications aim to restore the normal pattern of neuronal firing, thereby alleviating the symptoms. Incorrect answer options: A. Absence seizure. Absence seizures, formerly known as “petit mal” seizures, are characterized by brief lapses in consciousness where the individual appears to be staring off into space. There are no convulsive movements. This type of seizure is more common in children and is often so brief that it goes unnoticed. It’s like a brief “system freeze” on a computer, where all activity halts for a few seconds before resuming as if nothing happened. C. Myoclonic seizure. Myoclonic seizures involve quick, sudden muscle jerks, but they are typically shorter in duration than clonic seizures. They can occur in a series or as isolated events and can affect a specific part of the body or be generalized. Unlike clonic seizures, myoclonic seizures don’t have the rhythmic, repetitive jerking. It’s like a computer experiencing random, quick “glitches” that cause brief, unexpected actions but don’t last long. D. Tonic seizure. Tonic seizures involve the sudden stiffening of the muscles, usually those in the back, arms, and legs. The person may fall to the ground if standing. There are no jerking movements in tonic seizures, making it different from clonic seizures. Imagine a computer where the mouse cursor suddenly freezes in place; it’s stuck but not moving erratically as in a clonic seizure. 16. Correct answer: A. Nicotine (Nicotrol). Buerger’s disease, also known as thromboangiitis obliterans, is a condition that causes inflammation and thrombosis (clotting) in small and medium-sized blood vessels. It is strongly associated with tobacco use, including smoking and chewing tobacco. One of the most effective ways to manage this disease is to stop using tobacco products. Nicotine replacement therapies like Nicotrol can be a crucial part of a smoking cessation program. They work by providing a controlled amount of nicotine to ease withdrawal symptoms, making it easier for the individual to quit smoking. This approach aims to reduce the inflammation and clotting associated with Buerger’s disease. Imagine your blood vessels are like pipes in a plumbing system, and tobacco is like debris that clogs those pipes. Nicotrol acts like a specialized tool that helps you gradually remove the debris without causing a sudden blockage (withdrawal symptoms). Over time, this allows the pipes to function more efficiently, reducing the risk of severe clogs (blood clots and inflammation). Nicotine stimulates the release of dopamine in the brain, which is associated with pleasure and reward. When a person tries to quit smoking, the sudden drop in nicotine levels leads to reduced dopamine release, causing withdrawal symptoms like irritability, anxiety, and cravings. Nicotrol provides a controlled amount of nicotine, allowing the brain to adjust gradually and making it easier to quit smoking. By quitting smoking, the patient reduces the inflammation and clotting in the blood vessels, thereby managing the symptoms of Buerger’s disease. Incorrect answer options: B. Paracetamol. Paracetamol (also known as acetaminophen) is an analgesic and antipyretic medication. While it may help relieve pain, it does not address the root cause of Buerger’s disease, which is tobacco use. Using paracetamol would be like using a bucket to remove water from a leaking pipe; it may manage the symptom (pain), but it doesn’t fix the underlying issue (tobacco use). C. Nitroglycerin. Nitroglycerin is primarily used for managing angina pectoris by dilating blood vessels. While it may improve blood flow, it does not directly address the tobacco use that is the primary cause of Buerger’s disease. It’s like widening a clogged pipe without removing the debris; the problem still remains. D. Ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that may alleviate pain and inflammation but does not help with smoking cessation. Using ibuprofen for Buerger’s disease is akin to using a band-aid on a wound that requires stitches; it may offer temporary relief but doesn’t solve the underlying problem. 17. Correct answer: B. To prevent sleep disturbances during the night due to frequent urination. Furosemide is a loop diuretic that works by inhibiting the reabsorption of sodium and chloride in the kidneys, leading to increased urine output. This diuresis usually begins within 30 minutes to an hour after taking the medication and can last for about 6 to 8 hours. Taking Furosemide in the morning is advised primarily to prevent nocturia, or frequent urination during the night, which can lead to sleep disturbances. A good night’s sleep is essential for overall well-being and particularly important for individuals with heart failure, as inadequate sleep can exacerbate symptoms and contribute to poor cardiovascular health. Imagine your body as a water tank with a spigot at the bottom (your kidneys). Furosemide is like opening that spigot wider for a certain period, allowing more water (urine) to flow out. If you open the spigot wide in the evening, you’ll find yourself having to empty the overflowing catch basin (your bladder) multiple times during the night, disrupting your sleep. By opening the spigot in the morning, you can manage the outflow during waking hours, ensuring a more restful sleep. The kidneys play a crucial role in fluid balance, electrolyte regulation, and blood pressure maintenance. Furosemide acts on the ascending limb of the loop of Henle in the kidneys, inhibiting the sodium-potassium-chloride cotransporter. This action leads to increased excretion of water, sodium, chloride, magnesium, and calcium, effectively reducing fluid overload in conditions like heart failure. Timing the medication correctly allows for optimal diuretic effect while minimizing disruptions to the patient’s daily life and sleep cycle. Incorrect answer options: A. To help excrete excessive fluids that may have accumulated overnight. While it’s true that Furosemide helps in fluid excretion, the timing isn’t specifically aimed at addressing overnight fluid accumulation. The body’s circadian rhythm naturally regulates fluid balance, and the medication’s primary timing concern is to prevent sleep disturbances. C. To aid in the prevention of electrolyte imbalance. Furosemide does affect electrolyte levels, but taking it in the morning is not specifically aimed at preventing electrolyte imbalance. Monitoring and supplementing electrolytes is a separate aspect of managing patients on diuretics. D. To retard rapid drug absorption and prolong its effects. The timing of Furosemide is not intended to retard its absorption or prolong its effects. The drug has a relatively quick onset and a specific duration of action, regardless of when it is taken. The primary concern is to minimize nocturia and the resulting sleep disturbances. 18. Correct answer: A. An episodic vasospastic disorder affecting the small arteries in extremities. Raynaud’s disease is a condition characterized by episodic vasospasm of the small arteries, primarily affecting the fingers and toes. During an episode, the affected extremities may turn white, blue, and then red as the blood flow is first reduced and then returns. These episodes are often triggered by cold temperatures or emotional stress. The vasospasm reduces blood flow to the affected areas, leading to the characteristic color changes and often causing numbness, tingling, or pain. Imagine the small arteries in the extremities as narrow roads leading to a small town (your fingers and toes). Normally, these roads are open, allowing cars (blood cells) to flow freely. However, in Raynaud’s disease, it’s as if these roads suddenly have toll booths (vasospasms) that pop up unpredictably, slowing down or even stopping the flow of cars. This causes a “traffic jam,” leading to changes in the town’s “environment” (color changes, numbness, etc.). The exact cause of Raynaud’s disease is not well understood, but it is believed to involve dysfunction in the smooth muscle lining of the small arteries. During a vasospasm, these smooth muscles contract excessively, narrowing the arterial lumen and reducing blood flow. This is a localized response and does not generally affect larger arteries or veins. The condition can be primary (Raynaud’s disease) or secondary to another condition (Raynaud’s phenomenon), such as autoimmune diseases. Incorrect answer options: B. A periodic vasospastic disorder involving the aorta. Raynaud’s disease specifically affects the small arteries in the extremities, not large arteries like the aorta. Involvement of the aorta would likely result in more severe and systemic symptoms, not the localized symptoms seen in Raynaud’s. C. An intermittent vasospastic disorder targeting small veins. Raynaud’s disease affects the small arteries, not veins. Veins are responsible for returning blood to the heart and do not typically undergo the kind of vasospasm seen in this condition. D. A recurring vasospastic disorder impacting capillaries. While capillaries are involved in the microcirculation of blood, Raynaud’s disease specifically targets the small arteries. Capillaries don’t have the muscular walls that are capable of the vasospasm characteristic of this condition. 19. Correct answer: B. Blood glucose testing provides more accurate results. Self-monitoring of blood glucose levels is the gold standard for diabetes management because it provides real-time, accurate measurements of glucose concentration in the blood. Urine glucose testing, on the other hand, is not as reliable because it only detects glucose that has been filtered by the kidneys and excreted in the urine. This means that urine glucose testing can miss episodes of hypoglycemia (low blood sugar) and may not accurately reflect current blood glucose levels. Furthermore, factors like hydration status can influence urine glucose concentration, making it an unreliable marker for blood glucose control. Think of managing diabetes like managing the finances of a business. Blood glucose testing is akin to real-time accounting software that gives you up-to-the-minute information on your financial status, allowing for immediate adjustments and informed decisions. Urine glucose testing, however, is like reviewing bank statements from a month ago; it provides some information, but it’s outdated and influenced by various factors, making it less reliable for making current financial decisions. Blood glucose levels can fluctuate rapidly due to various factors such as food intake, physical activity, stress, and medications. Self-monitoring of blood glucose allows for immediate feedback, enabling timely interventions like adjusting insulin doses or carbohydrate intake. This real-time data is crucial for preventing both hyperglycemia (high blood sugar) and hypoglycemia, both of which can have severe consequences if not managed promptly. Incorrect answer options: A. Blood glucose testing is not influenced by medications. While it’s true that blood glucose testing is generally less influenced by medications compared to urine testing, this is not the primary reason for its preference. Some medications can indeed affect blood glucose levels, but the key advantage of blood glucose testing is its accuracy. C. Blood glucose testing is easy to perform and user-friendly. While user-friendliness is an advantage, it’s not the primary reason for preferring blood glucose testing over urine glucose testing. The main benefit is the accuracy and real-time feedback it provides, which is crucial for effective diabetes management. D. Blood glucose testing can be done independently by the client. Although it’s true that blood glucose testing can be done independently, this is not the primary reason for its preference. Urine glucose testing can also be done independently but lacks the accuracy and real-time feedback provided by blood glucose testing. 20. Correct answer: C. 2.0 L of fluid loss. In medical settings, it’s commonly accepted that a weight loss of 1 kilogram (approximately 2.2 pounds) is roughly equivalent to a loss of 1 liter of fluid. Anna initially weighed 210 pounds and now weighs 205.5 pounds. The weight loss is 210 – 205.5 = 4.5 pounds. To convert this weight loss into fluid loss, we divide 4.5 pounds by 2.2 pounds per liter, which gives us approximately 2.05 liters. This is rounded to 2.0 L, indicating that Anna has lost about 2.0 L of fluid. Imagine you have a water balloon that weighs 210 grams. If you poke a small hole in it and let some water leak out until the balloon weighs 205.5 grams, you’ve lost 4.5 grams of water. In the medical world, weight and fluid volume are closely related, just like the weight and water content of the balloon. So, by knowing the weight loss, you can estimate how much “water” (or in Anna’s case, fluid) has been lost. Diuretic therapy is often used to manage conditions like heart failure, liver cirrhosis, or kidney disease, where fluid retention is a concern. Diuretics work by promoting the excretion of sodium and water by the kidneys. This is reflected in weight loss, as excess fluid is removed from the body. Monitoring weight is a practical way to gauge the effectiveness of diuretic therapy and to assess fluid balance, which is crucial for maintaining homeostasis in the body. Incorrect answer options: A. 3.5 L of fluid loss. This would imply a weight loss of 7.7 pounds (3.5 L x 2.2 pounds/L), which is not the case here. Anna lost 4.5 pounds, corresponding to approximately 2.0 L of fluid loss. B. 1.5 L of fluid loss. This would correspond to a weight loss of 3.3 pounds (1.5 L x 2.2 pounds/L), which is less than Anna’s actual weight loss of 4.5 pounds. D. 0.3 L of fluid loss. This would correspond to a weight loss of approximately 0.66 pounds (0.3 L x 2.2 pounds/L), which is significantly less than Anna’s actual weight loss of 4.5 pounds. 21. Correct answer: D. Osmosis, the movement of water across a semipermeable membrane from an area of low solute concentration to high solute concentration. Albumin is a protein that plays a crucial role in maintaining oncotic pressure, which is the osmotic pressure exerted by proteins in the blood plasma. When intravenous albumin is administered, it increases the concentration of albumin in the blood. This creates a higher osmotic pressure within the blood vessels, attracting water from the interstitial and intracellular spaces back into the circulatory system. In essence, albumin acts as a “magnet” for water, pulling it into the bloodstream and helping to increase blood volume and pressure. This is particularly useful in conditions like hypovolemia or shock, where fluid resuscitation is needed. Imagine a classroom where students (representing water molecules) are free to move between two adjacent rooms separated by a door (the semipermeable membrane). One room has a charismatic speaker (representing albumin), while the other room is empty. Naturally, students will be drawn to the room with the speaker, just as water molecules are drawn to areas with higher concentrations of solutes like albumin. The more captivating the speaker, the more students will move into that room, similar to how a higher concentration of albumin in the blood will draw more water into the circulatory system. Osmosis is a passive process that doesn’t require energy. It’s driven by the osmotic gradient between two compartments separated by a semipermeable membrane. In the human body, the vascular endothelium serves as this membrane, allowing water but not larger molecules like albumin to pass through freely. By administering intravenous albumin, healthcare providers can manipulate this osmotic gradient to shift fluids as needed, thereby managing conditions that involve fluid imbalances. Incorrect answer options: A. Diffusion, the movement of molecules from an area of high concentration to low concentration. While diffusion is a process that involves the movement of molecules, it doesn’t specifically apply to the action of albumin in shifting body fluids. Albumin works by altering osmotic pressure, not by diffusing from an area of high concentration to low concentration. B. Active transport, the movement of molecules against a concentration gradient using energy. Active transport requires energy to move molecules against a concentration gradient. The action of albumin in shifting body fluids is a passive process driven by osmotic pressure, not an active transport mechanism. C. Filtration, the movement of water and solutes through a membrane due to hydrostatic pressure. Filtration is driven by hydrostatic pressure differences and is not the primary mechanism by which albumin shifts body fluids. Albumin works by creating an osmotic gradient that passively draws water into the circulatory system. 22. Correct answer: C. Weakness in the forearm muscles. When using crutches, the forearm muscles are heavily engaged to maintain balance and support body weight during ambulation. These muscles are responsible for flexing and extending the wrist and fingers, which are crucial actions for effective crutch use. Overuse or improper use of crutches can lead to muscle fatigue and weakness in the forearm muscles, making it difficult for the client to maintain a firm grip on the crutches. This could lead to instability and increase the risk of falls, which is a significant concern, especially for a client with a fractured tibia like Emma. Imagine using a pair of tongs to pick up objects all day. At first, it might seem easy, but as the day progresses, you’ll notice that your hand and forearm muscles start to feel tired and weak. The same principle applies to crutch walking. The forearm muscles are like the “tongs” that help you grip and maneuver the crutches. If these muscles become weak, it becomes increasingly difficult to “pick up” or move yourself effectively, increasing the risk of dropping something—or in this case, falling. The forearm muscles, including the flexor carpi radialis, flexor carpi ulnaris, and extensor carpi radialis, play a vital role in wrist and finger movements. These muscles are activated during crutch walking to grip the crutch handles and provide stability. Overexertion without adequate rest or improper technique can lead to muscle fatigue, reduced muscle strength, and even injury. Therefore, assessing for signs of forearm muscle weakness is crucial in preventing complications related to crutch use. Incorrect answer options: A. Spasm in the triceps muscle. While the triceps are used in crutch walking, they are not the primary muscles responsible for gripping the crutches. Spasms in the triceps could occur due to various reasons and are not specifically indicative of a complication related to crutch use. B. Discomfort in the left leg. Discomfort in the left leg would likely be related to the fractured tibia rather than crutch use. While it’s essential to monitor for signs of increased pain or complications related to the fracture, this is not specifically a crutch-related issue. D. Weakness in the biceps brachii muscles. The biceps brachii muscles are used in flexing the elbow and are engaged during crutch walking. However, they are not the primary muscles responsible for gripping the crutches. Weakness in the biceps brachii would not be as indicative of a crutch-related complication as weakness in the forearm muscles. 23. Correct answer: B. Increase cardiac output. Pulmonary edema and heart failure are conditions that are intrinsically linked to the heart’s inability to pump blood effectively, leading to fluid accumulation in the lungs and other parts of the body. The primary goal of therapy in such cases is to increase cardiac output, which is the amount of blood the heart pumps per minute. By improving cardiac output, you not only enhance the perfusion of vital organs but also help alleviate symptoms like shortness of breath and fatigue. Medications like diuretics, vasodilators, and inotropes are commonly used to achieve this goal, along with lifestyle modifications and other supportive therapies. Imagine your heart as a water pump in a garden that needs to supply water to various plants (organs). If the pump isn’t working efficiently, some plants won’t get enough water, and you’ll also have water pooling in unwanted areas (edema). The primary goal is to fix the pump (increase cardiac output) so that all plants get adequately watered and the pooling water is eliminated. Just like you’d adjust the settings or repair the pump to make it more efficient, medications and therapies aim to make the heart pump more effectively. Cardiac output is calculated as the heart rate multiplied by the stroke volume (the amount of blood ejected by the left ventricle with each contraction). In heart failure, the stroke volume is often compromised due to weakened cardiac muscles or other structural issues. Increasing cardiac output involves improving these parameters, thereby enhancing the overall function of the heart. This, in turn, helps in the redistribution of fluids and reduces the symptoms associated with pulmonary edema and heart failure. Incorrect answer options: A. Decrease peripheral edema. While decreasing peripheral edema is an important aspePractice Mode
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B. Flexion of all extremities in response to a stimulus.
C. Flexion of both the upper and lower extremities.
D. Extension of all extremities in response to a stimulus.
B. Onset of peptic ulcer disease.
C. Gastrointestinal bleeding.
D. Occurrence of abdominal cramps.
B. Obtain daily serum potassium levels for the client.
C. Ensure that an infusion pump is available for administering the medication.
D. Frequently monitor the client’s urine output.
B. Ability to recognize the risk factors associated with Myocardial Infarction.
C. Capability to participate in cardiac rehabilitation walking programs.
D. Able to engage in self-care activities without experiencing pain.
B. Apply elastic stockings to prevent muscle flaccidity.
C. Utilize a bed cradle to prevent dorsiflexion of the feet.
D. Place a hand roll and extend the left upper extremity on a pillow to prevent muscle contractions.
B. Morphine is given to prevent shock and alleviate pain.
C. Morphine helps in preventing fibrillation of the heart.
D. Morphine is used to decrease anxiety and restlessness.
B. Ensuring the client is able to turn from side to side.
C. Keeping track of the client’s hourly urine output.
D. Confirming that the client is able to sip clear liquids.
B) To obtain a visual representation of the disease affecting the coronary arteries.
C) To evaluate the electrical conduction system of the heart.
D) To measure the volume of blood ejected by the left ventricle per minute (cardiac output).
B. Frequently assess the client’s apical pulse and blood pressure.
C. Instruct the client to perform coughing and deep breathing exercises every 2 hours.
D. Elevate the head of the client’s bed to a 45° angle.
B. Quinidine Sulfate
C. Protamine Sulfate
D. Coumadin
B) A hard-bristle toothbrush.
C) A soft-bristle toothbrush .
D) A dental pick.
B. Developing a skin rash across the chest and back areas.
C. Noticing an elevation in blood pressure levels.
D. Feeling an unusual increase in appetite.
B. Showing an increase in creatine phosphokinase concentration.
C. Exhibiting exceptional dyspnea or difficulty breathing.
D. Having an altered level of consciousness.
B. Labium, or the folds around the vulva.
C. Urinary meatus, or the opening of the urethra.
D. Suprapubic area, or the region just above the pubic bone.
B. Clonic seizure
C. Myoclonic seizure
D. Tonic seizure
B. Paracetamol
C. Nitroglycerin
D. Ibuprofen
B. To prevent sleep disturbances during the night due to frequent urination.
C. To aid in the prevention of electrolyte imbalance.
D. To retard rapid drug absorption and prolong its effects.
B. A periodic vasospastic disorder involving the aorta.
C. An intermittent vasospastic disorder targeting small veins.
D. A recurring vasospastic disorder impacting capillaries.
B. Blood glucose testing provides more accurate results.
C. Blood glucose testing is easy to perform and user-friendly.
D. Blood glucose testing can be done independently by the client.
B. 1.5 L of fluid loss.
C. 2.0 L of fluid loss.
D. 0.3 L of fluid loss.
B. Active transport, the movement of molecules against a concentration gradient using energy.
C. Filtration, the movement of water and solutes through a membrane due to hydrostatic pressure.
D. Osmosis, the movement of water across a semipermeable membrane from an area of low solute concentration to high solute concentration.
B. Discomfort in the left leg.
C. Weakness in the forearm muscles.
D. Weakness in the biceps brachii muscles.
B. Increase cardiac output.
C. Encourage participation in group therapy.
D. Enhance overall comfort, alleviating symptoms.
B. Performing oral hygiene after every meal.
C. Using suppositories or enemas.
D. Using a filter mask to reduce exposure to airborne pathogens.
B. Supine position
C. Sims position
D. Semi-fowlers position
B. Regularly assess for hypoventilation by auscultating the lungs.
C. Carefully remove the airway only when the client is fully conscious.
D. Thoughtfully position the client laterally with the neck extended.
B. Proceed to “strip” the chest tube catheter.
C. Recognize that the system is functioning correctly and continue monitoring.
D. Carefully decrease the amount of suction pressure applied.
B. Consistency in pulse rate.
C. Stability of blood pressure.
D. Presence of distension of the bladder.
B) “I’ll focus on eating whole, unprocessed foods and will avoid adding salt while cooking.”
C) “I can switch to low-fat products since they generally contain less sodium.”
D) “It’s beneficial to eat more potassium-rich foods only, without worrying about sodium.”
B) Pressure within the interstitial osmotic spaces.
C) Serum albumin being produced.
D) Pressure occurring in the portal vein system.
B) Current vital signs.
C) Integrity of the airway.
D) Condition of the incision site.
B) Systolic blood pressure reading lower than 90 mm Hg.
C) The patient’s pupils appearing unequally dilated.
D) A pulse rate registering less than 60 beats per minute.
B) Utilizing normal saline nose drops will be necessary before the surgery.
C) Medications containing aspirin must be avoided for a period of 14 days prior to surgery.
D) The desired results of the surgery will be instantly noticeable right after the operation.
B) Regular insulin administration.
C) An injection of sodium bicarbonate.
D) Administration of calcium gluconate.
B) Leafy greens and tropical fruits like spinach and mangoes.
C) Seafood selections including fish, accompanied by fruit jam.
D) Root vegetables such as carrots and potatoes.
B) Engage in vigorous exercise to speed up metabolism.
C) Wait at least 2-3 hours before lying down.
D) Drink a cup of strong coffee to neutralize stomach acid.
B) Fever and chills.
C) Mild nausea and dizziness.
D) Slight discomfort in the throat.
B) “Most people can gradually return to a regular diet following this kind of surgery.”
C) “I should continue to avoid foods that gave me trouble before the surgery.”
D) “I’ll need to focus on a high-protein diet for the next 12 months after surgery.”
B) A feeling of restlessness.
C) Stools with a clay-colored appearance.
D) The presence of yellow-colored urine.
B) Para-Aminosalicylic Acid (PAS)
C) Isoniazid (INH)
D) Ethambutol Hydrochloride (Myambutol)
B) A genetic defect within the gastric mucosa.
C) Constant exposure to stressful situations.
D) An infection with the Helicobacter pylori bacteria.
B) The sound of wheezes.
C) Friction rubs during respiration.
D) A stridor or harsh sound.
B) Lifting heavy objects.
C) Watching TV in moderation.
D) Attending visually stimulating events like a circus.
B) A ligament sprain.
C) A bone fracture.
D) A skin contusion.
B) Allowing the solution to warm to room temperature.
C) Pulling the auricle in a backward and upward direction.
D) Placing the tip of the dropper on the edge of the ear canal.
B. Absence of drainage from the ileostomy for 6 or more hours.
C. Passage of liquid stool in the stoma, consistent with normal function.
D. A temperature of 37.6 °C, slightly above normal.
B. Intestinal obstruction, blocking the flow of contents.
C. Bowel ischemia, restricting blood flow.
D. Peritonitis, an inflammation of the peritoneum.
B. Cirrhosis
C. Myocardial Infarction
D. Peptic ulcer
B. Occurrence of watery, loose stool.
C. Appearance of yellowing in the sclera.
D. Experience of shortness or difficulty in breathing.
B. Dark brown.
C. Greenish bile.
D. Yellowish fluid.Answers and Rationales