Preoperative Nursing

Questions preoperative nursing
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 th is 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 under stand 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 “stop 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 tub es
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 premedicatio n 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 understa nd 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. “This medicine will shield me from acquiring colds or infections.”

B. “I should cut back on potassium in my diet since hyperkalemia is a consequence of this medication.”
C. “I need to follow the doctor’s directions in taking this medication, not missing any doses.”
D. “My 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, “Why 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. “The medication will mitigate the cardiovascular symptoms of Graves’ disease.”

B. “The medication will foster the production of thyroid hormones.”
C. “The medication will curtail thyroid hormone secretion.”
D. “The 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. “I will make sure to get an annual chest x-ray done.”
B. “I will make a point to engage in daily physical exercise.”
C. “I will make an effort to include an abundance of fresh fruits and vegetables in my daily meals.”
D. “I 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 ho ld, 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.
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.
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.
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.
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.
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, t he 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.
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 ga rden
suffers. But if you remove the pressure (quit smoking), the water flow returns, and the garden begins to thrive again.
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.
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.
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.
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 th is 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).
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.
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.
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).
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.
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.
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.
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 wa iting
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.
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.
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.
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 (exha le
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.
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.
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 indica tion
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, wh ich 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.
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.
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.
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. “I 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.
A. “This 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. “I 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. “My 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.
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.
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. “The 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 a ddress
the underlying problem.
B. “The 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. “The 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. “The 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.
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 a ctive
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.
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 en hance
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 becom es
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.
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 b e on
keeping the roads clear and traffic flowing smoothly through proper care and attention to circulation.
A. Storing the insulin that’s not in use in the refrigerator. Storing insulin in the refrigerator is a standard practice to m aintain 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).
B. Keep the nasogastric tube (NGT) on intermittent suction. This action is not typically required after a gastroscopy. Interm ittent
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.
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.
A. Irrigate the NGT with 50 cc of sterile solution. Irrigating the NGT without proper assessment and authorization from the M D 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 tr ansit 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.

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.
A. “I don’t need any treatment at this time.” This statement is incorrect, as an elevated titer of H. pylori typically requir es 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 per itoneal
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.

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.
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.
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.
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. This
action will relieve the obstruction and allow the patient to breathe more easily. Once the balloon is deflated, the nurse should assess
the patient’s respiratory status and notify the medical doctor of the situation. The physician may need to reevaluate the placement of
the tube and the inflation of the balloons.
Imagine the esophagus as a narrow tunnel that allows both air and food to pass through. The Sengstaken-Blakemore tube is like a
temporary barrier placed in the tunnel to stop a leak (bleeding). If the barrier is inflated too much, it can block the entir e tunnel,
preventing air from passing through. Deflating the esophageal balloon is like partially lowering the barrier, allowing air to flow again
while still controlling the leak.
A. Carefully monitor vital signs (VS). While monitoring vital signs is essential, it is not the immediate action needed to address the
patient’s difficulty breathing.
C. Immediately notify the medical doctor (MD). Notifying the physician is important, but the immediate action to relieve the patient’s
distress is to deflate the esophageal balloon.
D. Encourage the patient to engage in deep breathing exercises. Deep breathing exercises are not appropriate in this situation, as
the patient’s difficulty breathing is likely due to a physical obstruction caused by the inflated balloon.
45. Correct answer:
A. Presentation of Ulcerative Colitis. Ulcerative Colitis (UC) is a chronic inflammatory bowel disease that affects the innermost lining
of the large intestine (colon) and rectum. The symptoms described by the client, including severe rectal bleeding, frequent diarrheal
stools, intense abdominal pain, tenesmus (a constant feeling of the need to empty the bowels), and dehydration, are character istic
of a severe flare-up of UC. This condition can lead to serious complications if not treated promptly.
UC can cause inflammation and ulcers in the colon and rectum, leading to the symptoms described. The inflammation can be
continuous and may lead to complications such as toxic megacolon (a life-threatening widening of the colon), increased risk of colon
cancer, and severe dehydration. Treatment typically involves medications to reduce inflammation and may require hospitalization or
surgery in severe cases.
Imagine the colon as a garden hose that carries water (digestive material) from one end to the other. In Ulcerative Colitis, the inner
lining of the hose becomes inflamed and develops sores or ulcers. This is like having a hose that’s not only kinked and twisted but
also has holes and tears in it. The result is a messy, painful flow that can lead to severe symptoms and complications, such as the
hose bursting (toxic megacolon) or becoming irreparably damaged (requiring surgical removal).
B. Indication of Crohn’s Disease. Crohn’s Disease is another type of inflammatory bowel disease, and it shares some symptoms
with Ulcerative Colitis. However, Crohn’s Disease typically affects deeper layers of the bowel wall and can occur anywhere in the
digestive tract, from the mouth to the anus. Unlike UC, Crohn’s often leads to “skip lesions,” where inflammation occurs in patches,
leaving healthy tissue in between. The specific symptoms described in the question, such as severe rectal bleeding and very
frequent diarrheal stools, are more characteristic of UC. Crohn’s might present with abdominal pain, diarrhea, weight loss, and
fatigue, but the pattern and severity of the symptoms described align more closely with UC.
C. Manifestation of Peritonitis. Peritonitis is the inflammation of the peritoneum, the lining of the abdominal cavity. It is usually
caused by an infection, often due to a ruptured appendix, perforated ulcer, or other abdominal injuries. While it can cause severe
abdominal pain, fever, nausea, and vomiting, it does not typically present with the specific symptoms described for UC, such as
severe rectal bleeding and frequent diarrheal stools. Peritonitis is a medical emergency that requires immediate treatment, often
including antibiotics and surgery to remove the infected tissue. The symptoms described in the question are not consistent with the
typical presentation of peritonitis.
D. Signs of Diverticulitis. Diverticulitis is the inflammation or infection of small pouches in the colon called diverticula. These pouches
can become inflamed or infected, leading to symptoms such as abdominal pain, fever, and changes in bowel habits. While
diverticulitis can cause discomfort and altered bowel function, the severe rectal bleeding and frequent diarrheal stools described in
the question are more indicative of UC. Diverticulitis might lead to complications such as abscesses, perforation, or fistulas, but the
pattern of symptoms described, including tenesmus and intense abdominal pain with such frequent stools, aligns more closely with
a severe flare-up of UC rather than diverticulitis.
46. Correct answer:
B. The potential development of lipodystrophic areas, leading to erratic insulin absorption from those sites. Rotating insulin injection
sites is a crucial practice for individuals with diabetes who require insulin therapy. The primary reason for this rotation is to prevent
the development of lipodystrophic areas. Lipodystrophy refers to abnormal changes in the fat tissue at the injection site, which can
occur with repeated injections in the same area.
These lipodystrophic areas can lead to erratic insulin absorption rates, causing unpredictable fluctuations in blood glucose levels.
This inconsistency in absorption can make diabetes management more challenging, as it can lead to both unexpected high and low
blood sugar levels. By rotating injection sites, the nurse helps the patient avoid these areas of altered tissue, promoting more
consistent insulin absorption and better overall blood glucose control.
Think of the skin as a garden and the insulin injections as planting seeds in different spots. If you keep planting in the same spot, the
soil (skin) becomes overworked and less fertile (lipodystrophic), leading to unpredictable growth (insulin absorption). By rotating
where you plant (inject), you allow the soil to recover, ensuring consistent and healthy growth.
A. The belief that injection sites should never be reused. This statement is incorrect, as injection sites can indeed be reused.
However, the key is to rotate the sites to prevent complications like lipodystrophy. Reusing the same site repeatedly without rotation
can lead to problems with the skin and underlying tissue. The idea is not to avoid reusing sites altogether but to use a systematic
rotation pattern to allow areas to recover and maintain healthy tissue.
C. The risk that poor rotation technique may induce superficial hemorrhaging. While proper injection technique is essential, and
improper technique can lead to bruising or bleeding, the primary reason for rotating sites is not to prevent superficial hemorrhaging.
The main concern with poor rotation is the development of lipodystrophic areas, leading to erratic insulin absorption. Superficial
hemorrhaging might occur with any injection if done improperly, but it’s not the underlying reason for site rotation. The focus of
rotation is to promote consistent insulin absorption and avoid long-term changes in the tissue.
D. The concern that lipodystrophy can occur and cause severe pain. Lipodystrophy refers to abnormal changes in fat tissue at the
injection site. While it can cause changes in the appearance of the skin and may be uncomfortable, it is not typically described as
extremely painful. The main concern with lipodystrophy is its effect on insulin absorption, leading to unpredictable blood glucose
levels. Pain or discomfort might be a secondary concern, but the primary reason for rotating injection sites is to ensure that insulin is
absorbed consistently and effectively. This helps in maintaining stable blood glucose levels, which is crucial for the overall
management of diabetes.
47. Correct answer:
C. Administer laxatives the night before and provide a cleansing enema on the morning of the test. A barium enema is a diagnostic
procedure used to examine the large intestine (colon and rectum) for abnormalities, including potential colon cancer. The procedure
involves introducing a contrast material called barium into the colon through the rectum. To obtain clear and accurate images, the
colon must be completely empty and free of stool.
Administering laxatives the night before and providing a cleansing enema on the morning of the test ensures that the colon is
thoroughly cleaned. Laxatives help to clear the bowel by stimulating bowel movements, while a cleansing enema further ensures
that any remaining stool is removed. This preparation is essential for allowing the radiologist to visualize the colon’s lining without
obstruction, thereby increasing the accuracy of the test.
Think of the colon as a winding road that needs to be examined for potholes (abnormalities). If there are cars (stool) on the road, it
becomes difficult to see the surface clearly. By clearing the road (administering laxatives and a cleansing enema), the inspector
(radiologist) can easily see the surface and identify any issues.
A. Implement complete bed rest (CBR) a day prior to the study. Complete bed rest is not a standard preparation for a barium
enema. The focus should be on ensuring the colon is empty, not restricting the client’s mobility. This option does not address the
primary need for bowel cleansing.
B. Advise the client to consume 6 radiopaque tablets the evening before the study. Radiopaque tablets are not typically used in
preparation for a barium enema. The main preparation involves cleaning the colon, and this option does not contribute to that goal.
Radiopaque tablets might be used in other types of diagnostic imaging but are not relevant to this procedure.
D. Administer an oil retention enema and give a laxative the evening prior. An oil retention enema is not appropriate for preparing for
a barium enema, as it may leave residue that could interfere with the imaging. The focus should be on thoroughly cleansing the
colon, and an oil retention enema does not achieve this goal. The correct preparation involves a cleansing enema, not an oil
retention enema.
48. Correct answer:

D. Protect the wound with a sterile, moist saline dressing. Wound dehiscence refers to the partial or complete separation of the
wound edges following surgery. This is a serious complication that requires immediate attention. The safest initial nursing
intervention is to protect the wound with a sterile, moist saline dressing. This helps to keep the wound clean and moist, preventing
further damage and reducing the risk of infection.
Applying a sterile, moist saline dressing also helps to prepare the wound for medical evaluation and possible surgical intervention.
It’s essential to keep the wound environment controlled and protected to prevent additional complications. The nurse should also
promptly notify the healthcare provider to assess the wound and determine the appropriate course of action.
Think of the wound as a delicate piece of fabric that has torn. Rather than attempting to mend it yourself with tape or other methods,
you would carefully cover it to prevent further tearing and seek professional help to repair it properly. The sterile, moist saline
dressing acts as a protective cover, keeping the “fabric” (wound) safe until it can be properly assessed and repaired by the
healthcare provider.
A. Bring the wound edges together using tapes. This action is inappropriate for a nurse to undertake without specific orders from a
healthcare provider. Attempting to close the wound without proper assessment and technique could cause further damage and
increase the risk of infection.
B. Maintain the abdominal contents’ position with a sterile gloved hand. While it may be necessary to protect exposed organs in
cases of complete wound evisceration, the question specifies dehiscence, not evisceration. This option may not be appropriate
unless there is a protrusion of internal organs or tissues, and even then, it should be done with extreme caution and under the
guidance of a healthcare provider.
C. Cleanse the wound using sterile saline. While cleansing may be part of wound care, it is not the initial or safest intervention for
wound dehiscence. Cleaning the wound without proper assessment and protection could cause further damage. The priority is to
protect the wound and notify the healthcare provider.
49. Correct answer:
B. Advise the patient to strain all urine. A renal calculus, or kidney stone, is a hard mineral deposit that forms within the kidneys. In
Peter’s case, Nurse Thompson believes the small stone will pass spontaneously, meaning it will travel through the urinary tract and
be excreted in the urine. To monitor this process and confirm that the stone has passed, it is essential to advise the patient to strain
all urine.
Straining the urine allows the stone to be captured and analyzed if needed. This can provide valuable information about the
composition of the stone, which can guide future prevention strategies. It also confirms that the stone has indeed passed, relieving
the patient’s symptoms and reducing the risk of complications.
Imagine the kidney stone as a small pebble stuck in a garden hose. By increasing the water flow (fluid intake) and using a filter
(straining the urine), you can help the pebble move through the hose and catch it when it comes out the other end. This allows you
to examine the pebble and make sure it’s no longer blocking the hose, ensuring that everything is flowing smoothly again.
A. Encourage the patient to limit physical activity. Limiting physical activity is not typically necessary for a patient with a small kidney
stone that is expected to pass spontaneously. In fact, moderate physical activity might even help the stone move through the urinary
tract.
C. Recommend a diet high in calcium. While dietary changes may be part of long-term kidney stone prevention, recommending a
diet high in calcium may not be appropriate without knowing the specific type of stone. Some stones are formed from calcium
oxalate, and dietary recommendations would be based on the stone’s composition.
D. Suggest using antacids to dissolve the stone. Antacids are not used to dissolve kidney stones, and this recommendation would
be inappropriate. Treatment for kidney stones may include medications to relieve pain or relax the muscles in the urinary tract, but
antacids would not have a direct effect on the stone itself.
50. Correct answer:

C. “I will make an effort to include an abundance of fresh fruits and vegetables in my daily meals.” Colon cancer risk can be
influenced by dietary habits. Consuming a diet rich in fresh fruits and vegetables is often recommended as a strategy to reduce the
risk of developing colon cancer. These foods are high in fiber, vitamins, minerals, and antioxidants, which can promote a healthy
digestive system and may have protective effects against cancer.
The fiber found in fruits and vegetables helps to keep the digestive system functioning smoothly, reducing the time that pote ntial
carcinogens spend in contact with the colon’s lining. Additionally, the vitamins and antioxidants in these foods may help to neutralize
harmful substances that could otherwise contribute to cancer development.
Think of the colon as a busy highway, and the food you eat as the traffic on that highway. Consuming fresh fruits and vegetab les is
like adding smooth lanes and efficient traffic signals, allowing everything to flow smoothly and reducing the risk of accidents
(cancer). On the other hand, a diet high in processed or red meat might be like adding more congestion and hazards, increasing the
risk of problems.
A. “I will make sure to get an annual chest x-ray done.” Chest x-rays are not related to colon cancer screening or prevention. They
are used to evaluate the lungs and other structures within the chest, not the colon.
B. “I will make a point to engage in daily physical exercise.” While physical exercise is generally beneficial for overall health and may
reduce the risk of certain cancers, it is not as directly related to colon cancer prevention as dietary choices. Exercise can support a
healthy weight and metabolism, but the statement about including fresh fruits and vegetables in the diet is more specific to colon
cancer prevention.
D. “I plan to add more red meat to my diet for overall health.” Contrary to this statement, a diet high in red meat has been associated
with an increased risk of colon cancer. Reducing red meat consumption and replacing it with plant-based proteins and fiber-rich
foods is generally recommended for colon cancer prevention.

Preoperative Nursing

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Questions preoperative nursing

A) Administer oxygen at 100% to maximize oxygenation.

A) Evidence of bleeding from the ears.

A) Experiencing gagging sensations while brushing teeth.

A) “You may be allowed to use most everyday electrical appliances.”

A) Because older people often experience a general reduction in sensory perception.

A) Massaging the affected area to relieve pain.

A) “It works by interfering with vitamin K absorption, affecting clotting.”

A) Presence of foamy, blood-tinged sputum during coughing.

A) “It’s designed to cause less irritation to your gastrointestinal tract.”

A. A sign of anxiety due to Grace’s upcoming surgery.

A. Regular coughing and deep-breathing exercises will be performed every 2 hours.

A. Reduce the oxygen rate to the prescribed level.

A. “This medicine will shield me from acquiring colds or infections.”

A. Propose a cup of coffee to the guest.

A. “The medication will mitigate the cardiovascular symptoms of Graves’ disease.”

A) Persistent headaches and dizziness.

A. Impaired gas exchange.

A. Storing the insulin that’s not in use in the refrigerator.

A. Evaluate the gag reflex before administering fluids.

A. Right upper quadrant (RUQ) pain that intensifies after a meal.

A. Irrigate the NGT with 50 cc of sterile solution.

A) Consuming small, frequent meals that are high in protein.

A. “I don’t need any treatment at this time.”

A. Empty the bladder before the procedure.

A. Utilization of NSAIDS (Non-Steroidal Anti-Inflammatory Drugs).

A. Frequently irrigating the T-tube.

A. Carefully monitor vital signs (VS).

A. Presentation of Ulcerative Colitis.

A. The belief that injection sites should never be reused.

A. Implement complete bed rest (CBR) a day prior to the study.

A. Bring the wound edges together using tapes.

A. Encourage the patient to limit physical activity.

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