NCLEX Practice Exam for Medical Surgical Nursing 1

Practice Mode

Welcome to your NCLEX Practice Exam for Medical Surgical Nursing 1! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

βœ” Exam Details

  • Number of Questions: 50 items
  • Mode: Practice Mode

βœ” Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

βœ” Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

πŸ’‘ Hint

Consider the immediate post-operative care and the signs that could indicate a potential complication. What action should the nurse take to ensure the safety and well-being of the client?

1 / 50

1. Following Billroth surgery for a gastric ulcer, the client's NGT (nasogastric tube) drainage becomes thick, and the volume of secretions dramatically reduces in the last 2 hours. The client also feels nauseated. As Nurse Allen is assessing the situation, what would be the most appropriate nursing action to take?

πŸ’‘ Hint

Consider the physiological effects of repeated insulin injections at the same site. What complication can specifically affect the absorption of insulin? The correct reason revolves around this underlying concern.

2 / 50

2. Nurse Wallace is educating a diabetic client about the importance of rotating insulin injection sites. What is the primary reason for the nurse to emphasize this particular practice?

πŸ’‘ Hint

Think about the primary actions and effects of Digoxin on the heart and body. One of the statements contradicts the expected therapeutic effects of the drug. Consider what a positive inotropic effect should do to the urine output.

3 / 50

3. Mr. Briggs, a patient with heart failure, has been prescribed Digoxin 0.25 mg once daily. As his nurse, you're reviewing the teaching plan with him. Which of the following statements by Mr. Briggs would indicate poor understanding or incorrect knowledge regarding this drug?

πŸ’‘ Hint

Consider the reason for combining these specific medications in the treatment of a positive Tuberculin skin test. The correct answer reflects an understanding of how they work synergistically to combat the tuberculosis infection effectively.

4 / 50

4. You are a nurse in a busy clinic, caring for a client who has recently tested positive for a Tuberculin skin test. Dr. John prescribes a combination of oral rifampin (Rimactane) and isoniazid (INH). You need to explain the purpose of this treatment to the client. What would you say is the main reason for this combination therapy?

πŸ’‘ Hint

Cushing's syndrome includes specific signs that go beyond general obesity. Consider the characteristic features that align with hormonal imbalances, such as fat redistribution.

5 / 50

5. While working at a weight loss clinic, Nurse Anderson evaluates a client exhibiting symptoms of a large abdomen and a rounded face. In differentiating between obesity and another medical condition, Nurse Anderson considers the additional assessment findings. Which one would lead her to suspect that the client may have Cushing's syndrome rather than obesity?

πŸ’‘ Hint

Consider the unique needs of a client with COPD and how oxygen therapy is specifically managed for them. The correct answer reflects an understanding of the delicate balance required in administering oxygen to a COPD patient.

6 / 50

6. As a nurse working in a respiratory unit, you are orienting a new nurse on caring for clients with COPD. When discussing oxygen administration for these clients, which point would you emphasize as the most relevant knowledge?

πŸ’‘ Hint

Dumping syndrome often leads to rapid emptying of the stomach contents into the small intestine. Think about the impact of body positioning on gastric emptying and how it might exacerbate or mitigate symptoms.

7 / 50

7. Following Billroth II Surgery, the client has developed dumping syndrome. Nurse Harris is creating a plan of care. Recognizing the specifics of dumping syndrome management, which of the following should be excluded from the plan?

πŸ’‘ Hint

Think about dietary choices that are generally recommended to support colon health. What adjustments to one's diet align with advice to reduce colon cancer risk?

8 / 50

8. Nurse Martinez is discussing with a client various strategies that can decrease the risk of developing colon cancer. The client reveals proper comprehension of these measures when stating:

πŸ’‘ Hint

In the context of acute pancreatitis, think about the specific characteristics of pain medications. One of these drugs is often preferred to manage pain without aggravating the patient's existing symptoms. What drug aligns with this criteria?

9 / 50

9. Nurse Franklin is faced with the task of managing pain for a patient diagnosed with acute pancreatitis. Among the options available, which medication is typically selected for pain control in this particular medical condition?

πŸ’‘ Hint

Think about the primary problem in pneumonia and its effect on the respiratory system. What is the main physiological issue that needs to be addressed?

10 / 50

10. Nurse Robinson is developing a plan of care for a patient diagnosed with pneumonia. Being attuned to the specific needs and challenges of treating pneumonia, which nursing diagnosis would be most appropriate for this patient?

πŸ’‘ Hint

Think about the changes that may occur in the respiratory system when lung cancer develops. The correct answer refers to a common early sign that could indicate the presence of this serious condition.

11 / 50

11. You are a nurse leading a β€œstop smoking” class and discussing the serious consequences of smoking, including lung cancer. A participant asks what a common symptom of lung cancer might be. How would you describe one typical sign of lung cancer?

πŸ’‘ Hint

Consider the symptoms presented: rectal bleeding, frequent diarrhea, abdominal pain, and dehydration. These are classic signs associated with a particular inflammatory bowel disease. Which one of the diseases listed corresponds directly with these symptoms?

12 / 50

12. Nurse Taylor is attending to a client who arrives with symptoms including severe rectal bleeding, frequent diarrheal stools (16 times a day), intense abdominal pain, tenesmus, and dehydration. Recognizing these symptoms, the nurse should be vigilant for complications associated with which specific disease?

πŸ’‘ Hint

Consider the immediate postoperative care necessary after thyroid surgery. Focus on what would be most important to monitor to ensure that no complications are developing.

13 / 50

13. Nurse Mitchell is caring for a client during the first 24 hours after thyroid surgery. Understanding the unique needs and potential complications following this type of surgery, what should be included in Nurse Mitchell's care for the client?

πŸ’‘ Hint

Consider the principles of diabetes care, especially regarding circulation and foot care. Which option might not align with standard diabetic self-management practices?

14 / 50

14. Nurse Johnson is formulating a teaching plan for a diabetic patient. Understanding the special care and precautions required for diabetes management, which of the following would be inappropriate to include in this teaching plan?

πŸ’‘ Hint

Consider which response would foster a supportive and empathetic conversation. Focus on patient-centered care and communication that would allow Mr. Jackson to express his feelings and concerns.

15 / 50

15. Mr. Jackson, a 68-year-old individual diagnosed with Bladder Cancer, is on the schedule for a cystectomy along with the formation of an ileal conduit come morning. Upon entering his room, you, as his dedicated nurse, observe him anxiously pacing and wringing his hands. What is your best nursing approach to handle his evident anxiety?

πŸ’‘ Hint

Consider the specific pharmacological action of heparin. The correct answer will outline how heparin prevents clot formation without referring to unrelated mechanisms or incorrect information about its function in the body.

16 / 50

16. You are a nurse caring for a client who is receiving heparin sodium to prevent clot formation. The client, eager to understand his treatment, asks how the medication works. How would you explain the action of heparin sodium to the client?

πŸ’‘ Hint

The correct guidance helps in capturing the kidney stone once it's passed, allowing for analysis to prevent future occurrences.

17 / 50

17. Peter, a 38-year-old patient, has been diagnosed with a renal calculus through an intravenous pyelogram. Nurse Thompson believes the small stone will pass spontaneously. Along with instructing the patient to increase fluid intake, what additional guidance should the nurse provide?

πŸ’‘ Hint

Consider the instructions usually given for taking corticosteroids like Prednisone. Which option aligns with the general guidance provided for adhering to a prescribed medication regimen?

18 / 50

18. Nurse Taylor is educating a patient about the potential side effects of Prednisone therapy. The patient needs to understand the importance of following the doctor's instructions and the potential impact on their health. Which statement made by the patient would indicate that they understand the potential side effects of Prednisone therapy?

πŸ’‘ Hint

Consider the patient's symptoms of shock and think about the appropriate interventions. One of these orders may not align with treating shock and could even exacerbate the situation. Focus on what would be necessary to stabilize Rhian's condition.

19 / 50

19. Rhian has just returned from surgery and is displaying alarming vital signs: blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. As her nurse, you suspect shock and review the doctor's orders. Which of the following orders would you question as inappropriate for this situation?

πŸ’‘ Hint

Think about the direct link between the nasogastric tube and nausea. Assessing a key aspect of the tube could reveal the underlying cause of the symptom.

20 / 50

20. After gallbladder surgery, Maya has been moved from the Post-anesthesia Care Unit (Recovery Room) and now has a nasogastric tube in place. As her nurse, you note her continual complaints of nausea. In this postoperative context, which nursing action would be most appropriate to address her nausea?

πŸ’‘ Hint

Think about the best practice for managing incisional pain during postoperative exercises like deep-breathing and coughing. One of these options involves a specific technique to minimize discomfort while supporting the incision.

21 / 50

21. Following a gallbladder surgery, Roger, a 54-year-old patient, complains of mild incisional pain while performing deep-breathing and coughing exercises as part of his postoperative care. As his nurse, you need to guide him on how to manage the pain during these exercises. What would be your best response?

πŸ’‘ Hint

Focus on the patient's pain and discomfort, and think about the most compassionate approach to assist him with his daily care. The correct choice should reflect empathy and gentleness, given his current condition.

22 / 50

22. Mr. Gerald, who is suffering from relentless pain due to cancer that has metastasized to his bones, finds little relief from his pain medication and adamantly refuses to move. In this delicate situation, as his attentive nurse, what should you plan to do in caring for him?

πŸ’‘ Hint

Consider the necessary precautions and lifestyle modifications that are often required for a patient with a permanent artificial cardiac pacemaker. The correct option contradicts the standard advice given to protect the device and the patient's health.

23 / 50

23. You are a charge nurse overseeing a teaching session between a staff nurse and a patient who has received a permanent artificial cardiac pacemaker. During the session, you notice that the staff nurse makes one statement that reveals a knowledge deficit about the care of an artificial cardiac pacemaker. Which statement was it?

πŸ’‘ Hint

In the context of a traumatic fall, think about which of these findings might directly indicate a severe head injury or internal damage. The correct answer reflects a sign that is commonly associated with a critical injury in the given scenario.

24 / 50

24. A 56-year-old construction worker has been brought to the emergency department unconscious after falling from a 2-story building. As his nurse, you begin assessing the client. Which finding would raise the most concern during your examination?

πŸ’‘ Hint

Consider the pharmacological effects of Atropine sulfate, including its common side effects. This will help you determine the most likely explanation for Grace's symptoms.

25 / 50

25. You are a nurse on a preoperative unit, and your patient Grace has just received Atropine sulfate (AtSO4) as premedication for surgery. 30 minutes later, she starts to complain of a dry mouth, and you notice that her pulse rate is higher than before the medication was administered. You recognize this as:

πŸ’‘ Hint

After a bronchoscopy, the throat might still be numb due to the local anesthesia. Swallowing food or liquids immediately could lead to choking or aspiration. Therefore, the nurse would instruct the patient to avoid consuming anything for a specific period until normal throat sensation returns.

26 / 50

26. A client is scheduled for a bronchoscopy procedure, during which a flexible tube will be inserted through the nose or mouth to examine the lungs. When educating the client about what to expect following the procedure, the nurse's information of utmost importance would be:

πŸ’‘ Hint

Think about the method of administration that ensures quick absorption of nitroglycerine into the bloodstream. Reflect on how this route aligns with the need for immediate relief from angina pain, and consider the commonly advised repetition and limits for the medication.

27 / 50

27. You are providing discharge education to a patient diagnosed with angina pectoris and prescribed nitroglycerine tablets. As part of your patient teaching, which of the following instructions accurately conveys the correct procedure for taking nitroglycerine tablets when experiencing chest pain?

πŸ’‘ Hint

Think about the procedure and its goal in detecting abnormalities in the colon. What preparation steps would be essential to ensure that the colon is clear and visualized accurately during this specific diagnostic test?

28 / 50

28. Nurse Parker is caring for a client who is to be evaluated for potential colon cancer with a barium enema. What preparation should the nurse specifically include to ensure the client is ready for this study?

πŸ’‘ Hint

Reflect on how physiological changes associated with aging might influence the perception of pain. The correct answer relates to a common alteration that could affect an elderly person's ability to perceive or communicate pain.

29 / 50

29. You are attending a training session on pain assessment in elderly patients. The presenter emphasizes the importance of careful assessment of pain in older individuals. According to best nursing practices, why must nurses be particularly attentive to pain complaints in the elderly?

πŸ’‘ Hint

Consider the changes in the vital signs and think about the best course of action to assess if these changes are a trend or an anomaly. The correct response would ensure continuous and timely monitoring without alarming or unnecessary measures.

30 / 50

30. A client has returned to the ward at 9AM, alert and oriented, with an IV infusing post-procedure. His vital signs are stable and within normal range. However, at noon, you note a slight increase in his pulse rate (94), a decrease in blood pressure to 116/74, and respirations at 24. As his nurse, what action would be the most appropriate in this situation?

πŸ’‘ Hint

Reflect on the Valsalva maneuver and what triggers it. The correct option is related to an activity that typically does not involve forced exhalation against a closed airway, a common characteristic of the Valsalva maneuver.

31 / 50

31. You are educating a patient about the Valsalva maneuver, which can lead to bradycardia, and the activities that may stimulate it. Which of the following activities should you instruct the patient will not likely stimulate the Valsalva maneuver?

πŸ’‘ Hint

Focus on the known risk factors for Coronary Artery Disease. One of these statements refers to a habit that is widely recognized as a leading risk factor for heart disease.

32 / 50

32. You are conducting a health assessment on a middle-aged client to evaluate risk factors for Coronary Artery Disease (CAD). During your conversation, which statement made by the client would indicate a significant risk factor for developing CAD?

πŸ’‘ Hint

Consider the specific pathology associated with advanced liver disease and how protein metabolism is affected. What would be the direct reason for a protein-restricted diet in this context?

33 / 50

33. A client's husband is inquiring about the protein-restricted diet prescribed for his wife's advanced liver disease. Nurse Mitchell must explain the purpose of the diet. What statement by the nurse would best describe the reason for this diet?

πŸ’‘ Hint

Consider the specific characteristics of pain associated with a duodenal ulcer, including its location, nature, and how it typically responds to food consumption.

34 / 50

34. Nurse Davis is assessing a patient's pain and suspects a duodenal ulcer based on the description provided. Which description of pain would be most characteristic of a duodenal ulcer?

πŸ’‘ Hint

Pheochromocytoma is related to the adrenal glands and can affect the cardiovascular system. Think about what vital sign would be most directly impacted and needs immediate assessment.

35 / 50

35. Nurse Williams is attending to a client suspected of having Pheochromocytoma, who is experiencing symptoms like sweating, palpitation, and headache. In prioritizing the client's care, what is the essential assessment that Nurse Williams should make first?

πŸ’‘ Hint

In the event of wound dehiscence, the immediate concern is to minimize infection risk and protect the exposed internal tissues. Which option corresponds with the best initial intervention to provide a protective barrier?

36 / 50

36. Several days following abdominal surgery, Nurse Adams notices that the client's wound has dehisced. What is the safest nursing intervention to undertake when this complication occurs?

πŸ’‘ Hint

Consider the immediate postoperative care needed after cholecystectomy. Focus on actions that would prevent common complications such as atelectasis. What specific nursing intervention will directly address this concern?

37 / 50

37. Nurse Anderson is caring for a client immediately after a cholecystectomy. Among the various nursing actions that need to be undertaken, which one should be prioritized as the most crucial at this stage?

πŸ’‘ Hint

Consider the common approach to treating Helicobacter pylori infection associated with peptic ulcers. What combination of treatments is typically utilized to eradicate the bacteria and relieve the ulcer symptoms?

38 / 50

38. Nurse Thompson is discussing the laboratory results with a male patient diagnosed with a peptic ulcer, showing an elevated titer of Helicobacter pylori. Which of the following statements made by the patient would indicate a proper understanding of this data?

πŸ’‘ Hint

In managing thrombophlebitis, it's essential to promote blood flow and reduce inflammation in the affected area. Think about what intervention would help in achieving these objectives without risking the dislodging of the clot.

39 / 50

39. As a clinical instructor, you are observing a student nurse who is caring for a client diagnosed with thrombophlebitis. The student is determined to provide proper care. Which of the following actions taken by the student nurse demonstrates the most appropriate intervention for a patient with thrombophlebitis?

πŸ’‘ Hint

In this specific situation, think about the immediate potential cause of the patient's difficulty in breathing. What direct action would alleviate the issue and is within the nurse's scope of practice?

40 / 50

40. Nurse Johnson is caring for a patient with complicated liver cirrhosis who has had a Sengstaken-Blakemore tube inserted to halt bleeding esophageal varices. After the insertion, the patient reports difficulty breathing. What should be the nurse's initial response to this complaint?

πŸ’‘ Hint

Think about the immediate post-procedure care after a gastroscopy and the importance of ensuring that certain reflexes are intact before proceeding with other interventions. What assessment would be crucial?

41 / 50

41. Nurse Parker is formulating a plan of care for a patient in the immediate post-gastroscopy period. Recognizing the specific needs and precautions following this procedure, what should be included in the plan of care?

πŸ’‘ Hint

Graves' disease can cause hyperthyroidism, which may lead to specific symptoms. Think about how Propranolol, a beta-blocker, would act in this situation.

42 / 50

42. An adult patient newly diagnosed with Graves' disease is inquiring about the prescription of Propranolol (Inderal). They ask Nurse Thompson, β€œWhy do I need to take this medication?” Based on Nurse Thompson's comprehensive understanding of both the medication and Graves' disease, the best response would be:

πŸ’‘ Hint

Consider foods that are typically high in sodium content. One of these options is commonly known to contain a significant amount of sodium and would be inappropriate for a sodium-restricted diet.

43 / 50

43. You are assessing the understanding of a client with chronic heart failure who has been instructed to follow a 2000 mg sodium-restricted diet. During your discussion about dietary habits, the client demonstrates adequate knowledge of this dietary restriction by not adding salt to food and mentioning the avoidance of which food item?

πŸ’‘ Hint

Consider the patient's diagnosis and the current oxygen rate. Remember the principles of oxygen therapy for patients with COPD, focusing on preventing oxygen-induced hypercapnia.

44 / 50

44. Nurse Thomas enters the room of a patient diagnosed with chronic obstructive pulmonary disease (COPD). Observing the patient's nasal cannula oxygen running at 6 L per minute, pink skin color, and shallow respirations at 9 per minute, Thomas must quickly decide on the most appropriate initial intervention. What is Nurse Thomas's best initial action for this patient with COPD?

πŸ’‘ Hint

Consider the surgical procedure Mario has undergone, and the importance of proper lung function following the surgery. The correct answer will focus on the goal of maintaining proper ventilation in the specific context of this patient's condition.

45 / 50

45. You are a surgical nurse caring for Mario, who has just undergone a left thoracotomy and partial pneumonectomy. Chest tubes are in place with one-bottle water-seal drainage, and you are tasked with positioning him correctly in the postanesthesia care unit. Mario is placed in Fowler's position on his right side or back. As a nursing student observing the procedure asks you the purpose of this positioning, what would be your response?

πŸ’‘ Hint

Think about the nature of a paracentesis and the area of the body it involves. What preparation would be necessary to provide better access to the area and minimize potential risks during the procedure?

46 / 50

46. Nurse Williams is preparing a client for a paracentesis procedure. What instruction should be provided to the client to ensure proper preparation for the procedure?

πŸ’‘ Hint

The correct symptom relates to a condition where the thyroid gland is underactive, leading to a decrease in metabolism. Look for symptoms that reflect a slowing down of bodily processes.

47 / 50

47. Upon discharge, Nurse Wallace educates the patient about observing for signs of surgically induced hypothyroidism following thyroid surgery. The nurse would recognize that the patient comprehends the teaching when the patient states that she should contact her medical doctor if she develops:

πŸ’‘ Hint

Consider the safety protocols and guidelines for suctioning mucus from a client's lungs. The incorrect action will relate to an unsafe or improper procedure during suctioning.

48 / 50

48. You are a nursing educator demonstrating proper suctioning techniques to a group of student nurses. During a simulation, one student asks what would be an incorrect action when suctioning mucus from a client's lungs. Which of the following would you indicate as the least appropriate action?

πŸ’‘ Hint

Think about the purpose of using an oral inhaler for COPD and the technique involved in ensuring the medication reaches the lungs properly. One of these instructions does not align with the correct inhaler technique.

49 / 50

49. Your client, Mrs. Thompson, has COPD and is being prepared for discharge. You are instructing her on the use of her prescribed oral inhaler. As a part of the patient education, you cover the following instructions EXCEPT:

πŸ’‘ Hint

Consider the symptoms of low blood sugar in a diabetic person. What immediate action can be taken to help raise the blood sugar level temporarily?

50 / 50

50. While enjoying a bridal shower, Nurse Martinez notices another guest, known to be diabetic, beginning to tremble and complain of dizziness. As a trained medical professional, what would be Nurse Martinez's next best action to assist the guest?

Exam Mode

Welcome to your NCLEX Practice Exam for Medical Surgical Nursing 1! This exam is carefully designed to provide you with a realistic test-taking experience, preparing you for the pressures of an actual nursing exam.

 

βœ” Exam Details

  • Number of Questions: 50 items
  • Mode: Exam Mode

βœ” Exam Instructions

  1. Exam Mode: This mode is intended to simulate the environment of an actual exam. Questions and choices will be presented one at a time.
  2. Time Limit: Each question must be answered within 90 seconds. The entire exam should be completed within 1 hour and 15 minutes.
  3. Feedback and Grading: Upon completion of the exam, you will be able to see your grade and the correct answers to all questions. This will allow you to evaluate your performance and understand areas for improvement.

βœ” Tips For Success

  • Read each question carefully. You have 90 seconds per question, so make sure you understand the question before selecting your answer.
  • Pace yourself. Remember, you have 1 hour and 15 minutes in total, so try to maintain a steady rhythm.
  • Focus on one question at a time. Try not to worry about the questions to come.
  • Stay calm under pressure. Use your knowledge and trust your instincts.
  • Remember, it's not just about the score, but about the learning process.

This exam is not only a measurement of your current understanding, but also a valuable learning tool to prepare you for your future nursing career. Click 'Start Exam' when you're ready to begin. Good luck!

1 / 50

1. Nurse Williams is preparing a client for a paracentesis procedure. What instruction should be provided to the client to ensure proper preparation for the procedure?

2 / 50

2. A 56-year-old construction worker has been brought to the emergency department unconscious after falling from a 2-story building. As his nurse, you begin assessing the client. Which finding would raise the most concern during your examination?

3 / 50

3. Rhian has just returned from surgery and is displaying alarming vital signs: blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. As her nurse, you suspect shock and review the doctor's orders. Which of the following orders would you question as inappropriate for this situation?

4 / 50

4. After gallbladder surgery, Maya has been moved from the Post-anesthesia Care Unit (Recovery Room) and now has a nasogastric tube in place. As her nurse, you note her continual complaints of nausea. In this postoperative context, which nursing action would be most appropriate to address her nausea?

5 / 50

5. You are assessing the understanding of a client with chronic heart failure who has been instructed to follow a 2000 mg sodium-restricted diet. During your discussion about dietary habits, the client demonstrates adequate knowledge of this dietary restriction by not adding salt to food and mentioning the avoidance of which food item?

6 / 50

6. Nurse Mitchell is caring for a client during the first 24 hours after thyroid surgery. Understanding the unique needs and potential complications following this type of surgery, what should be included in Nurse Mitchell's care for the client?

7 / 50

7. Mr. Jackson, a 68-year-old individual diagnosed with Bladder Cancer, is on the schedule for a cystectomy along with the formation of an ileal conduit come morning. Upon entering his room, you, as his dedicated nurse, observe him anxiously pacing and wringing his hands. What is your best nursing approach to handle his evident anxiety?

8 / 50

8. A client has returned to the ward at 9AM, alert and oriented, with an IV infusing post-procedure. His vital signs are stable and within normal range. However, at noon, you note a slight increase in his pulse rate (94), a decrease in blood pressure to 116/74, and respirations at 24. As his nurse, what action would be the most appropriate in this situation?

9 / 50

9. Nurse Parker is caring for a client who is to be evaluated for potential colon cancer with a barium enema. What preparation should the nurse specifically include to ensure the client is ready for this study?

10 / 50

10. You are a nurse on a preoperative unit, and your patient Grace has just received Atropine sulfate (AtSO4) as premedication for surgery. 30 minutes later, she starts to complain of a dry mouth, and you notice that her pulse rate is higher than before the medication was administered. You recognize this as:

11 / 50

11. As a clinical instructor, you are observing a student nurse who is caring for a client diagnosed with thrombophlebitis. The student is determined to provide proper care. Which of the following actions taken by the student nurse demonstrates the most appropriate intervention for a patient with thrombophlebitis?

12 / 50

12. Following Billroth II Surgery, the client has developed dumping syndrome. Nurse Harris is creating a plan of care. Recognizing the specifics of dumping syndrome management, which of the following should be excluded from the plan?

13 / 50

13. You are providing discharge education to a patient diagnosed with angina pectoris and prescribed nitroglycerine tablets. As part of your patient teaching, which of the following instructions accurately conveys the correct procedure for taking nitroglycerine tablets when experiencing chest pain?

14 / 50

14. You are a nursing educator demonstrating proper suctioning techniques to a group of student nurses. During a simulation, one student asks what would be an incorrect action when suctioning mucus from a client's lungs. Which of the following would you indicate as the least appropriate action?

15 / 50

15. Nurse Thompson is discussing the laboratory results with a male patient diagnosed with a peptic ulcer, showing an elevated titer of Helicobacter pylori. Which of the following statements made by the patient would indicate a proper understanding of this data?

16 / 50

16. You are a charge nurse overseeing a teaching session between a staff nurse and a patient who has received a permanent artificial cardiac pacemaker. During the session, you notice that the staff nurse makes one statement that reveals a knowledge deficit about the care of an artificial cardiac pacemaker. Which statement was it?

17 / 50

17. Several days following abdominal surgery, Nurse Adams notices that the client's wound has dehisced. What is the safest nursing intervention to undertake when this complication occurs?

18 / 50

18. Mr. Gerald, who is suffering from relentless pain due to cancer that has metastasized to his bones, finds little relief from his pain medication and adamantly refuses to move. In this delicate situation, as his attentive nurse, what should you plan to do in caring for him?

19 / 50

19. Nurse Robinson is developing a plan of care for a patient diagnosed with pneumonia. Being attuned to the specific needs and challenges of treating pneumonia, which nursing diagnosis would be most appropriate for this patient?

20 / 50

20. Upon discharge, Nurse Wallace educates the patient about observing for signs of surgically induced hypothyroidism following thyroid surgery. The nurse would recognize that the patient comprehends the teaching when the patient states that she should contact her medical doctor if she develops:

21 / 50

21. Nurse Martinez is discussing with a client various strategies that can decrease the risk of developing colon cancer. The client reveals proper comprehension of these measures when stating:

22 / 50

22. You are conducting a health assessment on a middle-aged client to evaluate risk factors for Coronary Artery Disease (CAD). During your conversation, which statement made by the client would indicate a significant risk factor for developing CAD?

23 / 50

23. A client is scheduled for a bronchoscopy procedure, during which a flexible tube will be inserted through the nose or mouth to examine the lungs. When educating the client about what to expect following the procedure, the nurse's information of utmost importance would be:

24 / 50

24. An adult patient newly diagnosed with Graves' disease is inquiring about the prescription of Propranolol (Inderal). They ask Nurse Thompson, β€œWhy do I need to take this medication?” Based on Nurse Thompson's comprehensive understanding of both the medication and Graves' disease, the best response would be:

25 / 50

25. A client's husband is inquiring about the protein-restricted diet prescribed for his wife's advanced liver disease. Nurse Mitchell must explain the purpose of the diet. What statement by the nurse would best describe the reason for this diet?

26 / 50

26. Nurse Johnson is caring for a patient with complicated liver cirrhosis who has had a Sengstaken-Blakemore tube inserted to halt bleeding esophageal varices. After the insertion, the patient reports difficulty breathing. What should be the nurse's initial response to this complaint?

27 / 50

27. Nurse Parker is formulating a plan of care for a patient in the immediate post-gastroscopy period. Recognizing the specific needs and precautions following this procedure, what should be included in the plan of care?

28 / 50

28. As a nurse working in a respiratory unit, you are orienting a new nurse on caring for clients with COPD. When discussing oxygen administration for these clients, which point would you emphasize as the most relevant knowledge?

29 / 50

29. Peter, a 38-year-old patient, has been diagnosed with a renal calculus through an intravenous pyelogram. Nurse Thompson believes the small stone will pass spontaneously. Along with instructing the patient to increase fluid intake, what additional guidance should the nurse provide?

30 / 50

30. Nurse Franklin is faced with the task of managing pain for a patient diagnosed with acute pancreatitis. Among the options available, which medication is typically selected for pain control in this particular medical condition?

31 / 50

31. You are a nurse in a busy clinic, caring for a client who has recently tested positive for a Tuberculin skin test. Dr. John prescribes a combination of oral rifampin (Rimactane) and isoniazid (INH). You need to explain the purpose of this treatment to the client. What would you say is the main reason for this combination therapy?

32 / 50

32. Following a gallbladder surgery, Roger, a 54-year-old patient, complains of mild incisional pain while performing deep-breathing and coughing exercises as part of his postoperative care. As his nurse, you need to guide him on how to manage the pain during these exercises. What would be your best response?

33 / 50

33. Nurse Johnson is formulating a teaching plan for a diabetic patient. Understanding the special care and precautions required for diabetes management, which of the following would be inappropriate to include in this teaching plan?

34 / 50

34. Your client, Mrs. Thompson, has COPD and is being prepared for discharge. You are instructing her on the use of her prescribed oral inhaler. As a part of the patient education, you cover the following instructions EXCEPT:

35 / 50

35. While working at a weight loss clinic, Nurse Anderson evaluates a client exhibiting symptoms of a large abdomen and a rounded face. In differentiating between obesity and another medical condition, Nurse Anderson considers the additional assessment findings. Which one would lead her to suspect that the client may have Cushing's syndrome rather than obesity?

36 / 50

36. Nurse Taylor is attending to a client who arrives with symptoms including severe rectal bleeding, frequent diarrheal stools (16 times a day), intense abdominal pain, tenesmus, and dehydration. Recognizing these symptoms, the nurse should be vigilant for complications associated with which specific disease?

37 / 50

37. Nurse Williams is attending to a client suspected of having Pheochromocytoma, who is experiencing symptoms like sweating, palpitation, and headache. In prioritizing the client's care, what is the essential assessment that Nurse Williams should make first?

38 / 50

38. You are a nurse leading a β€œstop smoking” class and discussing the serious consequences of smoking, including lung cancer. A participant asks what a common symptom of lung cancer might be. How would you describe one typical sign of lung cancer?

39 / 50

39. Nurse Wallace is educating a diabetic client about the importance of rotating insulin injection sites. What is the primary reason for the nurse to emphasize this particular practice?

40 / 50

40. You are attending a training session on pain assessment in elderly patients. The presenter emphasizes the importance of careful assessment of pain in older individuals. According to best nursing practices, why must nurses be particularly attentive to pain complaints in the elderly?

41 / 50

41. While enjoying a bridal shower, Nurse Martinez notices another guest, known to be diabetic, beginning to tremble and complain of dizziness. As a trained medical professional, what would be Nurse Martinez's next best action to assist the guest?

42 / 50

42. Following Billroth surgery for a gastric ulcer, the client's NGT (nasogastric tube) drainage becomes thick, and the volume of secretions dramatically reduces in the last 2 hours. The client also feels nauseated. As Nurse Allen is assessing the situation, what would be the most appropriate nursing action to take?

43 / 50

43. You are a nurse caring for a client who is receiving heparin sodium to prevent clot formation. The client, eager to understand his treatment, asks how the medication works. How would you explain the action of heparin sodium to the client?

44 / 50

44. You are educating a patient about the Valsalva maneuver, which can lead to bradycardia, and the activities that may stimulate it. Which of the following activities should you instruct the patient will not likely stimulate the Valsalva maneuver?

45 / 50

45. Nurse Thomas enters the room of a patient diagnosed with chronic obstructive pulmonary disease (COPD). Observing the patient's nasal cannula oxygen running at 6 L per minute, pink skin color, and shallow respirations at 9 per minute, Thomas must quickly decide on the most appropriate initial intervention. What is Nurse Thomas's best initial action for this patient with COPD?

46 / 50

46. Nurse Taylor is educating a patient about the potential side effects of Prednisone therapy. The patient needs to understand the importance of following the doctor's instructions and the potential impact on their health. Which statement made by the patient would indicate that they understand the potential side effects of Prednisone therapy?

47 / 50

47. Nurse Anderson is caring for a client immediately after a cholecystectomy. Among the various nursing actions that need to be undertaken, which one should be prioritized as the most crucial at this stage?

48 / 50

48. You are a surgical nurse caring for Mario, who has just undergone a left thoracotomy and partial pneumonectomy. Chest tubes are in place with one-bottle water-seal drainage, and you are tasked with positioning him correctly in the postanesthesia care unit. Mario is placed in Fowler's position on his right side or back. As a nursing student observing the procedure asks you the purpose of this positioning, what would be your response?

49 / 50

49. Mr. Briggs, a patient with heart failure, has been prescribed Digoxin 0.25 mg once daily. As his nurse, you're reviewing the teaching plan with him. Which of the following statements by Mr. Briggs would indicate poor understanding or incorrect knowledge regarding this drug?

50 / 50

50. Nurse Davis is assessing a patient's pain and suspects a duodenal ulcer based on the description provided. Which description of pain would be most characteristic of a duodenal ulcer?

Text Mode

Text ModeΒ – Text version of the exam

Questions

1. Rhian has just returned from surgery and is displaying alarming vital signs: blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. As her nurse, you suspect shock and review the doctor’s orders. Which of the following orders would you question as inappropriate for this situation?

A) Administer oxygen at 100% to maximize oxygenation.
B) Put the client in a modified Trendelenburg’s position to improve blood flow.
C) Administer Demerol 50 mg IM every 4 hours for pain control.
D) Monitor urine output every hour to assess kidney function.

2. Following a gallbladder surgery, Roger, a 54-year-old patient, complains of mild incisional pain while performing deep-breathing and coughing exercises as part of his postoperative care. As his nurse, you need to guide him on how to manage the pain during these exercises. What would be your best response?

A) “With a pillow, apply pressure against the incision to support it during coughing.”
B) “Pain will become less each day, so just continue with the exercises.”
C) “This is a normal reaction after surgery, don’t worry about it.”
D) “I will give you the pain medication the physician ordered, so you can continue the exercises.”

3. Mr. Jackson, a 68-year-old individual diagnosed with Bladder Cancer, is on the schedule for a cystectomy along with the formation of an ileal conduit come morning. Upon entering his room, you, as his dedicated nurse, observe him anxiously pacing and wringing his hands. What is your best nursing approach to handle his evident anxiety?

A) “Mr. Jackson, you’ll certainly wear out both yourself and the hospital’s flooring at this pace.”
B) “Good evening, Mr. Jackson. Wasn’t today quite a pleasant day outside?”
C) “Mr. Jackson, you seem rather worried; perhaps I should leave you alone with your thoughts for now.”
D) “Mr. Jackson, you appear to be quite anxious to me. Can you tell me how you’re feeling about the surgery tomorrow?”

4. After gallbladder surgery, Maya has been moved from the Post-anesthesia Care Unit (Recovery Room) and now has a nasogastric tube in place. As her nurse, you note her continual complaints of nausea. In this postoperative context, which nursing action would be most appropriate to address her nausea?

A) Carefully check the nasogastric tube’s patency to rule out any potential obstruction.
B) Promptly administer the physician-prescribed antiemetic medication as indicated.
C) Gently change the patient’s position to see if it alleviates the discomfort.
D) Immediately call the physician to report the ongoing issue.

5. Mr. Gerald, who is suffering from relentless pain due to cancer that has metastasized to his bones, finds little relief from his pain medication and adamantly refuses to move. In this delicate situation, as his attentive nurse, what should you plan to do in caring for him?

A) Approach him with care and handle him gently when assisting with required tasks.
B) Encourage him to perform his own activities of daily living to maintain independence.
C) Sincerely reassure him that the nursing staff will not hurt him during care.
D) Aim to complete A.M. care as swiftly as possible when it’s necessary.

6. A client has returned to the ward at 9AM, alert and oriented, with an IV infusing post-procedure. His vital signs are stable and within normal range. However, at noon, you note a slight increase in his pulse rate (94), a decrease in blood pressure to 116/74, and respirations at 24. As his nurse, what action would be the most appropriate in this situation?

A) Plan to take his vital signs again in an hour to monitor any further changes.
B) Immediately place the patient in a shock position as a precaution.
C) Promptly notify his physician to report the alterations.
D) Decide to take his vital signs again in 15 minutes to closely monitor the changes.

7. A 56-year-old construction worker has been brought to the emergency department unconscious after falling from a 2-story building. As his nurse, you begin assessing the client. Which finding would raise the most concern during your examination?

A) Evidence of bleeding from the ears.
B) A noticeable elevation in body temperature.
C) An apparent depressed fontanel, usually observed in infants.
D) The presence of reactive pupils responding to light.

8. You are conducting a health assessment on a middle-aged client to evaluate risk factors for Coronary Artery Disease (CAD). During your conversation, which statement made by the client would indicate a significant risk factor for developing CAD?

A) “I smoke 1 1/2 packs of cigarettes daily, and I know it’s a bad habit.”
B) “I make sure to exercise every other day to stay fit.”
C) “My father passed away due to Myasthenia Gravis, a neuromuscular disease.”
D) “My cholesterol level is 180, which seems to be within the normal range.”

9. Mr. Briggs, a patient with heart failure, has been prescribed Digoxin 0.25 mg once daily. As his nurse, you’re reviewing the teaching plan with him. Which of the following statements by Mr. Briggs would indicate poor understanding or incorrect knowledge regarding this drug?

A) “The positive inotropic effect of Digoxin might decrease my urine output, right?”
B) “Toxicity can occur more easily if I have hypokalemia, or liver and renal problems, correct?”
C) “I should avoid taking the drug if my apical heart rate is less than 60 beats per minute, shouldn’t I?”
D) “Digoxin has both positive inotropic and negative chronotropic effects on my heart, doesn’t it?”

10. You are educating a patient about the Valsalva maneuver, which can lead to bradycardia, and the activities that may stimulate it. Which of the following activities should you instruct the patient will not likely stimulate the Valsalva maneuver?

A) Experiencing gagging sensations while brushing teeth.
B) Utilizing stool softeners to ease bowel movements.
C) Lifting heavy objects during daily activities.
D) Undergoing enema administration for constipation relief.

11. You are a charge nurse overseeing a teaching session between a staff nurse and a patient who has received a permanent artificial cardiac pacemaker. During the session, you notice that the staff nurse makes one statement that reveals a knowledge deficit about the care of an artificial cardiac pacemaker. Which statement was it?

A) “You may be allowed to use most everyday electrical appliances.”
B) “You may still engage in contact sports if you feel comfortable.”
C) “Take your pulse rate once a day, in the morning upon awakening, to monitor the pacemaker.”
D) “Make sure to have regular follow-up care with your healthcare provider.”

12. You are providing discharge education to a patient diagnosed with angina pectoris and prescribed nitroglycerine tablets. As part of your patient teaching, which of the following instructions accurately conveys the correct procedure for taking nitroglycerine tablets when experiencing chest pain?

A) “Take one tablet and swallow it with a full glass of water if you experience chest pain. Repeat every 5 minutes.”
B) “Place one tablet under your tongue, and if the pain does not go away in 5 minutes, take another tablet. You may repeat this up to three times.”
C) “Chew one tablet and swallow it immediately if you experience chest pain. Do not take more than one tablet per episode.”
D) “Dissolve one tablet in a glass of water and drink it if you feel chest pain. Repeat every 30 minutes as needed.”

13. You are attending a training session on pain assessment in elderly patients. The presenter emphasizes the importance of careful assessment of pain in older individuals. According to best nursing practices, why must nurses be particularly attentive to pain complaints in the elderly?

A) Because older people often experience a general reduction in sensory perception.
B) Because the aging process may contribute to altered mental function in some individuals.
C) Because chronic pain is an expected and normal part of aging.
D) Because elderly individuals typically have a decreased pain threshold and may feel pain more acutely.

14. You are assessing the understanding of a client with chronic heart failure who has been instructed to follow a 2000 mg sodium-restricted diet. During your discussion about dietary habits, the client demonstrates adequate knowledge of this dietary restriction by not adding salt to food and mentioning the avoidance of which food item?

A) Canned sardines
B) Whole milk
C) Eggs
D) Plain nuts

15. As a clinical instructor, you are observing a student nurse who is caring for a client diagnosed with thrombophlebitis. The student is determined to provide proper care. Which of the following actions taken by the student nurse demonstrates the most appropriate intervention for a patient with thrombophlebitis?

A) Massaging the affected area to relieve pain.
B) Applying heat to the affected area and keeping the limb elevated.
C) Encouraging the patient to walk vigorously for exercise.
D) Administering an intramuscular injection into the affected limb.

16. You are a nurse caring for a client who is receiving heparin sodium to prevent clot formation. The client, eager to understand his treatment, asks how the medication works. How would you explain the action of heparin sodium to the client?

A) “It works by interfering with vitamin K absorption, affecting clotting.”
B) “Heparin sodium prevents the conversion of certain factors that are needed in the formation of clots.”
C) “The drug dissolves existing blood clots in your vessels.”
D) “It acts by inactivating thrombin, which then forms and dissolves existing blood clots.”

17. You are a nurse leading a β€œstop smoking” class and discussing the serious consequences of smoking, including lung cancer. A participant asks what a common symptom of lung cancer might be. How would you describe one typical sign of lung cancer?

A) Presence of foamy, blood-tinged sputum during coughing.
B) Experiencing shortness of breath (dyspnea) upon exertion.
C) Hearing a wheezing sound during inspiration.
D) Experiencing a new cough or a change in a pre-existing chronic cough.

18. As a nurse working in a respiratory unit, you are orienting a new nurse on caring for clients with COPD. When discussing oxygen administration for these clients, which point would you emphasize as the most relevant knowledge?

A) Monitoring blood gases through a pulse oximeter to maintain appropriate oxygen levels.
B) Administering oxygen at 1-2L/min to maintain the hypoxic stimulus for breathing, balancing oxygenation.
C) Explaining that hypoxia stimulates the central chemoreceptors in the medulla, initiating the client’s breath.
D) Teaching that oxygen is best administered using a non-rebreathing mask for optimal delivery.

19. You are a nursing educator demonstrating proper suctioning techniques to a group of student nurses. During a simulation, one student asks what would be an incorrect action when suctioning mucus from a client’s lungs. Which of the following would you indicate as the least appropriate action?

A) “You should suction until the client signals you to stop, but no longer than 20 seconds.”
B) “Make sure to lubricate the catheter tip with sterile saline before inserting it.”
C) “Remember to use a sterile technique, wearing two gloves during the procedure.”
D) “Always hyperoxygenate the client both before and after suctioning to maintain oxygenation.”

20. You are a nurse in a busy clinic, caring for a client who has recently tested positive for a Tuberculin skin test. Dr. John prescribes a combination of oral rifampin (Rimactane) and isoniazid (INH). You need to explain the purpose of this treatment to the client. What would you say is the main reason for this combination therapy?

A) “It’s designed to cause less irritation to your gastrointestinal tract.”
B) “This combination will help in gaining a more rapid systemic effect.”
C) “The combination is used to destroy resistant organisms and maintain proper blood levels of the drugs.”
D) “The two drugs work together to delay resistance and increase the tuberculostatic effect of the treatment.”

21. You are a surgical nurse caring for Mario, who has just undergone a left thoracotomy and partial pneumonectomy. Chest tubes are in place with one-bottle water-seal drainage, and you are tasked with positioning him correctly in the postanesthesia care unit. Mario is placed in Fowler’s position on his right side or back. As a nursing student observing the procedure asks you the purpose of this positioning, what would be your response?

A) “This positioning is to facilitate ventilation of the left lung.”
B) “It’s mainly to reduce incisional pain that Mario might feel.”
C) “This position is to increase venous return.”
D) “The purpose is to equalize pressure in the pleural space.”

22. Your client, Mrs. Thompson, has COPD and is being prepared for discharge. You are instructing her on the use of her prescribed oral inhaler. As a part of the patient education, you cover the following instructions EXCEPT:

A) “Remember to inhale slowly through your mouth as you press down on the canister.”
B) “Hold your breath for about 10 seconds before gently exhaling.”
C) “After inhaling the medication, slowly breathe out through your mouth with pursed lips.”
D) “Make sure to breathe in and out as fully as possible before placing the mouthpiece inside your mouth.”

23. You are a nurse on a preoperative unit, and your patient Grace has just received Atropine sulfate (AtSO4) as premedication for surgery. 30 minutes later, she starts to complain of a dry mouth, and you notice that her pulse rate is higher than before the medication was administered. You recognize this as:

A. A sign of anxiety due to Grace’s upcoming surgery.
B. A normal side-effect of Atropine sulfate (AtSO4).
C. An indication of an allergic reaction to the drug.
D. A sign that Grace needs a higher dose of this drug.

24. A client is scheduled for a bronchoscopy procedure, during which a flexible tube will be inserted through the nose or mouth to examine the lungs. When educating the client about what to expect following the procedure, the nurse’s information of utmost importance would be:

A. Regular coughing and deep-breathing exercises will be performed every 2 hours.
B. Consumption of food and fluids will be withheld for at least 2 hours.
C. Initially, only ice chips and cold liquids will be allowed.
D. Warm saline gargles will be performed every 2 hours.

25. Nurse Thomas enters the room of a patient diagnosed with chronic obstructive pulmonary disease (COPD). Observing the patient’s nasal cannula oxygen running at 6 L per minute, pink skin color, and shallow respirations at 9 per minute, Thomas must quickly decide on the most appropriate initial intervention. What is Nurse Thomas’s best initial action for this patient with COPD?

A. Reduce the oxygen rate to the prescribed level.
B. Position the patient in Fowler’s position.
C. Measure the patient’s heart rate and blood pressure.
D. Immediately call the physician.

26. While working at a weight loss clinic, Nurse Anderson evaluates a client exhibiting symptoms of a large abdomen and a rounded face. In differentiating between obesity and another medical condition, Nurse Anderson considers the additional assessment findings. Which one would lead her to suspect that the client may have Cushing’s syndrome rather than obesity?

A. Presence of a fat pad on the posterior neck and thinning of the extremities.
B. Noticeable abdominal striae and enlargement around the ankles.
C. A pendulous abdomen paired with pronounced hips.
D. Pronounced size in the thighs and upper arms.

27. Nurse Taylor is educating a patient about the potential side effects of Prednisone therapy. The patient needs to understand the importance of following the doctor’s instructions and the potential impact on their health. Which statement made by the patient would indicate that they understand the potential side effects of Prednisone therapy?

A. β€œThis medicine will shield me from acquiring colds or infections.”
B. β€œI should cut back on potassium in my diet since hyperkalemia is a consequence of this medication.”
C. β€œI need to follow the doctor’s directions in taking this medication, not missing any doses.”
D. β€œMy surgical wound will recover more swiftly due to this medication.”

28. Nurse Williams is attending to a client suspected of having Pheochromocytoma, who is experiencing symptoms like sweating, palpitation, and headache. In prioritizing the client’s care, what is the essential assessment that Nurse Williams should make first?

A. Testing the strength of the hand grips.
B. Checking the blood glucose levels.
C. Monitoring the blood pressure.
D. Evaluating the pupil reaction.

29. While enjoying a bridal shower, Nurse Martinez notices another guest, known to be diabetic, beginning to tremble and complain of dizziness. As a trained medical professional, what would be Nurse Martinez’s next best action to assist the guest?

A. Propose a cup of coffee to the guest.
B. Urge the guest to consume some baked macaroni.
C. Reach out to the guest’s personal physician.
D. Provide the guest with a glass of orange juice.

30. An adult patient newly diagnosed with Graves’ disease is inquiring about the prescription of Propranolol (Inderal). They ask Nurse Thompson, β€œWhy do I need to take this medication?” Based on Nurse Thompson’s comprehensive understanding of both the medication and Graves’ disease, the best response would be:

A. β€œThe medication will mitigate the cardiovascular symptoms of Graves’ disease.”
B. β€œThe medication will foster the production of thyroid hormones.”
C. β€œThe medication will curtail thyroid hormone secretion.”
D. β€œThe medication suppresses the synthesis of thyroid hormones.”

31. Nurse Mitchell is caring for a client during the first 24 hours after thyroid surgery. Understanding the unique needs and potential complications following this type of surgery, what should be included in Nurse Mitchell’s care for the client?

A. Informing the client that resuming normal activities right away is acceptable.
B. Inspecting the back and sides of the operative dressing for any signs of leakage or complications.
C. Encouraging the client to discuss her emotions regarding the surgery.
D. Assisting in supporting the head during mild range-of-motion exercises.

32. Upon discharge, Nurse Wallace educates the patient about observing for signs of surgically induced hypothyroidism following thyroid surgery. The nurse would recognize that the patient comprehends the teaching when the patient states that she should contact her medical doctor if she develops:

A) Persistent headaches and dizziness.
B) Increased appetite and weight loss.
C) Fatigue, constipation, and cold intolerance .
D) Palpitations and excessive sweating.

33. Nurse Robinson is developing a plan of care for a patient diagnosed with pneumonia. Being attuned to the specific needs and challenges of treating pneumonia, which nursing diagnosis would be most appropriate for this patient?

A. Impaired gas exchange.
B. Decreased tissue perfusion.
C. Risk for infection.
D. Fluid volume deficit.

34. Nurse Johnson is formulating a teaching plan for a diabetic patient. Understanding the special care and precautions required for diabetes management, which of the following would be inappropriate to include in this teaching plan?

A. Storing the insulin that’s not in use in the refrigerator.
B. Conducting daily inspections of feet and legs for any alterations.
C. Elevating the legs on 2 pillows while sleeping.
D. Altering the position hourly to enhance circulation.

35. Nurse Parker is formulating a plan of care for a patient in the immediate post-gastroscopy period. Recognizing the specific needs and precautions following this procedure, what should be included in the plan of care?

A. Evaluate the gag reflex before administering fluids.
B. Keep the nasogastric tube (NGT) on intermittent suction.
C. Assess for pain and administer medication as prescribed.
D. Measure the abdominal girth every 4 hours.

36. Nurse Davis is assessing a patient’s pain and suspects a duodenal ulcer based on the description provided. Which description of pain would be most characteristic of a duodenal ulcer?

A. Right upper quadrant (RUQ) pain that intensifies after a meal.
B. Sharp pain in the epigastric area that extends to the right shoulder.
C. Gnawing, dull, aching, hunger-like pain in the epigastric area that diminishes with food intake.
D. A sensation of painful pressure in the midsternal area.

37. Following Billroth surgery for a gastric ulcer, the client’s NGT (nasogastric tube) drainage becomes thick, and the volume of secretions dramatically reduces in the last 2 hours. The client also feels nauseated. As Nurse Allen is assessing the situation, what would be the most appropriate nursing action to take?

A. Irrigate the NGT with 50 cc of sterile solution.
B. Cease the low-intermittent suction.
C. Alert the medical doctor (MD) of the findings.
D. Reposition the NGT by advancing it gently with normal saline solution (NSS).

38. Following Billroth II Surgery, the client has developed dumping syndrome. Nurse Harris is creating a plan of care. Recognizing the specifics of dumping syndrome management, which of the following should be excluded from the plan?

A) Consuming small, frequent meals that are high in protein.
B) Sit upright for at least 30 minutes after meals.
C) Avoiding fluids with meals.
D) Reducing the amount of simple carbohydrates in the diet.

39. Nurse Thompson is discussing the laboratory results with a male patient diagnosed with a peptic ulcer, showing an elevated titer of Helicobacter pylori. Which of the following statements made by the patient would indicate a proper understanding of this data?

A. “I don’t need any treatment at this time.”
B. “The treatment will probably include medications like ranitidine and antibiotics.”
C. “Surgery is needed to treat this problem.”
D. “This result shows that I have gastric cancer caused by the organism.”

40. Nurse Williams is preparing a client for a paracentesis procedure. What instruction should be provided to the client to ensure proper preparation for the procedure?

A. Empty the bladder before the procedure.
B. Empty the bowel before the procedure.
C. Maintain strict bed rest following the procedure.
D. Remain NPO (nothing by mouth) for 12 hours before the procedure.

41. A client’s husband is inquiring about the protein-restricted diet prescribed for his wife’s advanced liver disease. Nurse Mitchell must explain the purpose of the diet. What statement by the nurse would best describe the reason for this diet?

A. “The liver’s inability to eliminate ammonia produced by protein breakdown in the digestive system necessitates this diet.”
B. “Most people consume too much protein; this diet is better suited for liver healing.”
C. “Due to portal hypertension, blood bypasses the liver, causing protein-derived ammonia to accumulate in the brain, leading to hallucinations.”
D. “The liver heals more effectively with a high-carbohydrate diet rather than a protein-rich one.”

42. Nurse Franklin is faced with the task of managing pain for a patient diagnosed with acute pancreatitis. Among the options available, which medication is typically selected for pain control in this particular medical condition?

A. Utilization of NSAIDS (Non-Steroidal Anti-Inflammatory Drugs).
B. Administration of Meperidine.
C. Prescription of Codeine.
D. Usage of Morphine.

43. Nurse Anderson is caring for a client immediately after a cholecystectomy. Among the various nursing actions that need to be undertaken, which one should be prioritized as the most crucial at this stage?

A. Frequently irrigating the T-tube.
B. Encouraging the client to take deep breaths orally with adequate frequency.
C. Prompting the client to engage in both coughing and deep breathing exercises.
D. Ensuring the dressing is changed at least twice daily (BID).

44. Nurse Johnson is caring for a patient with complicated liver cirrhosis who has had a Sengstaken-Blakemore tube inserted to halt bleeding esophageal varices. After the insertion, the patient reports difficulty breathing. What should be the nurse’s initial response to this complaint?

A. Carefully monitor vital signs (VS).
B. Promptly deflate the esophageal balloon.
C. Immediately notify the medical doctor (MD).
D. Encourage the patient to engage in deep breathing exercises.

45. Nurse Taylor is attending to a client who arrives with symptoms including severe rectal bleeding, frequent diarrheal stools (16 times a day), intense abdominal pain, tenesmus, and dehydration. Recognizing these symptoms, the nurse should be vigilant for complications associated with which specific disease?

A. Presentation of Ulcerative Colitis.
B. Indication of Crohn’s Disease.
C. Manifestation of Peritonitis.
D. Signs of Diverticulitis.

46. Nurse Wallace is educating a diabetic client about the importance of rotating insulin injection sites. What is the primary reason for the nurse to emphasize this particular practice?

A. The belief that injection sites should never be reused.
B. The potential development of lipodystrophic areas, leading to erratic insulin absorption from those sites.
C. The risk that poor rotation technique may induce superficial hemorrhaging.
D. The concern that lipodystrophy can occur and cause severe pain.

47. Nurse Parker is caring for a client who is to be evaluated for potential colon cancer with a barium enema. What preparation should the nurse specifically include to ensure the client is ready for this study?

A. Implement complete bed rest (CBR) a day prior to the study.
B. Advise the client to consume 6 radiopaque tablets the evening before the study.
C. Administer laxatives the night before and provide a cleansing enema on the morning of the test.
D. Administer an oil retention enema and give a laxative the evening prior.

48. Several days following abdominal surgery, Nurse Adams notices that the client’s wound has dehisced. What is the safest nursing intervention to undertake when this complication occurs?

A. Bring the wound edges together using tapes.
B. Maintain the abdominal contents’ position with a sterile gloved hand.
C. Cleanse the wound using sterile saline.
D. Protect the wound with a sterile, moist saline dressing.

49. Peter, a 38-year-old patient, has been diagnosed with a renal calculus through an intravenous pyelogram. Nurse Thompson believes the small stone will pass spontaneously. Along with instructing the patient to increase fluid intake, what additional guidance should the nurse provide?

A. Encourage the patient to limit physical activity.
B. Advise the patient to strain all urine.
C. Recommend a diet high in calcium.
D. Suggest using antacids to dissolve the stone.

50. Nurse Martinez is discussing with a client various strategies that can decrease the risk of developing colon cancer. The client reveals proper comprehension of these measures when stating:

A. β€œI will make sure to get an annual chest x-ray done.”
B. β€œI will make a point to engage in daily physical exercise.”
C. β€œI will make an effort to include an abundance of fresh fruits and vegetables in my daily meals.”
D. β€œI plan to add more red meat to my diet for overall health.”

Answers and Rationales

1. Correct answer:

C. Administer Demerol 50 mg IM every 4 hours for pain control. In the context of shock, where the patient is displaying signs of hypotension (low blood pressure) and tachycardia (increased heart rate), administering Demerol (an opioid analgesic) would be inappropriate. Opioids can cause further respiratory depression and hypotension, exacerbating the symptoms of shock. Pain control is essential, but in a situation like this, the choice of medication and the method of administration must be carefully considered.

Demerol can also mask some of the symptoms that are crucial for monitoring the patient’s condition, such as changes in pain level or consciousness, which might indicate a worsening or improvement of the shock. In this critical situation, alternative pain management strategies or medications that do not have these side effects should be considered.

Think of the body in shock as a car running out of fuel and struggling to function. Administering Demerol in this situation would be like putting the wrong type of fuel into the car. Not only would it not solve the problem, but it could also make the situation worse by causing further complications.

Incorrect answer options:

A. Administer oxygen at 100% to maximize oxygenation. In the case of shock, the body’s tissues are not receiving enough oxygen. Administering 100% oxygen would be an appropriate intervention to ensure that as much oxygen as possible is delivered to the vital organs.

B. Put the client in a modified Trendelenburg’s position to improve blood flow. This position, where the patient’s legs are elevated, can help increase blood flow to the vital organs, including the brain and heart. It’s a common intervention in the initial management of shock.

D. Monitor urine output every hour to assess kidney function. Monitoring urine output is an essential indicator of kidney function and overall perfusion to the organs. In shock, blood flow to the kidneys may be reduced, leading to decreased urine output. Regular monitoring can provide valuable information about the patient’s response to treatment.

2. Correct answer:

A) “With a pillow, apply pressure against the incision to support it during coughing.” Deep-breathing and coughing exercises are essential postoperative care practices, especially after abdominal or chest surgeries. They help prevent respiratory complications like pneumonia and atelectasis. However, these exercises can cause discomfort or pain at the incision site. Teaching the patient to use a technique called “splinting” can alleviate this pain.

Splinting involves holding a pillow or a rolled-up towel firmly against the incision while coughing or taking deep breaths. This support helps stabilize the area, reducing movement and strain on the healing tissues, thus minimizing pain. It’s a simple yet effective way to encourage the patient to continue these vital exercises without unnecessary discomfort.

Imagine the incision as a freshly glued piece of paper. If you move it around too much without support, the glue might not hold, and the paper might tear. Holding it steady with a support (like the pillow) allows the glue to set without disturbance, just like the support helps the incision heal without unnecessary strain.

Incorrect answer options:

B) “Pain will become less each day, so just continue with the exercises.” While it’s true that pain may decrease over time, this response does not address the patient’s immediate concern or provide a solution to manage the pain. It might discourage the patient from performing the exercises, leading to potential complications.

C) “This is a normal reaction after surgery, don’t worry about it.” While pain may be a normal reaction, dismissing the patient’s concern without offering a solution is not therapeutic communication. It fails to acknowledge the patient’s feelings and does not provide guidance on managing the pain.

D) “I will give you the pain medication the physician ordered, so you can continue the exercises.” While pain medication may be part of the pain management strategy, it’s not the only solution. Teaching the patient techniques like splinting empowers them to manage the pain actively and continue essential exercises without relying solely on medication.

3. Correct answer:

D) “Mr. Jackson, you appear to be quite anxious to me. Can you tell me how you’re feeling about the surgery tomorrow?” This response is the most therapeutic and patient-centered approach. It acknowledges Mr. Jackson’s visible anxiety and opens the door for him to express his feelings and concerns. By directly addressing the issue and inviting him to talk about it, the nurse is showing empathy and creating an environment where the patient feels heard and supported.

Understanding the patient’s specific fears or concerns allows the nurse to provide targeted education, reassurance, or interventions that may alleviate anxiety. It may also help in identifying if professional mental health support is needed. This approach aligns with the principles of patient-centered care and therapeutic communication.

Think of the patient’s anxiety as a tightly closed jar. Ignoring it or making light of it won’t open the jar. But by gently acknowledging the issue and asking the patient to share their feelings (like using a jar opener), the nurse can “open” the patient up to communication and support.

Incorrect answer options:

A) “Mr. Jackson, you’ll certainly wear out both yourself and the hospital’s flooring at this pace.” This response is dismissive and makes light of the patient’s anxiety. It does not acknowledge the patient’s feelings or provide an opportunity for him to express his concerns.

B) “Good evening, Mr. Jackson. Wasn’t today quite a pleasant day outside?” While this statement is friendly, it avoids addressing the patient’s evident anxiety. Ignoring or avoiding the issue does not provide the support or intervention that the patient may need at this time.

C) “Mr. Jackson, you seem rather worried; perhaps I should leave you alone with your thoughts for now.” This response acknowledges the anxiety but does not offer support or an opportunity for the patient to discuss his feelings. Leaving the patient alone may increase his anxiety rather than alleviate it.

4. Correct answer:

A) Carefully check the nasogastric tube’s patency to rule out any potential obstruction. After gallbladder surgery, a nasogastric (NG) tube may be in place to decompress the stomach and prevent nausea and vomiting. If the NG tube becomes obstructed, it can lead to the accumulation of gastric secretions, causing nausea. Therefore, the first and most appropriate nursing action would be to check the patency of the NG tube.

Checking the patency involves aspirating the tube to assess for gastric contents and observing the color and consistency. Flushing the tube with a small amount of saline may also be necessary. Ensuring that the NG tube is patent and functioning correctly can alleviate the nausea by allowing proper drainage of gastric secretions.

Think of the NG tube as a drain in a sink. If the drain is clogged, water accumulates in the sink, causing a problem. By checking and clearing the clog (ensuring patency), the water can drain properly, resolving the issue. Similarly, by ensuring the NG tube is patent, gastric secretions can drain, potentially alleviating the nausea.

Incorrect answer options:

B) Promptly administer the physician-prescribed antiemetic medication as indicated. While administering antiemetic medication may be part of the treatment plan for nausea, it should not be the first step without assessing the underlying cause, especially when an NG tube is in place.

C) Gently change the patient’s position to see if it alleviates the discomfort. Changing the patient’s position may be helpful in some cases of nausea, but in the context of an NG tube post-gallbladder surgery, it is more appropriate to assess the patency of the tube first.

D) Immediately call the physician to report the ongoing issue. While communication with the physician is essential, the nurse should first assess and address the potential cause of the nausea, such as an obstructed NG tube, before contacting the physician.

5. Correct answer:

A) Approach him with care and handle him gently when assisting with required tasks. In the case of Mr. Gerald, who is experiencing severe pain due to cancer that has spread to his bones, a gentle and compassionate approach is essential. Pain from bone metastases can be excruciating, and even slight movements can cause significant discomfort. The nurse’s priority should be to provide comfort and minimize pain during care.

Approaching him with care means assessing his pain level, understanding his specific needs, and planning interventions that minimize discomfort. Handling him gently involves using proper techniques to move and position him, coordinating care with pain medication administration, and possibly involving other healthcare professionals, such as physical therapists, to ensure that his needs are met in the most comfortable way possible.

Think of handling a fragile piece of glass art. You would approach it with extreme care, understanding its delicate nature, and taking every precaution to ensure that it doesn’t break. Similarly, the nurse must approach Mr. Gerald with the utmost care, recognizing his vulnerability and taking all necessary precautions to minimize his pain.

Incorrect answer options:

B) Encourage him to perform his own activities of daily living to maintain independence. While promoting independence is generally a good practice, in this specific situation, it may not be appropriate due to the severity of Mr. Gerald’s pain. His refusal to move indicates that assistance is likely needed.

C) Sincerely reassure him that the nursing staff will not hurt him during care. While reassurance is important, it may not be enough in this situation. The focus should be on actual gentle handling and coordinated care to minimize pain, rather than merely offering verbal reassurance.

D) Aim to complete A.M. care as swiftly as possible when it’s necessary. Rushing through care may lead to unnecessary discomfort and pain. While efficiency is important, the priority in this case should be on gentle handling and patient comfort, even if it takes more time.

6. Correct answer:

D) Decide to take his vital signs again in 15 minutes to closely monitor the changes. The slight increase in pulse rate, decrease in blood pressure, and increase in respirations could be indicative of an underlying issue, but they are not yet at a critical level. The changes are subtle and within a range that doesn’t necessarily warrant immediate intervention, but they do require close monitoring.

Monitoring vital signs at more frequent intervals (every 15 minutes) allows the nurse to detect any trends or further changes that might signal a more serious problem. This approach is consistent with the nursing process of assessment, analysis, and ongoing evaluation. If the trend continues or if other symptoms develop, the nurse would then take further action, such as notifying the physician.

Monitoring vital signs is similar to driving a car and paying attention to the dashboard. If you notice a slight change in the fuel gauge or a small warning light, you don’t immediately pull over and call for help. Instead, you keep a closer eye on the dashboard, watching for further changes or more significant warnings. If the warning light becomes more pronounced or other indicators show a problem, then you take action. Similarly, the nurse is keeping a closer eye on the patient’s vital signs to ensure that if a problem is developing, it can be addressed promptly.

Incorrect answer options:

A) Plan to take his vital signs again in an hour to monitor any further changes. An hour might be too long to wait if there is an underlying issue causing the changes in vital signs. More frequent monitoring is warranted in this situation.

B) Immediately place the patient in a shock position as a precaution. This action would be premature, as the changes in vital signs are not yet indicative of shock. Such an intervention could cause unnecessary anxiety for the patient.

C) Promptly notify his physician to report the alterations. While communication with the physician is essential, the changes in vital signs are not yet at a level that requires immediate intervention. More data is needed to determine the appropriate course of action, and closely monitoring the vital signs will provide that information.

7. Correct answer:

A) Evidence of bleeding from the ears. Bleeding from the ears in a patient who has suffered a fall from a significant height is a highly concerning sign. This could indicate a basilar skull fracture or traumatic brain injury (TBI), both of which are serious and potentially life-threatening conditions.

Basilar Skull Fracture: This type of fracture occurs at the base of the skull. It can lead to cerebrospinal fluid (CSF) leakage, which might mix with blood and exit through the ears. This condition requires immediate medical intervention to prevent complications such as meningitis or further brain damage.
Traumatic Brain Injury (TBI): Bleeding from the ears could also be a sign of internal bleeding within the brain. TBI can lead to increased intracranial pressure, which, if not treated promptly, can cause permanent brain damage or death.

Immediate Action Required: The nurse must promptly report this finding to the medical team so that appropriate diagnostic tests (such as a CT scan) can be ordered, and necessary interventions can be initiated.

Think of the skull as the hard shell of an egg, protecting the delicate interior. If you were to drop an egg from a height, the shell might crack, and the contents could leak out. Similarly, a fall from a height can crack the skull, leading to leakage of blood or CSF. Just as you would handle a cracked egg with extreme care, medical professionals must act quickly and carefully to manage a patient with these symptoms.

Incorrect answer options:

B) A noticeable elevation in body temperature. While an increase in body temperature might be a concern in some contexts, it is not as immediately alarming as bleeding from the ears in a trauma patient. Fever could be a sign of infection or other underlying issues but is not typically a direct result of a fall.

C) An apparent depressed fontanel, usually observed in infants. This option is not relevant to the patient’s condition, as a depressed fontanel is a clinical sign in infants, not in adults.

D) The presence of reactive pupils responding to light. Reactive pupils are a normal finding and indicate that the cranial nerves responsible for pupil response are functioning properly. This would not be a concern in this context.

8. Correct answer:

A) “I smoke 1 1/2 packs of cigarettes daily, and I know it’s a bad habit.” Smoking is one of the most significant risk factors for Coronary Artery Disease (CAD). Here’s why:

Nicotine Effect: Nicotine, a key component in cigarettes, causes the blood vessels to constrict, reducing blood flow to the heart. This constriction increases the heart’s workload, leading to higher blood pressure and heart rate.
Atherosclerosis Development: Smoking accelerates the process of atherosclerosis, where fatty substances, cholesterol, and other matter build up on the artery walls. This buildup narrows the arteries, reducing blood flow to the heart, and can lead to heart attacks.
Oxygen Deprivation: Carbon monoxide in cigarette smoke replaces some of the oxygen in the blood, depriving the heart and other tissues of the necessary oxygen. This forces the heart to work harder to supply the body with the oxygen it needs.

Reversibility and Intervention: The good news is that quitting smoking can reverse some of the damage to the heart and blood vessels. Nurses and healthcare providers play a vital role in educating patients about the risks of smoking and providing support and resources to help them quit.

Think of the coronary arteries as garden hoses supplying water (blood) to a garden (the heart). Smoking is like stepping on the hose; it restricts the flow of water, and the garden starts to wither. The more you step on the hose (smoke), the more the garden suffers. But if you remove the pressure (quit smoking), the water flow returns, and the garden begins to thrive again.

Incorrect answer options:

B) “I make sure to exercise every other day to stay fit.” Exercise is a protective factor against CAD, not a risk factor. Regular physical activity helps maintain healthy weight, reduces blood pressure, and improves cholesterol levels.

C) “My father passed away due to Myasthenia Gravis, a neuromuscular disease.” Family history of CAD would be a risk factor, but Myasthenia Gravis is not related to CAD, so this statement does not indicate a risk.

D) “My cholesterol level is 180, which seems to be within the normal range.” A cholesterol level of 180 is generally considered within the normal range, and it does not indicate a risk factor for CAD. High levels of LDL cholesterol would be a risk factor.

9. Correct answer:

A) “The positive inotropic effect of Digoxin might decrease my urine output, right?” Digoxin is a medication used to treat heart failure and certain types of irregular heartbeats. It has a positive inotropic effect, meaning it increases the force of the heart’s contractions. This increased force helps the heart pump more blood, which in turn increases urine output, not decreases it. The kidneys receive more blood, leading to increased filtration and urine production.

Think of the heart as a water pump in a garden. If the pump is weak, it can’t push enough water through the hoses, and the plants (organs) don’t get enough water. Digoxin is like upgrading the pump, making it stronger, so it can push more water to the plants, and excess water (urine) is drained away.

Incorrect answer options:

B) “Toxicity can occur more easily if I have hypokalemia, or liver and renal problems, correct?” – This statement is correct. Hypokalemia (low potassium levels) can increase the risk of Digoxin toxicity. Liver and renal problems can also affect how the drug is metabolized and excreted, increasing the risk of toxicity.

C) “I should avoid taking the drug if my apical heart rate is less than 60 beats per minute, shouldn’t I?” – This statement is also correct. Digoxin can slow down the heart rate, so if the apical heart rate is already less than 60 beats per minute, taking the drug might further decrease the heart rate to a dangerous level.

D) “Digoxin has both positive inotropic and negative chronotropic effects on my heart, doesn’t it?” – This statement is correct as well. As mentioned earlier, Digoxin has a positive inotropic effect, increasing the force of heart contractions. It also has a negative chronotropic effect, meaning it can slow down the heart rate.

10. Correct answer:

B) Utilizing stool softeners to ease bowel movements. The Valsalva maneuver is a specific action where a person tries to exhale forcefully with a closed glottis (the windpipe), causing increased pressure within the chest cavity. This can affect the return of blood to the heart and stimulate the vagus nerve, leading to bradycardia or a slowed heart rate.

Utilizing stool softeners to ease bowel movements is unlikely to stimulate the Valsalva maneuver. Stool softeners work by increasing the water content in the stool, making it softer and easier to pass. This action does not require the forceful exhalation or straining that characterizes the Valsalva maneuver. Instead, stool softeners facilitate a more gentle and natural bowel movement, reducing the need for straining.

Imagine trying to squeeze a thick paste through a narrow tube. It would require a lot of force and pressure, similar to the Valsalva maneuver when straining during a bowel movement. Now, imagine adding water to the paste, making it more fluid and easier to squeeze through the tube. This is what stool softeners do; they make the “paste” (stool) softer so it can pass through the “tube” (intestines) more easily, without the need for forceful pressure or straining.

Incorrect answer options:

A) Experiencing gagging sensations while brushing teeth – This activity can stimulate the Valsalva maneuver. Gagging sensations can lead to forceful exhalation and straining, similar to the actions involved in the Valsalva maneuver, potentially affecting heart rate.

C) Lifting heavy objects during daily activities – Lifting heavy objects often involves holding one’s breath and straining, especially if proper breathing techniques are not used. This can inadvertently lead to the Valsalva maneuver, affecting the return of blood to the heart and potentially slowing the heart rate.

D) Undergoing enema administration for constipation relief – An enema can stimulate the Valsalva maneuver, especially if it leads to straining during the process of administration or evacuation. The pressure and discomfort associated with an enema can cause a person to hold their breath and strain, similar to the Valsalva maneuver.

11. Correct answer:

B) “You may still engage in contact sports if you feel comfortable.” Patients with artificial cardiac pacemakers are generally advised to avoid contact sports. The reason for this is that physical trauma to the chest area where the pacemaker is implanted can cause damage to the device or the leads that connect it to the heart. This could lead to malfunction of the pacemaker, which could have serious consequences for the patient’s heart rhythm.

The artificial cardiac pacemaker is a device implanted under the skin, usually in the chest, to help control abnormal heart rhythms. It sends electrical pulses to prompt the heart to beat at a normal rate. Engaging in contact sports could lead to hits or blows to the chest area, potentially damaging the delicate device or dislodging the wires that connect it to the heart.

Think of the pacemaker as a delicate piece of machinery, like a finely tuned watch. If you were to play a rough sport like rugby with a delicate watch on your wrist, there’s a good chance it could get damaged. Similarly, a pacemaker is a finely tuned device that can be damaged by physical trauma. Just as you would take off the watch to protect it, you would avoid contact sports to protect the pacemaker.

Incorrect answer options:

A) “You may be allowed to use most everyday electrical appliances.” This statement is correct. Most everyday electrical appliances do not interfere with the functioning of a cardiac pacemaker. Patients are usually educated about specific devices or situations to avoid, but normal household appliances are generally safe.

C) “Take your pulse rate once a day, in the morning upon awakening, to monitor the pacemaker.” This statement is also correct. Monitoring the pulse rate can help detect any irregularities or changes in heart rhythm, which could indicate an issue with the pacemaker. Regular self-monitoring is often part of the care plan for patients with pacemakers.

D) “Make sure to have regular follow-up care with your healthcare provider.” This statement is correct as well. Regular follow-up care is essential for patients with artificial cardiac pacemakers. Healthcare providers need to regularly check the device to ensure it’s working properly and make any necessary adjustments.

12. Correct answer:

B) “Place one tablet under your tongue, and if the pain does not go away in 5 minutes, take another tablet. You may repeat this up to three times.” Nitroglycerine tablets are used to relieve chest pain in angina pectoris by dilating the blood vessels and increasing blood flow to the heart. The correct procedure is to place one tablet under the tongue, allowing it to dissolve. This sublingual administration ensures rapid absorption into the bloodstream. If the pain does not go away in 5 minutes, another tablet can be taken, and this process can be repeated up to three times. If the pain continues after three doses, emergency medical help should be sought.

The sublingual administration is essential because it allows the medication to enter the bloodstream quickly, bypassing the digestive system. This rapid action is vital in relieving chest pain promptly. The specific timing and repetition are also crucial, as they provide a structured approach to managing the pain while also recognizing when medical intervention may be necessary.

Think of the nitroglycerine tablet as a fire extinguisher for a small fire (angina pain). If a small fire starts, you use the extinguisher (place a tablet under the tongue), and if the fire doesn’t go out, you use it again (another tablet in 5 minutes). If the fire continues after using the extinguisher three times, it’s time to call the fire department (seek emergency medical help).

Incorrect answer options:

A) “Take one tablet and swallow it with a full glass of water if you experience chest pain. Repeat every 5 minutes.” – Swallowing the tablet would delay its absorption, as it would have to go through the digestive system. This method would not provide the rapid relief needed for angina pain.

C) “Chew one tablet and swallow it immediately if you experience chest pain. Do not take more than one tablet per episode.” – Chewing and swallowing the tablet would also delay its effect, and limiting to one tablet per episode does not align with the standard procedure of repeating the dose if the pain persists.

D) “Dissolve one tablet in a glass of water and drink it if you feel chest pain. Repeat every 30 minutes as needed.” – Dissolving the tablet in water and drinking it would not provide the rapid absorption needed, and repeating every 30 minutes is not the correct timing for managing angina pain.

13. Correct answer:

A) Because older people often experience a general reduction in sensory perception. Pain assessment in elderly patients requires particular attention due to several factors, one of which is the general reduction in sensory perception that often accompanies aging. This reduction can make it more challenging for older individuals to perceive and describe pain accurately.

Sensory perception includes not only the ability to feel pain but also the ability to communicate it. As sensory receptors become less sensitive, the intensity of pain may be perceived differently, and the ability to localize pain may be diminished. This can lead to underreporting or misreporting of pain, which in turn can lead to inadequate pain management. Furthermore, other factors such as cognitive impairment, communication barriers, or fear of being a burden may also contribute to the complexity of assessing pain in the elderly.

Think of sensory perception like the volume control on a stereo. In younger individuals, the volume (sensory perception) is turned up, and they can hear (perceive) everything clearly. As people age, it’s as if the volume gets turned down gradually. The music (pain) is still playing, but it’s harder to hear (perceive) and describe accurately. Nurses must “tune in” carefully to understand what the older individual is experiencing.

Incorrect answer options:

B) Because the aging process may contribute to altered mental function in some individuals. While cognitive changes may occur with aging, it is not the primary reason for being attentive to pain complaints in the elderly. Cognitive changes may affect communication, but they don’t necessarily change the perception of pain itself.

C) Because chronic pain is an expected and normal part of aging. Chronic pain is not a normal part of aging, and this belief can lead to under-treatment of pain in older individuals. Pain should always be assessed and managed appropriately, regardless of age.

D) Because elderly individuals typically have a decreased pain threshold and may feel pain more acutely. This statement is not universally true. While some older individuals may have a decreased pain threshold, others may have a reduced ability to perceive pain. Pain perception in the elderly is complex and can vary widely among individuals.

14. Correct answer:

A) Canned sardines. Patients with chronic heart failure are often instructed to follow a sodium-restricted diet to help manage fluid balance and reduce the workload on the heart. Sodium can cause the body to retain water, which can exacerbate heart failure symptoms.

Canned sardines, like many canned foods, are typically high in sodium. The sodium is used as a preservative and to enhance flavor. By avoiding canned sardines and other high-sodium foods, the client is demonstrating an understanding of the dietary restriction. Reading labels and choosing fresh or frozen options instead of canned can help in managing sodium intake.

Think of the heart as a pump and the blood vessels as hoses. If you add more water (sodium causing water retention) to the hoses, the pump has to work harder to move it around. If the pump is already weak (heart failure), adding more water can cause it to struggle even more. By avoiding adding extra water (sodium from canned sardines), you’re helping the pump work more efficiently.

Incorrect answer options:

B) Whole milk. While whole milk contains some sodium, it is not considered a high-sodium food. Avoiding whole milk would not necessarily indicate an understanding of a sodium-restricted diet, though it might be relevant for other dietary considerations.

C) Eggs. Eggs are not high in sodium and would not be a food that needs to be avoided on a sodium-restricted diet. They can be part of a heart-healthy diet when prepared without added salt.

D) Plain nuts. Plain, unsalted nuts are low in sodium and can be a healthy part of a sodium-restricted diet. Avoiding plain nuts would not demonstrate an understanding of the need to restrict sodium.

15. Correct answer:

B) Applying heat to the affected area and keeping the limb elevated. Thrombophlebitis is an inflammation of a vein due to a blood clot. The primary goals in managing thrombophlebitis are to reduce inflammation, prevent the clot from growing, and prevent complications such as a pulmonary embolism.

Applying Heat: Applying gentle heat to the affected area can help to reduce pain and inflammation by dilating the blood vessels and improving circulation. This promotes healing and can make the patient more comfortable. The heat should be applied with care, using a warm compress or heating pad, and the skin should be monitored to prevent burns.
Elevating the Limb: Keeping the affected limb elevated helps to reduce swelling and promotes venous return. Elevation should be gentle, keeping the limb slightly above the level of the heart. This position encourages blood flow away from the affected area, reducing pressure and swelling.

Imagine the affected vein as a congested road due to an accident (the blood clot). Applying heat is like sending traffic officers to direct the flow and ease congestion, while elevating the limb is like building a slight downhill slope to help the traffic move more smoothly. Both actions together create a more efficient flow without causing further accidents (complications).

Incorrect answer options:

A) Massaging the affected area to relieve pain. – Massaging the affected area could dislodge the clot, leading to serious complications such as a pulmonary embolism. This action should be avoided.

C) Encouraging the patient to walk vigorously for exercise. – While gentle movement can be beneficial, vigorous exercise might be too aggressive and could exacerbate the condition. Guided and gentle exercises might be more appropriate.

D) Administering an intramuscular injection into the affected limb. – Injecting into the affected limb could cause further irritation and inflammation. Injections should be avoided in the affected limb, and alternative sites should be used.

16. Correct answer:

B) “Heparin sodium prevents the conversion of certain factors that are needed in the formation of clots.” Heparin sodium is an anticoagulant, or blood thinner, that works by inhibiting specific clotting factors in the blood. It does not dissolve existing clots but rather prevents new clots from forming. Here’s how it works:

1. Inhibition of Clotting Factors: Heparin binds to a substance called antithrombin, which in turn inhibits several clotting factors, particularly Factor Xa and thrombin (Factor IIa). By inhibiting these factors, heparin interrupts the clotting cascade, preventing the conversion of fibrinogen to fibrin, a key step in clot formation.

2. Prevention of Clot Growth: By inhibiting the clotting factors, heparin doesn’t just prevent new clots from forming; it also prevents existing clots from growing larger. This can help to stabilize the patient’s condition and prevent complications such as stroke or pulmonary embolism.

3. Monitoring and Adjustment: Heparin therapy requires careful monitoring, as the balance between preventing clots and causing excessive bleeding is delicate. Regular blood tests help healthcare providers adjust the dose to maintain the desired level of anticoagulation.

Think of the blood clotting process as a complex assembly line in a factory, where each step leads to the next, culminating in the final product (a blood clot). Heparin acts like a supervisor who notices a flaw in the process and shuts down specific machines (clotting factors) along the assembly line. This doesn’t destroy the products already made (existing clots) but prevents new ones from being produced and existing ones from getting bigger.

Incorrect answer options:

A) “It works by interfering with vitamin K absorption, affecting clotting.” This describes the mechanism of action for warfarin, another anticoagulant, not heparin.

C) “The drug dissolves existing blood clots in your vessels.” Heparin does not dissolve existing clots; it prevents new ones from forming and existing ones from growing.

D) “It acts by inactivating thrombin, which then forms and dissolves existing blood clots.” While heparin does inhibit thrombin, it does not directly dissolve existing clots or cause thrombin to dissolve clots.

17. Correct answer:

D) Experiencing a new cough or a change in a pre-existing chronic cough. Lung cancer often leads to a new, persistent cough or a change in a pre-existing chronic cough. This change occurs because cancerous growth may block or irritate the airways, leading to alterations in the cough reflex. The symptom itself is non-specific and might be mistaken for other respiratory conditions, but its persistence and change can signal lung cancer’s underlying pathology.

Imagine a well-functioning water pipe that suddenly develops a blockage or leak. The normal flow of water would be altered, and the pipe might make a different noise or even spill water. In the same way, the growth of cancer in the lungs interferes with the normal flow of air, leading to changes in the cough.

Incorrect answer options:

A) Presence of foamy, blood-tinged sputum during coughing. Although this can be a symptom of lung cancer, especially in later stages, it is not as common or typical as a new or changed cough. It might also be indicative of other respiratory or cardiac conditions.

B) Experiencing shortness of breath (dyspnea) upon exertion. Shortness of breath can occur in many lung conditions, including asthma, chronic obstructive pulmonary disease (COPD), or even heart failure. It is a more generalized symptom and not as indicative of lung cancer specifically as the correct option.

C) Hearing a wheezing sound during inspiration. Wheezing can be caused by various factors like asthma, bronchitis, or foreign body obstruction, not necessarily lung cancer. While it might occur in some lung cancer cases, it is not a typical or specific sign of the disease.

18. Correct answer:

B) Administering oxygen at 1-2L/min to maintain the hypoxic stimulus for breathing, balancing oxygenation. Chronic Obstructive Pulmonary Disease (COPD) is characterized by chronic airflow limitation, which often leads to low levels of oxygen in the blood. Clients with COPD may rely on low levels of oxygen (hypoxic drive) to stimulate their breathing. If too much oxygen is administered, it may remove the stimulus for the client to breathe. Therefore, oxygen therapy should be administered cautiously, typically at low flow rates of 1-2L/min, to avoid suppressing the hypoxic drive and potentially leading to respiratory failure.

Think of the hypoxic drive as a delicate balance on a seesaw. On one side, you have the need to provide enough oxygen to meet the body’s demands, and on the other, you have the need to maintain enough of a low-oxygen state to stimulate breathing. Administering oxygen at 1-2L/min is like finding the perfect balance on that seesaw. It provides enough oxygen to support the body’s needs without tipping the balance too far, which could stop the stimulus to breathe.

In COPD patients, high levels of oxygen can be dangerous. The goal is to maintain oxygen saturation levels at a lower target, often around 88-92%, which can be counterintuitive when caring for patients without COPD, where higher saturation levels are typically aimed for. This targeted approach requires careful monitoring and understanding of the unique pathophysiology of COPD.

Incorrect answer options:

A) Monitoring blood gases through a pulse oximeter to maintain appropriate oxygen levels. While this is important in managing clients with COPD, it’s a more generalized care aspect rather than a specific approach tailored to the COPD population. It doesn’t address the fundamental issue of the hypoxic drive that COPD patients might rely upon.

C) Explaining that hypoxia stimulates the central chemoreceptors in the medulla, initiating the client’s breath. While this statement is true, it is more of a physiological explanation of how breathing is initiated and doesn’t directly translate into a specific nursing action or priority in caring for clients with COPD.

D) Teaching that oxygen is best administered using a non-rebreathing mask for optimal delivery. A non-rebreathing mask delivers high concentrations of oxygen, which might be inappropriate for COPD clients. Using such a mask could override the hypoxic drive and suppress the stimulus to breathe, leading to respiratory failure in a COPD patient.

19. Correct answer:

A) “You should suction until the client signals you to stop, but no longer than 20 seconds.” Suctioning mucus from a client’s lungs is a delicate procedure that must be performed with caution to avoid harming the client. Suctioning for an extended period or waiting for the client to signal to stop can be harmful and is not an appropriate guide for the duration of suctioning. The correct practice is to suction for no longer than 10-15 seconds at a time to avoid hypoxia and potential damage to the mucosal lining of the airway.

Think of suctioning like using a vacuum cleaner on a delicate fabric. If you vacuum the fabric too aggressively or for too long, you risk damaging it. Similarly, suctioning the client’s lungs for too long can damage the sensitive tissues and lead to other complications. The proper technique requires a balance, like gently vacuuming the fabric with attention to timing and pressure to clean it without causing damage.

The guideline to limit suctioning to no more than 10-15 seconds is based on understanding the risk of hypoxia, where the client’s oxygen levels can drop dangerously low during suctioning. Monitoring and limiting the time of suctioning is a crucial aspect of this procedure to protect the client’s well-being. The rule of “no longer than 20 seconds” or waiting for the client’s signal is not a safe guideline.

Incorrect answer options:

B) “Make sure to lubricate the catheter tip with sterile saline before inserting it.” This is a correct procedure and helps reduce friction and potential trauma to the airway, making the process smoother and more comfortable for the client.

C) “Remember to use a sterile technique, wearing two gloves during the procedure.” This statement is also correct. Using a sterile technique, including the use of two gloves, helps prevent infection and is a standard practice in suctioning mucus from the lungs.

D) “Always hyperoxygenate the client both before and after suctioning to maintain oxygenation.” Hyperoxygenation before and after suctioning is a standard practice, as it helps maintain adequate oxygen levels in the blood during the procedure. It’s aimed at preventing potential hypoxia, which can occur during suctioning.

20. Correct answer:

D) “The two drugs work together to delay resistance and increase the tuberculostatic effect of the treatment.” This combination therapy is an integral part of tuberculosis (TB) treatment. The main purpose of using rifampin and isoniazid together is to delay the development of resistance to the drugs and to increase the tuberculostatic effect of the treatment, meaning that it helps halt the growth and spread of the TB bacteria in the body.

Think of the combination therapy as using two different types of weed killers in your garden. If you were to use only one type of weed killer, some stubborn weeds might develop resistance and continue to grow. By using two different types of weed killers together, you target the weeds more effectively and reduce the chance of them becoming resistant. Similarly, rifampin and isoniazid together target the TB bacteria more effectively and reduce the risk of drug resistance.

The combination of rifampin and isoniazid is part of a standard TB treatment regimen to prevent the bacteria from developing resistance to one or both drugs. Resistance in TB treatment can lead to multi-drug resistant TB (MDR-TB), which is much more difficult to treat. By using these drugs in combination, the treatment increases the likelihood of effectively controlling and eventually eradicating the TB bacteria from the patient’s system.

Incorrect answer options:

A) “It’s designed to cause less irritation to your gastrointestinal tract.” This statement is incorrect. While minimizing gastrointestinal irritation is often a consideration in drug therapy, the primary reason for combining rifampin and isoniazid is not to reduce gastrointestinal irritation but to delay resistance and increase the tuberculostatic effect.

B) “This combination will help in gaining a more rapid systemic effect.” Though the combination might achieve systemic effects, the main reason for this specific combination is to delay resistance and increase the tuberculostatic effect. It’s not primarily aimed at achieving a rapid systemic effect.

C) “The combination is used to destroy resistant organisms and maintain proper blood levels of the drugs.” While the combination can be effective against some resistant organisms, the main purpose is not to maintain proper blood levels of the drugs but to increase the effectiveness of the treatment by working synergistically.

21. Correct answer:

A) “This positioning is to facilitate ventilation of the left lung.” After a left thoracotomy and partial pneumonectomy (removal of part of the left lung), positioning Mario in Fowler’s position on his right side or back is essential to facilitate proper ventilation of the remaining left lung.

Imagine a garden hose that is partially kinked, restricting the flow of water. To ensure that the water flows freely, you would position the hose so that the kink is opened, allowing the water to pass through. In Mario’s case, after the removal of part of the left lung, the remaining lung tissue needs optimal positioning to facilitate the free flow of air. By placing him in Fowler’s position on his right side or back, it’s akin to adjusting the “kink” in the lung, ensuring that air can flow into and expand the remaining left lung tissue efficiently, just like the water flows through the hose when positioned correctly.

The first priority in positioning is to ensure that the remaining lung tissue on the left side can expand fully. Placing the patient in the Fowler’s position on his right side or back allows gravity to work in favor of the left lung, helping it to expand and fill with air. This position also helps in keeping the airways open, reducing the risk of atelectasis, and ensuring that the left lung receives sufficient oxygen, which is critical for healing and recovery.

Incorrect answer options:

B) “It’s mainly to reduce incisional pain that Mario might feel.” While positioning may contribute to some relief of incisional pain, the primary purpose of positioning in this context is to facilitate the ventilation of the remaining left lung. Pain management is vital but not the main reason for this specific positioning.

C) “This position is to increase venous return.” Venous return is essential for cardiovascular function, but the positioning of Mario on his right side or back in Fowler’s position after a left thoracotomy and partial pneumonectomy is primarily aimed at facilitating ventilation, not directly affecting venous return.

D) “The purpose is to equalize pressure in the pleural space.” Equalizing pressure in the pleural space is an important consideration in chest tube management, but it’s not the primary purpose of positioning the patient in this way after this specific surgery. The main goal is to enhance the ventilation of the remaining left lung tissue.

22. Correct answer:

C) “After inhaling the medication, slowly breathe out through your mouth with pursed lips.” When educating a patient on the use of an oral inhaler, especially for COPD, the goal is to ensure the medication reaches the lungs as effectively as possible. Instructions typically cover techniques that help with deep inhalation, breath holding, and coordinating the timing of inhalation with the activation of the inhaler. In this case, the direction to exhale slowly through the mouth with pursed lips after inhaling the medication contradicts the goal of retaining the medication in the lungs long enough to be absorbed.

Think of the process of using an inhaler like filling a balloon with air. When you blow into the balloon (inhale the medication), you want to keep the air inside to expand it (hold the medication in the lungs). If you were to let the air out too soon (exhale immediately), the balloon wouldn’t have a chance to fill properly. By holding your breath after inhaling the medication, it allows the medication time to settle into the lungs, much like allowing a balloon time to fill with air.

Incorrect answer options:

A) “Remember to inhale slowly through your mouth as you press down on the canister.” This instruction is correct as it helps coordinate the inhalation with the release of medication, allowing the medication to be drawn deep into the lungs.

B) “Hold your breath for about 10 seconds before gently exhaling.” This instruction is essential as holding the breath allows the medication to settle in the lungs and be absorbed effectively, ensuring maximum therapeutic benefit.

D) “Make sure to breathe in and out as fully as possible before placing the mouthpiece inside your mouth.” Breathing in and out fully before using the inhaler helps to empty the lungs, so that when the medication is inhaled, it can reach deeper into the lungs, thus increasing the efficacy of the treatment.

23. Correct answer:

B. A normal side-effect of Atropine sulfate (AtSO4).Atropine sulfate (AtSO4) is an anticholinergic agent that blocks the action of the neurotransmitter acetylcholine in the nervous system. This leads to a reduction in parasympathetic nervous system activity, which can cause symptoms such as dry mouth and an increased heart rate. These effects are expected and are considered normal side effects of the medication.

Imagine the parasympathetic nervous system as a brake on a car, slowing down certain bodily functions. Atropine acts like lifting the foot off the brake, allowing the heart rate to increase and reducing secretions like saliva, leading to a dry mouth. It’s like taking a drive on a straight road where you don’t need to slow down, so you ease off the brake.

Incorrect answer options:

A. A sign of anxiety due to Grace’s upcoming surgery. While anxiety can indeed lead to an increased heart rate, the presence of dry mouth specifically after the administration of Atropine points more towards the known side effects of the drug rather than anxiety.

C. An indication of an allergic reaction to the drug. An allergic reaction would likely present with other symptoms such as rash, itching, swelling, or difficulty breathing. The symptoms described are consistent with the known pharmacological effects of Atropine and not indicative of an allergic reaction.

D. A sign that Grace needs a higher dose of this drug. The symptoms described are expected effects of Atropine, not an indication that a higher dose is needed. Administering a higher dose could exacerbate these effects and potentially lead to other complications.

24. Correct answer:

B. Consumption of food and fluids will be withheld for at least 2 hours. A bronchoscopy procedure involves inserting a flexible tube through the nose or mouth to examine the lungs. During the procedure, local anesthesia is often used to numb the throat, which can impair the gag reflex. The suppression of the gag reflex is necessary for the procedure but can persist for a period afterward. Therefore, it’s essential to withhold food and fluids for at least 2 hours following the procedure to prevent aspiration, which could lead to pneumonia or other serious complications.

The gag reflex is a natural defense mechanism that prevents foreign objects from entering the trachea and lungs. During a bronchoscopy, this reflex must be suppressed to allow the insertion of the bronchoscope. However, the suppression of the gag reflex can persist after the procedure, making it unsafe to consume food or fluids immediately afterward. The patient must be carefully monitored until the gag reflex returns to normal.

Aspiration is the inhalation of food, fluids, or other foreign material into the lungs. It can lead to serious complications such as aspiration pneumonia, a lung infection that can be life-threatening. By withholding food and fluids for at least 2 hours after the procedure, the risk of aspiration is minimized, allowing time for the gag reflex to return to normal.

Think of the gag reflex as a security guard at the entrance of a building (the lungs). During the bronchoscopy, the guard is temporarily off duty, allowing the medical team to enter and examine the building. After the procedure, it takes some time for the guard to return to duty. Until then, the entrance must be kept clear (no food or drink) to prevent unauthorized entry (aspiration) that could cause damage to the building.

Incorrect answer options:

A. Regular coughing and deep-breathing exercises will be performed every 2 hours. While these exercises are often encouraged after respiratory procedures to prevent atelectasis and promote lung expansion, they are not the primary concern immediately following a bronchoscopy. The risk of aspiration due to the suppressed gag reflex takes precedence.

C. Initially, only ice chips and cold liquids will be allowed. This option might seem reasonable, but it does not address the primary concern of aspiration risk due to the suppressed gag reflex. Even ice chips and cold liquids can lead to aspiration if the gag reflex has not returned to normal.

D. Warm saline gargles will be performed every 2 hours. While warm saline gargles might be soothing for a sore throat, they are not the primary concern following a bronchoscopy. The risk of aspiration due to the suppressed gag reflex is the most critical consideration, and gargling could potentially increase this risk if the gag reflex has not returned to normal.

25. Correct answer:

A. Reduce the oxygen rate to the prescribed level. Patients with chronic obstructive pulmonary disease (COPD) often have a chronic elevation of carbon dioxide (CO2) in their blood. They may rely on a low level of oxygen, rather than elevated CO2, to stimulate their breathing. Administering oxygen at a high rate can suppress this stimulus, leading to hypoventilation, or shallow and slow breathing, as observed in the patient. Reducing the oxygen rate to the prescribed level (usually 1-2 L per minute for COPD patients) is essential to avoid respiratory depression and maintain the appropriate stimulus for breathing.

The observation of pink skin color and shallow respirations at 9 per minute indicates that the patient may be experiencing oxygen-induced hypercapnia, where high levels of oxygen lead to a retention of CO2. This can cause respiratory acidosis and potentially lead to confusion, lethargy, or even loss of consciousness. Nurse Thomas’s immediate intervention should be to reduce the oxygen rate to the prescribed level to prevent further complications.

Think of the patient’s respiratory system as a car engine that runs on a specific fuel mixture. In COPD patients, the engine has adapted to run on a lower-oxygen fuel. If you suddenly flood the engine with a high-oxygen fuel (6 L per minute), it can cause the engine to run poorly or even stall (shallow respirations). By adjusting the fuel mixture back to the prescribed level, you allow the engine to run smoothly again.

Incorrect answer options:

B. Position the patient in Fowler’s position. While positioning the patient in Fowler’s position (sitting up at a 45-60 degree angle) can aid in breathing, it does not address the immediate concern of oxygen-induced hypercapnia. The primary intervention must be to correct the oxygen flow rate.

C. Measure the patient’s heart rate and blood pressure. Monitoring vital signs is essential in patient care, but in this situation, it is not the immediate priority. The patient’s shallow respirations and high oxygen flow rate require urgent intervention to prevent potential respiratory failure.

D. Immediately call the physician. While communication with the physician is vital, the situation requires immediate nursing intervention to correct the oxygen flow rate. Waiting for a physician’s response could delay essential care and lead to further deterioration in the patient’s condition.

26. Correct answer:

A. Presence of a fat pad on the posterior neck and thinning of the extremities. Cushing’s syndrome is a hormonal disorder caused by prolonged exposure to high levels of cortisol, a hormone produced by the adrenal glands. This condition leads to specific physical characteristics that can differentiate it from obesity. The presence of a fat pad on the posterior neck (often referred to as a “buffalo hump”) and thinning of the extremities are classic signs of Cushing’s syndrome. These features are not typically associated with obesity.

In addition to the “buffalo hump,” Cushing’s syndrome can cause a rounded face, known as “moon face,” and thinning of the skin, which can lead to easy bruising. The redistribution of fat, especially in the trunk, face, and neck, with relative sparing of the limbs, is a hallmark of this condition. These specific signs help healthcare providers like Nurse Anderson differentiate Cushing’s syndrome from obesity, which does not usually present with these particular characteristics.

Think of the body’s fat distribution as the way water fills different containers. In obesity, the water (fat) fills all containers (body parts) more or less evenly. In Cushing’s syndrome, it’s as if someone poured extra water into specific containers (face, neck, abdomen) while taking some out of others (extremities). This uneven distribution creates a unique pattern that helps identify the condition.

Incorrect answer options:

B. Noticeable abdominal striae and enlargement around the ankles. While abdominal striae (stretch marks) can be associated with Cushing’s syndrome, they can also be found in obesity. Enlargement around the ankles is not specific to Cushing’s syndrome and does not help differentiate it from obesity.

C. A pendulous abdomen paired with pronounced hips. This description is more consistent with obesity and does not specifically indicate Cushing’s syndrome. The redistribution of fat in Cushing’s syndrome is more characteristic in the face, neck, and trunk, with thinning of the extremities.

D. Pronounced size in the thighs and upper arms. This finding is not specific to Cushing’s syndrome and could be seen in obesity. It does not help differentiate between the two conditions.

27. Correct answer:

C. β€œI need to follow the doctor’s directions in taking this medication, not missing any doses.” Prednisone is a corticosteroid medication that is used to treat various inflammatory conditions, autoimmune disorders, and allergic reactions. It is essential to follow the doctor’s instructions when taking this medication, as abrupt cessation or irregular dosing can lead to withdrawal symptoms or exacerbation of the underlying condition. The patient’s statement reflects an understanding of the importance of adherence to the prescribed regimen.

Corticosteroids like Prednisone can have a wide range of side effects, including changes in mood, weight gain, increased blood sugar levels, and weakened immune system function. Following the prescribed dosing schedule helps to minimize these side effects and ensures that the medication is effective in treating the underlying condition. The patient’s acknowledgment of the need to follow the doctor’s directions indicates awareness of the potential consequences of non-compliance.

Think of Prednisone therapy like a carefully planned journey. The doctor’s instructions are the roadmap, guiding the patient to the desired destination (treatment of the underlying condition). Deviating from the planned route (missing doses or stopping abruptly) can lead to unexpected detours or roadblocks (side effects or worsening of the condition). Sticking to the prescribed path ensures a smoother and more successful journey.

Incorrect answer options:

A. β€œThis medicine will shield me from acquiring colds or infections.” Prednisone can actually suppress the immune system, making the patient more susceptible to infections, not less.

B. β€œI should cut back on potassium in my diet since hyperkalemia is a consequence of this medication.” Prednisone may lead to hypokalemia (low potassium levels), not hyperkalemia (high potassium levels). This statement reflects a misunderstanding of the medication’s potential impact on electrolyte balance.

D. β€œMy surgical wound will recover more swiftly due to this medication.” Prednisone can actually slow down wound healing due to its immunosuppressive effects. This statement does not reflect an accurate understanding of the medication’s potential side effects.

28. Correct answer:

C. Monitoring the blood pressure. Pheochromocytoma is a rare tumor of the adrenal gland that produces excessive amounts of catecholamines, such as adrenaline and noradrenaline. These hormones can cause significant increases in blood pressure, leading to hypertensive crises. Monitoring the blood pressure is the essential first assessment in a patient suspected of having Pheochromocytoma, as uncontrolled hypertension can lead to life-threatening complications such as stroke, heart failure, or kidney damage.

The symptoms of sweating, palpitation, and headache are consistent with the effects of excessive catecholamines and further emphasize the need to monitor blood pressure closely. Immediate intervention may be required to control the blood pressure and prevent complications. Regular monitoring allows for timely detection of changes and guides the medical management of the condition.

Think of the blood pressure in this situation as a pressure gauge on a steam boiler. If the pressure gets too high (as in a hypertensive crisis), it can cause the boiler to explode, leading to catastrophic damage. Monitoring the pressure gauge (blood pressure) allows you to detect if the pressure is getting too high and take action to reduce it before it reaches a dangerous level.

Incorrect answer options:

A. Testing the strength of the hand grips. While assessing muscle strength is an essential part of a neurological examination, it is not the priority in a patient suspected of having Pheochromocytoma. The immediate concern is the potential for hypertensive crisis.

B. Checking the blood glucose levels. Although catecholamines can affect glucose metabolism, the immediate threat in a patient with suspected Pheochromocytoma is uncontrolled hypertension. Blood glucose levels are not the priority assessment in this situation.

D. Evaluating the pupil reaction. Pupil reaction is part of a neurological assessment and is not directly related to the primary concern of hypertension in a patient with suspected Pheochromocytoma.

29. Correct answer:

D. Provide the guest with a glass of orange juice. The symptoms of trembling and dizziness in a known diabetic patient are suggestive of hypoglycemia, or low blood sugar. Hypoglycemia can occur in diabetics who have taken too much insulin, missed a meal, or exercised more than usual. It’s a potentially serious condition that requires immediate treatment to raise the blood sugar levels.

The quickest way to raise blood sugar levels is by consuming a source of simple carbohydrates. Orange juice is an excellent choice, as it contains easily digestible sugars that can quickly raise blood glucose levels. Providing the guest with a glass of orange juice is a prompt and effective intervention that can alleviate the symptoms of hypoglycemia.

It’s important to recognize that hypoglycemia can progress to more severe symptoms, including confusion, seizures, or loss of consciousness. If the guest does not improve after consuming the orange juice, further medical assistance may be required. However, the immediate priority is to raise the blood sugar levels, and orange juice is a suitable and readily available option.

Think of the body’s blood sugar level as the fuel gauge in a car. If the fuel level drops too low (hypoglycemia), the car starts to sputter and may stall. Orange juice acts like a quick splash of fuel, getting the car running smoothly again. It’s a fast and effective way to get things back on track.

Incorrect answer options:

A. Propose a cup of coffee to the guest. Coffee, especially if it’s black, does not contain the quick-acting carbohydrates needed to raise blood sugar levels in a hypoglycemic situation.

B. Urge the guest to consume some baked macaroni. While macaroni contains carbohydrates, it is not a quick-acting source of sugar. It would take longer to digest and would not provide the immediate relief needed for hypoglycemia.

C. Reach out to the guest’s personal physician. While medical consultation may be appropriate if the situation does not improve, the immediate need is to raise the blood sugar levels. Waiting for a physician’s response could delay essential treatment.

30. Correct answer:

A. β€œThe medication will mitigate the cardiovascular symptoms of Graves’ disease.” Graves’ disease is an autoimmune disorder that leads to overactivity of the thyroid gland, known as hyperthyroidism. This overactivity results in the production of excessive thyroid hormones, which can cause a range of symptoms, including increased heart rate, palpitations, anxiety, tremors, and heat intolerance. Propranolol (Inderal) is a beta-blocker that is often prescribed to help manage these symptoms.

Propranolol works by blocking the action of certain chemicals, such as adrenaline, on the heart and blood vessels. This leads to a reduction in heart rate and blood pressure, helping to alleviate the cardiovascular symptoms associated with Graves’ disease. While Propranolol does not directly affect the production or secretion of thyroid hormones, it can provide symptomatic relief while other treatments are used to address the underlying cause of the hyperthyroidism.

It’s essential for patients to understand the purpose of their medications, especially when dealing with complex conditions like Graves’ disease. By explaining that Propranolol will help mitigate the cardiovascular symptoms, Nurse Thompson provides the patient with a clear and accurate understanding of why the medication has been prescribed. This can enhance compliance and foster a collaborative approach to care.

Think of the thyroid hormones in Graves’ disease as the accelerator in a car that’s stuck in the downward position, causing the car to speed up uncontrollably. Propranolol acts like a brake, helping to slow down the car (heart rate) and bring it under control. It doesn’t fix the stuck accelerator (overactive thyroid), but it helps manage the symptoms while other treatments are used to address the underlying problem.

Incorrect answer options:

B. β€œThe medication will foster the production of thyroid hormones.” Propranolol does not increase the production of thyroid hormones; in fact, the goal in Graves’ disease is to reduce thyroid hormone levels.

C. β€œThe medication will curtail thyroid hormone secretion.” Propranolol does not directly affect the secretion of thyroid hormones; it helps manage the symptoms caused by excessive thyroid hormones.

D. β€œThe medication suppresses the synthesis of thyroid hormones.” Propranolol does not suppress the synthesis of thyroid hormones; it acts on the cardiovascular system to alleviate symptoms.

31. Correct answer:

B. Inspecting the back and sides of the operative dressing for any signs of leakage or complications. Thyroid surgery involves the removal of part or all of the thyroid gland and is performed for various reasons, including thyroid cancer, goiter, or hyperthyroidism. One of the potential complications following thyroid surgery is hemorrhage or bleeding at the surgical site. Inspecting the back and sides of the operative dressing for any signs of leakage or complications is a crucial nursing intervention to detect early signs of hemorrhage and prevent further complications.

Early detection of bleeding can lead to prompt intervention and minimize the risk of more serious problems, such as airway obstruction. Regular inspection of the surgical site, including the areas that may not be immediately visible, ensures that any signs of bleeding or other complications are identified and addressed promptly. This is a vital aspect of postoperative care for a client who has undergone thyroid surgery.

In addition to monitoring for hemorrhage, other essential aspects of care in the immediate postoperative period include monitoring vital signs, assessing for signs of respiratory distress, and providing pain management. Collaborative care with the surgical and anesthesia teams is also essential to ensure optimal outcomes.

Think of the surgical dressing as the cover of a book, and the surgical site as the pages inside. Just as you would carefully examine all the pages of a book for any hidden notes or markings, Nurse Mitchell must inspect all sides of the dressing, including the back and sides, to ensure that no signs of complications are missed. This thorough inspection helps ensure that the “story” of the patient’s recovery stays on track.

Incorrect answer options:

A. Informing the client that resuming normal activities right away is acceptable. Postoperative care requires a gradual return to normal activities, with specific instructions based on the type of surgery and individual patient needs.

C. Encouraging the client to discuss her emotions regarding the surgery. While emotional support is essential, the immediate postoperative period’s priority is monitoring for physical complications and providing appropriate medical care.

D. Assisting in supporting the head during mild range-of-motion exercises. While neck support and gentle exercises may be part of the recovery plan, the immediate priority in the first 24 hours is monitoring for complications such as hemorrhage.

32.Correct answer:

C. Fatigue, constipation, and cold intolerance. Hypothyroidism is a condition characterized by an underactive thyroid gland, leading to a deficiency in thyroid hormones. Following thyroid surgery, there is a risk of surgically induced hypothyroidism, especially if a significant portion or the entire thyroid gland has been removed. The symptoms of hypothyroidism include fatigue, constipation, cold intolerance, weight gain, dry skin, and slowed heart rate.

Educating the patient about the signs and symptoms of hypothyroidism is essential for early detection and intervention. If the patient recognizes these symptoms, she can contact her medical doctor promptly for evaluation and treatment, which may include thyroid hormone replacement therapy. Understanding the specific symptoms related to hypothyroidism ensures that the patient is prepared to monitor her condition and seek appropriate care if needed.

The patient’s statement that she should contact her medical doctor if she develops fatigue, constipation, and cold intolerance reflects an accurate understanding of the potential signs of hypothyroidism. This awareness empowers the patient to take an active role in her health and facilitates timely intervention if hypothyroidism develops.

Think of the thyroid gland as the thermostat of the body, regulating energy and metabolism. If the thermostat is set too low (hypothyroidism), the house (body) becomes cold, and everything slows down. The symptoms of fatigue, constipation, and cold intolerance are like signs that the thermostat is not working correctly, and it’s time to call the technician (medical doctor) for a check-up and possible repair.

Incorrect answer options:

A) Persistent headaches and dizziness. While these symptoms can be concerning, they are not specific to hypothyroidism and do not reflect an understanding of the condition.

B) Increased appetite and weight loss. These symptoms are more consistent with hyperthyroidism, an overactive thyroid, rather than hypothyroidism.

D) Palpitations and excessive sweating. These symptoms are also more indicative of hyperthyroidism and do not represent the signs of an underactive thyroid.

33. Correct answer:

A. Impaired gas exchange. Pneumonia is an infection that inflames the air sacs in one or both lungs, leading to the accumulation of fluid or pus in the alveoli. This accumulation impairs the exchange of oxygen and carbon dioxide, resulting in decreased oxygenation of the blood. The nursing diagnosis of “Impaired gas exchange” directly addresses this primary pathophysiological issue in pneumonia.

The goal of care for a patient with pneumonia is to improve respiratory function, promote the clearance of secretions, and enhance oxygenation. Interventions may include deep breathing and coughing exercises, chest physiotherapy, hydration, and positioning to facilitate drainage. Recognizing and addressing impaired gas exchange helps guide these interventions and supports the overall treatment plan.

Monitoring for signs of impaired gas exchange, such as changes in respiratory rate, oxygen saturation, and breath sounds, is essential for timely intervention and optimal outcomes. Collaborative care with the medical team, including potential supplemental oxygen therapy, may also be required to support respiratory function.

Think of the lungs as a sponge that needs to be clear and open to soak up oxygen from the air. In pneumonia, the sponge becomes clogged with fluid and pus, making it less effective at soaking up oxygen. The nursing diagnosis of “Impaired gas exchange” is like recognizing that the sponge needs to be cleaned and cared for to function properly again.

Incorrect answer options:

B. Decreased tissue perfusion. While impaired gas exchange can affect tissue perfusion, this diagnosis is not as directly related to the primary issue in pneumonia as “Impaired gas exchange.”

C. Risk for infection. Pneumonia is already an infection, so the risk for infection is not the primary concern in the plan of care for a patient already diagnosed with the condition.

D. Fluid volume deficit. Hydration is essential to help thin secretions and facilitate their clearance, but fluid volume deficit is not the primary concern in pneumonia and does not directly address the underlying pathophysiology.

34. Correct answer:

C. Elevating the legs on 2 pillows while sleeping. Elevating the legs on 2 pillows while sleeping is not a standard recommendation for diabetic patients and is inappropriate to include in the teaching plan. Excessive elevation of the legs can cause blood to pool in the lower extremities, leading to venous stasis. This can be particularly problematic for diabetic patients, who may already have compromised circulation due to peripheral vascular disease. Proper leg positioning is essential, but excessive elevation is not advised.

Instead of elevating the legs to such an extent, the focus for diabetic patients should be on regular exercise, proper foot care, and avoiding positions that may impede circulation. If there are specific concerns about swelling or circulation, these should be addressed with individualized care and consultation with healthcare providers, rather than through generalized elevation of the legs. The recommendation to elevate the legs on 2 pillows while sleeping does not align with standard diabetes care and may actually be counterproductive.

The importance of proper leg positioning and care in diabetes management cannot be overstated. Diabetes can affect blood flow, making proper circulation a significant concern. By avoiding excessive elevation and focusing on other aspects of care, such as regular movement and proper footwear, patients can reduce the risk of complications and promote overall circulatory health.

Think of the circulatory system as a series of roads and highways that transport blood throughout the body. In diabetes, these roads can become narrowed or blocked, leading to traffic jams (poor circulation). Elevating the legs on 2 pillows is like creating a steep hill on the road that causes cars (blood) to pile up at the bottom, making the traffic jam even worse. Instead, the focus should be on keeping the roads clear and traffic flowing smoothly through proper care and attention to circulation.

Incorrect answer options:

A. Storing the insulin that’s not in use in the refrigerator. Storing insulin in the refrigerator is a standard practice to maintain its efficacy. Insulin that is not in use should be kept in the refrigerator to prevent it from losing its potency. Exposure to extreme temperatures can alter the insulin’s effectiveness, so proper storage is vital to ensure that the medication works as intended.

B. Conducting daily inspections of feet and legs for any alterations. Daily foot inspections are a crucial part of diabetic care. Diabetes can lead to peripheral neuropathy, making it difficult for patients to feel injuries or irritations on their feet. Regular inspections help in early detection of any cuts, sores, or changes that could lead to more serious complications if left untreated. This practice emphasizes the importance of proactive self-care in managing diabetes.

D. Altering the position hourly to enhance circulation. Changing positions regularly is a general recommendation to promote circulation and prevent pressure injuries, especially for those with compromised circulation like diabetic patients. Diabetes can affect blood flow, making proper circulation a significant concern. By altering positions, patients can reduce the risk of pressure ulcers and promote overall circulatory health. This recommendation aligns with the broader goals of diabetes management, focusing on maintaining healthy blood flow and preventing complications.

35. Correct answer:

A. Evaluate the gag reflex before administering fluids. A gastroscopy, also known as an upper endoscopy, is a procedure that involves inserting a flexible tube with a camera down the throat to examine the esophagus, stomach, and upper part of the small intestine. During the procedure, local anesthesia is often administered to the throat to suppress the gag reflex. After the procedure, it’s essential to evaluate the return of the gag reflex before administering fluids or food. This ensures that the patient can swallow safely without the risk of aspiration.

As the anesthesia wears off, the nurse must carefully assess the patient’s ability to swallow and the return of the gag reflex. This may involve asking the patient to swallow or cough and observing for any signs of difficulty. If the gag reflex has not returned, the patient may be at risk for choking or aspirating fluids into the lungs. The nurse must communicate this information to the healthcare team and follow appropriate protocols for managing the patient’s care.

This situation could be likened to a road that has been temporarily closed for maintenance. The gag reflex is like a safety barrier that prevents food and fluids from going down the wrong path (into the lungs). After a gastroscopy, this barrier has been temporarily removed (due to anesthesia), and the nurse must ensure that it’s back in place (gag reflex has returned) before allowing traffic (food and fluids) to proceed. Otherwise, there could be a dangerous accident (aspiration).

Incorrect answer options:

B. Keep the nasogastric tube (NGT) on intermittent suction. This action is not typically required after a gastroscopy. Intermittent suction of an NGT is more associated with other gastrointestinal surgeries or conditions, not a diagnostic procedure like a gastroscopy.

C. Assess for pain and administer medication as prescribed. While pain assessment is a standard part of nursing care, significant pain is not typically associated with a gastroscopy. The procedure is usually done under sedation, and discomfort afterward is minimal.

D. Measure the abdominal girth every 4 hours. Measuring abdominal girth is not a standard post-gastroscopy intervention. It might be relevant in cases of abdominal surgery or conditions that might cause abdominal distension, but it does not directly relate to the care needs following a gastroscopy.

36. Correct answer:

C. Gnawing, dull, aching, hunger-like pain in the epigastric area that diminishes with food intake. Duodenal ulcers are sores that occur in the first part of the small intestine, known as the duodenum. The pain associated with a duodenal ulcer is often described as gnawing, dull, aching, or hunger-like. This type of pain is typically felt in the epigastric area, which is located just below the ribcage in the center of the abdomen. Interestingly, the pain often diminishes or temporarily goes away with food intake or antacids, only to return a few hours later.

The reason for this characteristic pain pattern is related to the production of stomach acid. When the stomach is empty, acid comes into direct contact with the ulcer, causing pain. Eating food or taking antacids neutralizes the acid, providing temporary relief. However, as the stomach continues to produce acid to digest the food, the pain may return. Proper diagnosis and treatment, often involving medications to reduce stomach acid, are essential for healing the ulcer and managing symptoms.

Think of the ulcer as a small wound on the inner lining of the intestine. Imagine pouring a strong acid on an open wound on your skin; it would cause a stinging, gnawing pain. Eating food is like applying a soothing ointment to the wound, providing temporary relief. However, as the acid continues to be produced (like if the ointment wore off), the pain returns. This analogy helps to illustrate why the pain associated with a duodenal ulcer diminishes with food intake but often returns later.

Incorrect answer options:

A. Right upper quadrant (RUQ) pain that intensifies after a meal. This description is more indicative of gallbladder issues, such as gallstones, rather than a duodenal ulcer. The gallbladder is located in the RUQ, and pain often intensifies after eating fatty meals.

B. Sharp pain in the epigastric area that extends to the right shoulder. This type of pain might suggest a problem with the liver or gallbladder, such as inflammation or gallstones, rather than a duodenal ulcer. The referred pain to the right shoulder is a common symptom in these conditions.

D. A sensation of painful pressure in the midsternal area. This description is more characteristic of cardiac-related pain or gastroesophageal reflux disease (GERD) rather than a duodenal ulcer. Pain in the midsternal area may indicate a more serious condition that requires immediate medical attention.

37. Correct answer:

C. Alert the medical doctor (MD) of the findings. Following Billroth surgery (a type of surgery for gastric ulcers), it is normal to have a nasogastric tube (NGT) in place to drain gastric secretions and prevent vomiting. A sudden change in the character or volume of the drainage, along with nausea, could indicate a problem such as a blockage or kinking of the tube, or even a complication related to the surgery itself. The most appropriate initial action for the nurse is to alert the medical doctor (MD) of the findings. This allows for a prompt evaluation and appropriate intervention by the healthcare provider who is most knowledgeable about the patient’s specific situation and surgical details.

Attempting to manage the situation without consulting the MD could lead to further complications. For example, irrigating or repositioning the NGT without proper assessment could cause damage to the surgical site or dislodge the tube. The MD may need to order specific tests or interventions based on the patient’s symptoms and surgical history. By alerting the MD, the nurse ensures that the patient receives the most appropriate and timely care.

A practical analogy for this situation might be a car that suddenly starts making a strange noise or behaving unusually. While some drivers might have the knowledge and skills to investigate and fix minor issues themselves, a sudden and unexplained change would typically warrant a call to a professional mechanic. The mechanic has the expertise to properly diagnose and fix the problem, whereas attempting to address it without the necessary knowledge could lead to further damage. Similarly, the nurse’s role in this situation is to recognize the problem and call in the expert (the MD) to diagnose and manage it.

Incorrect answer options:

A. Irrigate the NGT with 50 cc of sterile solution. Irrigating the NGT without proper assessment and authorization from the MD could cause further complications, such as dislodging a clot or causing trauma to the surgical site. It’s essential to understand the underlying cause of the change in drainage before taking action (1-2 paragraphs).

B. Cease the low-intermittent suction. Stopping the suction without understanding the cause of the change in drainage could exacerbate the problem. The suction is typically in place to prevent vomiting and reduce pressure on the surgical site, so stopping it without MD consultation could lead to other issues (1 paragraph).

D. Reposition the NGT by advancing it gently with normal saline solution (NSS). Repositioning the NGT without proper assessment could cause damage to the surgical site or further complications. The MD should be consulted to determine the appropriate course of action based on the specific situation and surgical details (1-2 paragraphs).

38. Correct answer:

B) Sit upright for at least 30 minutes after meals. Dumping syndrome occurs when food, particularly sugar, moves too quickly from the stomach into the first part of the small intestine. This rapid transit leads to a cascade of symptoms such as abdominal cramping, nausea, diarrhea, and even palpitations. For management of dumping syndrome, the opposite of sitting upright is often recommended: patients are usually advised to lie down or recline for about 30 minutes after eating. This can slow down the transit of food from the stomach to the small intestine, reducing symptoms.

Think of dumping syndrome like a water slide at a water park. If the slide is steep and straight (akin to sitting upright), water will rush down too quickly, causing a big splash at the bottom (dumping syndrome symptoms). If you can make the slide less steep or introduce some curves (akin to reclining after a meal), the water will travel down more slowly, reducing the impact of the splash (symptoms).

The gastrointestinal (GI) tract uses complex mechanisms to digest and absorb nutrients, involving various hormones and nerves that communicate between different sections of the gut. In dumping syndrome, the stomach empties too rapidly into the small intestine. The osmotic load in the small intestine rises too quickly, causing fluid to be pulled into the intestine. This disrupts digestion and absorption, leading to the characteristic symptoms. Lying down or reclining helps mitigate the speed of gastric emptying.

Incorrect answer options:

A) Consuming small, frequent meals that are high in protein. This is actually a recommended practice for managing dumping syndrome. Smaller, frequent meals help to regulate blood sugar and reduce symptoms.

C) Avoiding fluids with meals. This is also a recommended guideline. Consuming fluids with meals can exacerbate the rapid emptying of the stomach, worsening symptoms.

D) Reducing the amount of simple carbohydrates in the diet. This is advisable because simple carbohydrates are digested quickly and can exacerbate dumping syndrome. Complex carbohydrates are digested more slowly and are a better option for these patients.

39. Correct answer:

B. “The treatment will probably include medications like ranitidine and antibiotics.” Helicobacter pylori (H. pylori) is a type of bacteria that can infect the stomach lining and is a common cause of peptic ulcers. An elevated titer of H. pylori indicates an active infection, which often requires treatment to eradicate the bacteria and promote healing of the ulcer. The treatment typically includes a combination of medications such as antibiotics to kill the bacteria and acid reducers like ranitidine to reduce stomach acid and allow the ulcer to heal.

The treatment is usually administered as a regimen known as triple or quadruple therapy, depending on the specific antibiotics and other medications used. This therapy is highly effective in eradicating H. pylori and healing the ulcer. It’s essential for the patient to complete the entire course of treatment, even if symptoms improve before the medication is finished, to ensure that the infection is fully eradicated.

Think of the peptic ulcer as a small, painful wound in the lining of the stomach, and the H. pylori bacteria as pesky weeds growing in a garden. The antibiotics act like weed killer, targeting and eliminating the unwanted growth (bacteria), while the ranitidine is like a gentle watering system, creating a favorable environment for the flowers (stomach lining) to heal and thrive. Both elements are needed to restore the garden to health, just as both types of medication are needed to treat the ulcer and eradicate the infection.

Incorrect answer options:

A. “I don’t need any treatment at this time.” This statement is incorrect, as an elevated titer of H. pylori typically requires treatment to eradicate the bacteria and heal the ulcer. Left untreated, the ulcer can lead to complications such as bleeding or perforation.

C. “Surgery is needed to treat this problem.” Surgery is usually not the first line of treatment for H. pylori infection and peptic ulcers. Medication is typically effective in treating the condition, and surgery would only be considered if complications arise or if medical treatment fails.

D. “This result shows that I have gastric cancer caused by the organism.” While chronic H. pylori infection can increase the risk of gastric cancer, an elevated titer does not mean that the patient has cancer. It indicates an active infection that needs to be treated, but further tests would be needed to diagnose cancer.

40. Correct answer:

A. Empty the bladder before the procedure. Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity to remove excess fluid, often due to conditions like liver cirrhosis or heart failure. Emptying the bladder before the procedure is essential to reduce the risk of accidental puncture of the bladder during the procedure. Since the bladder is located close to the peritoneal cavity, it could be in the path of the needle if it is full. By ensuring that the bladder is empty, the risk of complications is minimized.

The procedure is usually performed under local anesthesia, and the patient may be asked to sit up or lie on their back with their head elevated. The area where the needle will be inserted is cleaned and numbed, and ultrasound may be used to guide the needle to the correct location. The process of emptying the bladder is a simple but crucial step in preparing for the procedure, ensuring that it can be performed safely and effectively.

Think of the procedure like trying to reach an object at the back of a crowded drawer. If there’s something large and easily movable (like the bladder when it’s full) in the way, it makes sense to remove or reduce it to get to the object (the peritoneal fluid) without damaging anything else in the drawer. Emptying the bladder before the procedure is like taking that large, movable object out of the way, making it easier and safer to reach the target without causing any harm.

Incorrect answer options:

B. Empty the bowel before the procedure. Emptying the bowel is not typically required for paracentesis. The focus is on the bladder, as it is closer to the site of needle insertion.

C. Maintain strict bed rest following the procedure. While some rest and observation may be necessary after the procedure, strict bed rest is not usually required. The patient’s mobility and activity will depend on their overall condition and the amount of fluid removed.

D. Remain NPO (nothing by mouth) for 12 hours before the procedure. Fasting is not typically required for paracentesis, as it is a minimally invasive procedure performed under local anesthesia. The focus of preparation is on the bladder rather than the digestive system.

41. Correct answer:

A. “The liver’s inability to eliminate ammonia produced by protein breakdown in the digestive system necessitates this diet.” In advanced liver disease, the liver’s function is compromised, and it becomes less efficient at processing and eliminating certain substances, including ammonia. Ammonia is a byproduct of protein metabolism, and the liver typically converts it into urea, which is then excreted in the urine. When the liver is not functioning properly, ammonia can build up in the blood, leading to a condition called hyperammonemia.

Hyperammonemia can have serious neurological effects, including confusion, lethargy, and even coma. A protein-restricted diet helps to reduce the amount of ammonia produced in the digestive system, thereby reducing the strain on the liver and the risk of hyperammonemia. It’s a carefully balanced approach, as some protein is still needed for overall health, but the amount must be controlled to prevent further complications.

Think of the liver as a factory responsible for processing and packaging various products, including handling the waste product ammonia. When the factory is running smoothly, it can handle the workload efficiently. But if the factory is damaged (as in liver disease), it struggles to keep up, and waste products like ammonia start to pile up. A protein-restricted diet is like reducing the amount of raw material (protein) coming into the factory, so there’s less waste (ammonia) for the struggling factory (liver) to deal with. It’s a way to ease the burden on the factory while it’s in a compromised state.

Incorrect answer options:

B. “Most people consume too much protein; this diet is better suited for liver healing.” While general overconsumption of protein can be a concern, the specific reason for a protein-restricted diet in liver disease is to reduce ammonia production, not merely to align with a “better” diet for liver healing.

C. “Due to portal hypertension, blood bypasses the liver, causing protein-derived ammonia to accumulate in the brain, leading to hallucinations.” While portal hypertension is a complication of liver disease, the explanation provided here is not the primary reason for a protein-restricted diet in advanced liver disease.

D. “The liver heals more effectively with a high-carbohydrate diet rather than a protein-rich one.” While carbohydrates may be emphasized in a liver disease diet, the primary reason for restricting protein is to control ammonia levels, not to promote liver healing through a high-carbohydrate diet.

42. Correct answer:

B. Administration of Meperidine. Acute pancreatitis is an inflammation of the pancreas that can cause severe abdominal pain. Pain management is a critical aspect of care for patients with this condition. Meperidine (Demerol) is often selected for pain control in acute pancreatitis because it provides effective analgesia without causing significant spasms in the sphincter of Oddi, a muscular valve that controls the flow of digestive juices to the duodenum.

Morphine, another opioid analgesic, has historically been avoided in acute pancreatitis due to concerns that it may cause spasms in the sphincter of Oddi, potentially exacerbating the condition. Meperidine, on the other hand, is less likely to cause this effect, making it a preferred choice for pain management in acute pancreatitis. It’s important to note that the use of meperidine has been somewhat controversial, and practices may vary. Some guidelines recommend other opioids like fentanyl, but meperidine remains a common choice.

Imagine the pancreas as a busy factory producing digestive enzymes, and the sphincter of Oddi as a gate controlling the flow of these enzymes into the digestive tract. In acute pancreatitis, the factory is on fire, causing chaos and pain. Using morphine to control the pain would be like trying to put out the fire with water that also jams the gate, causing more problems. Meperidine, on the other hand, is like using a special type of water that puts out the fire without affecting the gate, allowing the flow of enzymes to continue without additional disruption.

Incorrect answer options:

A. Utilization of NSAIDS (Non-Steroidal Anti-Inflammatory Drugs). NSAIDs are not typically used for pain control in acute pancreatitis, as they may not provide sufficient relief for the severe pain associated with this condition.

C. Prescription of Codeine. Codeine is an opioid that could be used for pain control, but it is not typically the first choice for acute pancreatitis due to its potential to cause spasms in the sphincter of Oddi, similar to morphine.

D. Usage of Morphine. Morphine has historically been avoided in acute pancreatitis due to concerns about causing spasms in the sphincter of Oddi, although recent studies have questioned this association. Meperidine is often preferred for its lower risk of this effect.

43. Correct answer:

C. Prompting the client to engage in both coughing and deep breathing exercises. After a cholecystectomy (surgical removal of the gallbladder), one of the primary nursing priorities is to prevent postoperative complications, particularly respiratory issues such as atelectasis (collapse of the lung) and pneumonia. Encouraging the client to engage in both coughing and deep breathing exercises helps to expand the lungs, clear secretions, and improve ventilation, reducing the risk of these complications.

These exercises are typically performed using an incentive spirometer, a device that helps the patient take slow, deep breaths to expand the lungs fully. The patient is usually instructed to perform these exercises every hour while awake. This intervention is essential in the immediate postoperative period, as anesthesia and surgical positioning can lead to decreased lung expansion and retained secretions.

Think of the lungs as balloons that need to be fully inflated to work properly. After surgery, especially abdominal surgery like a cholecystectomy, the balloons (lungs) might not inflate fully on their own due to pain, anesthesia effects, or immobility. Coughing and deep breathing exercises are like using a pump to inflate the balloons, ensuring they stay fully expanded and functional. If the balloons aren’t inflated regularly, they can start to collapse or become clogged, leading to problems like atelectasis or pneumonia.

Incorrect answer options:

A. Frequently irrigating the T-tube. While monitoring and managing a T-tube (if present) is important, it is not the immediate priority in post-cholecystectomy care.

B. Encouraging the client to take deep breaths orally with adequate frequency. While deep breathing is essential, the combination of coughing and deep breathing exercises is more effective in preventing respiratory complications.

D. Ensuring the dressing is changed at least twice daily (BID). While wound care is important, it is not the immediate priority in the postoperative period. Respiratory care takes precedence to prevent complications.

44. Correct answer:

B. Promptly deflate the esophageal balloon. The Sengstaken-Blakemore tube is used to control bleeding from esophageal varices, which are enlarged veins in the esophagus that can rupture in patients with liver cirrhosis. The tube has two balloons, one in the stomach and one in the esophagus, that can be inflated to apply pressure and stop the bleeding. If the esophageal balloon is inflated too much, it can obstruct the airway, leading to difficulty breathing.

The nurse’s immediate response to the patient’s complaint of difficulty breathing should be to deflate the esophageal balloon.