1.

Following surgery, Mario complains of mild incisional pain while performing deep-
breathing and coughing exercises. The nurses best response would be:
A. Pain will become less each day.
B. This is a normal reaction after surgery.
C. With a pillow, apply pressure against the incision.
D. I will give you the pain medication the physician ordered.
Answer: (C) With a pillow, apply pressure against the incision. Applying
pressure against the incision with a pillow will help lessen the intra-abdominal
pressure created by coughing which causes tension on the incision that leads to
pain.
2. The nurse needs to carefully assess the complaint of pain of the elderly because
older people
A. are expected to experience chronic pain
B. have a decreased pain threshold
C. experience reduced sensory perception
D. have altered mental function
Answer: (C) experience reduced sensory perception . Degenerative changes
occur in the elderly. The response to pain in the elderly maybe lessened because of
reduced acuity of touch, alterations in neural pathways and diminished processing
of sensory data.
3. Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now
complaining of dry mouth and her PR is higher, than before the medication was
administered. The nurses best
A. The patient is having an allergic reaction to the drug.
B. The patient needs a higher dose of this drug
C. This is normal side-effect of AtSO4
D. The patient is anxious about upcoming surgery
Answer: (C) This is normal side-effect of AtSO4. Atropine sulfate is a vagolytic
drug that decreases oropharyngeal secretions and increases the heart rate.
4. Anas postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of
140, and respirations of 32. Suspecting shock, which of the following orders would
the nurse question?
A. Put the client in modified Trendelenbergs position.
B. Administer oxygen at 100%.
C. Monitor urine output every hour.
 D. Administer Demerol 50mg IM q4h
Answer: (D) Administer Demerol 50mg IM q4h. Administering Demerol, which
is a narcotic analgesic, can depress respiratory and cardiac function and thus not
given to a patient in shock. What is needed is promotion for adequate oxygenation
and perfusion. All the other interventions can be expected to be done by the nurse.
5. Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the
creation of an ileal conduit in the morning. He is wringing his hands and pacing the
floor when the nurse enters his room. What is the best approach?
A. Good evening, Mr. Pablo. Wasnt it a pleasant day, today?
B. Mr, Pablo, you must be so worried, Ill leave you alone with your thoughts.
C. Mr. Pablo, youll wear out the hospital floors and yourself at this rate.
D. Mr. Pablo, you appear anxious to me. How are you feeling about tomorrows
surgery?
Answer: (D) Mr. Pablo, you appear anxious to me. How are you feeling
about tomorrows surgery?. The client is showing signs of anxiety reaction to a
stressful event. Recognizing the clients anxiety conveys acceptance of his behavior
and will allow for verbalization of feelings and concerns.
6. After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room)
with a nasogastric tube in place following a gall bladder surgery. She continues to
complain of nausea. Which action would the nurse take?
A. Call the physician immediately.
B. Administer the prescribed antiemetic.
C. Check the patency of the nasogastric tube for any obstruction.
D. Change the patients position.
Answer: (C) Check the patency of the nasogastric tube for any
obstruction. Nausea is one of the common complaints of a patient after receiving
general anesthesia. But this complaint could be aggravated by gastric distention
especially in a patient who has undergone abdominal surgery. Insertion of the NGT
helps relieve the problem. Checking on the patency of the NGT for any obstruction
will help the nurse determine the cause of the problem and institute the necessary
intervention
7. Mr. Perez is in continuous pain from cancer that has metastasized to the bone.
Pain medication provides little relief and he refuses to move. The nurse should plan
to:
A. Reassure him that the nurses will not hurt him
B. Let him perform his own activities of daily living
C. Handle him gently when assisting with required care
 D. Complete A.M. care quickly as possible when necessary
Answer: (C) Handle him gently when assisting with required care . Patients
with cancer and bone metastasis experience severe pain especially when moving.
Bone tumors weaken the bone to appoint at which normal activities and even
position changes can lead to fracture. During nursing care, the patient needs to be
supported and handled gently.
8. A client returns from the recovery room at 9AM alert and oriented, with an IV
infusing. His pulse is 82, blood pressure is 120/80, respirations are 20, and all are
within normal range. At 10 am and at 11 am, his vital signs are stable. At noon,
however, his pulse rate is 94, blood pressure is 116/74, and respirations are 24.
What nursing action is most appropriate?
A. Notify his physician.
B. Take his vital signs again in 15 minutes.
C. Take his vital signs again in an hour.
D. Place the patient in shock position.
Answer: (B) Take his vital signs again in 15 minutes. Monitoring the clients
vital signs following surgery gives the nurse a sound information about the clients
condition. Complications can occur during this period as a result of the surgery or
the anesthesia or both. Keeping close track of changes in the VS and validating
them will help the nurse initiate interventions to prevent complications from
occurring
9. A 56 year old construction worker is brought to the hospital unconscious after
falling from a 2-story building. When assessing the client, the nurse would be most
concerned if the assessment revealed:
A. Reactive pupils
B. A depressed fontanel
C. Bleeding from ears
D. An elevated temperature
Answer: (C) Bleeding from ears . The nurse needs to perform a thorough
assessment that could indicate alterations in cerebral function, increased
intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only
with basal skull fractures that can easily contribute to increased intracranial
pressure and brain herniation.
10. Which of the ff. statements by the client to the nurse indicates a risk factor for
CAD?
A. I exercise every other day.
B. My father died of Myasthenia Gravis.
 C. My cholesterol is 180.
D. I smoke 1 1/2 packs of cigarettes per day.
Answer: (D) I smoke 1 1/2 packs of cigarettes per day. Smoking has been
considered as one of the major modifiable risk factors for coronary artery disease.
Exercise and maintaining normal serum cholesterol levels help in its prevention.
11. Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding
this drug?
A. It has positive inotropic and negative chronotropic effects
B. The positive inotropic effect will decrease urine output
C. Toxixity can occur more easily in the presence of hypokalemia, liver and renal
problems
D. Do not give the drug if the apical rate is less than 60 beats per minute.
Answer: (B) The positive inotropic effect will decrease urine
output . Inotropic effect of drugs on the heart causes increase force of its
contraction. This increases cardiac output that improves renal perfusion resulting in
an improved urine output.
12. Valsalva maneuver can result in bradycardia. Which of the following activities
will not stimulate Valsalvas maneuver?
A. Use of stool softeners.
B. Enema administration
C. Gagging while toothbrushing.
D. Lifting heavy objects
Answer: (A) Use of stool softeners. Straining or bearing down activities can
cause vagal stimulation that leads to bradycardia. Use of stool softeners promote
easy bowel evacuation that prevents straining or the valsalva maneuver.
13. The nurse is teaching the patient regarding his permanent artificial pacemaker.
Which information given by the nurse shows her knowledge deficit about the
artificial cardiac pacemaker?
A. take the pulse rate once a day, in the morning upon awakening
B. may be allowed to use electrical appliances
C. have regular follow up care
D. may engage in contact sports
Answer: (D) may engage in contact sports . The client should be advised by
the nurse to avoid contact sports. This will prevent trauma to the area of the
pacemaker generator.
14. A patient with angina pectoris is being discharged home with nitroglycerine
tablets. Which of the following instructions does the nurse include in the teaching?
A. When your chest pain begins, lie down, and place one tablet under your
tongue. If the pain continues, take another tablet in 5 minutes.
B. Place one tablet under your tongue. If the pain is not relieved in 15 minutes,
go to the hospital.
C. Continue your activity, and if the pain does not go away in 10 minutes, begin
taking the nitro tablets one every 5 minutes for 15 minutes, then go lie
down.
D. Place one Nitroglycerine tablet under the tongue every five minutes for
three doses. Go to the hospital if the pain is unrelieved.
Answer: (D) Place one Nitroglycerine tablet under the tongue every five
minutes for three doses. Go to the hospital if the pain is unrelieved. Angina
pectoris is caused by myocardial ischemia related to decreased coronary blood
supply. Giving nitroglycerine will produce coronary vasodilation that improves the
coronary blood flow in 3 5 mins. If the chest pain is unrelieved, after three tablets,
there is a possibility of acute coronary occlusion that requires immediate medical
attention.
15. A client with chronic heart failure has been placed on a diet restricted to
2000mg. of sodium per day. The client demonstrates adequate knowledge if
behaviors are evident such as not salting food and avoidance of which food?
A. Whole milk
B. Canned sardines
C. Plain nuts
D. Eggs
Answer: (B) Canned sardines . Canned foods are generally rich in sodium
content as salt is used as the main preservative.
16. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis.
Which action by this team member is most appropriate?
A. Apply a heating pad to the involved site.
B. Elevate the clients legs 90 degrees.
C. Instruct the client about the need for bed rest.
D. Provide active range-of-motion exercises to both legs at least twice every
shift.
Answer: (C) Instruct the client about the need for bed rest. In a client with
thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity
which can lead to pulmonary embolism.
17. A client receiving heparin sodium asks the nurse how the drug works. Which of
the following points would the nurse include in the explanation to the client?
A. It dissolves existing thrombi.
B. It prevents conversion of factors that are needed in the formation of clots.
C. It inactivates thrombin that forms and dissolves existing thrombi.
D. It interferes with vitamin K absorption.
Answer: (B) It prevents conversion of factors that are needed in the
formation of clots. Heparin is an anticoagulant. It prevents the conversion of
prothrombin to thrombin. It does not dissolve a clot.
18. The nurse is conducting an education session for a group of smokers in a stop
smoking class. Which finding would the nurse state as a common symptom of lung
cancer? :
A. Dyspnea on exertion
B. Foamy, blood-tinged sputum
C. Wheezing sound on inspiration
D. Cough or change in a chronic cough
Answer: (D) Cough or change in a chronic cough .Cigarette smoke is a
carcinogen that irritates and damages the respiratory epithelium. The irritation
causes the cough which initially maybe dry, persistent and unproductive. As the
tumor enlarges, obstruction of the airways occurs and the cough may become
productive due to infection.
19. Which is the most relevant knowledge about oxygen administration to a client
with COPD?
A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
B. Hypoxia stimulates the central chemoreceptors in the medulla that makes the
client breath.
C. Oxygen is administered best using a non-rebreathing mask
D. Blood gases are monitored using a pulse oximeter.
Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus
for breathing. COPD causes a chronic CO2 retention that renders the medulla
insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then
becomes the stimulus for breathing. Giving the clientoxygen in low concentrations
will maintain the clients hypoxic drive.
20. When suctioning mucus from a clients lungs, which nursing action would be
least appropriate?
A. Lubricate the catheter tip with sterile saline before insertion.
 B. Use sterile technique with a two-gloved approach
C. Suction until the client indicates to stop or no longer than 20 second
D. Hyperoxygenate the client before and after suctioning
Answer: (C) Suction until the client indicates to stop or no longer than 20
second .One hazard encountered when suctioning a client is the development of
hypoxia. Suctioning sucks not only the secretions but also the gases found in the
airways. This can be prevented by suctioning the client for an average time of 5-10
seconds and not more than 15 seconds and hyperoxygenating the client before and
after suctioning.
21. Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client
with a positive Tuberculin skin test. When informing the client of this decision, the
nurse knows that the purpose of this choice of treatment is to
A. Cause less irritation to the gastrointestinal tract
B. Destroy resistant organisms and promote proper blood levels of the drugs
C. Gain a more rapid systemic effect
D. Delay resistance and increase the tuberculostatic effect
Answer: (D) Delay resistance and increase the tuberculostatic
effect . Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12
mons. A prolonged treatment duration is necessary to ensure eradication of the
organisms and to prevent relapse. The increasing prevalence of drug resistance
points to the need to begin the treatment with drugs in combination. Using drugs in
combination can delay the drug resistance.
22. Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes
are inserted, and one-bottle water-seal drainage is instituted in the operating room.
In the postanesthesia care unit Mario is placed in Fowlers position on either his
right
side or on his back to
A. Reduce incisional pain.
B. Facilitate ventilation of the left lung.
C. Equalize pressure in the pleural space.
D. Increase venous return
Answer: (B) Facilitate ventilation of the left lung. Since only a partial
pneumonectomy is done, there is a need to promote expansion of this remaining
Left lung by positioning the client on the opposite unoperated side.
23. A client with COPD is being prepared for discharge. The following are relevant
instructions to the client regarding the use of an oral inhaler EXCEPT
 A. Breath in and out as fully as possible before placing the mouthpiece inside
the mouth.
B. Inhale slowly through the mouth as the canister is pressed down
C. Hold his breath for about 10 seconds before exhaling
D. Slowly breath out through the mouth with pursed lips after inhaling the drug.
Answer: (D) Slowly breath out through the mouth with pursed lips after
inhaling the drug. If the client breathes out through the mouth with pursed lips,
this can easily force the just inhaled drug out of the respiratory tract that will lessen
its effectiveness.
24. A client is scheduled for a bronchoscopy. When teaching the client what to
expect afterward, the nurses highest priority of information would be
A. Food and fluids will be withheld for at least 2 hours.
B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done q2h.
D. Only ice chips and cold liquids will be allowed initially.
Answer: (A) Food and fluids will be withheld for at least 2 hours. Prior to
bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize
the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client
food and drink after the procedure without checking on the return of the gag reflex
can cause the client to aspirate. The gag reflex usually returns after two hours.
25. The nurse enters the room of a client with chronic obstructive pulmonary
disease. The clients nasal cannula oxygen is running at a rate of 6 L per minute, the
skin color is pink, and the respirations are 9 per minute and shallow. What is the
nurses best initial action?
A. Take heart rate and blood pressure.
B. Call the physician.
C. Lower the oxygen rate.
D. Position the client in a Fowlers position.
Answer: (C) Lower the oxygen rate. The client with COPD is suffering from
chronic CO2 retention. The hypoxic drive is his chief stimulus for breathing. Giving
O2 inhalation at a rate that is more than 2-3L/min can make the client lose his
hypoxic drive which can be assessed as decreasing RR.
26. The nurse is preparing her plan of care for her patient diagnosed with
pneumonia. Which is the most appropriate nursing diagnosis for this patient?
A. Fluid volume deficit
B. Decreased tissue perfusion.
 C. Impaired gas exchange.
D. Risk for infection
Answer: (C) Impaired gas exchange. Pneumonia, which is an infection, causes
lobar consolidation thus impairing gas exchange between the alveoli and the blood.
Because the patient would require adequate hydration, this makes him prone to
fluid volume excess.
27. A nurse at the weight loss clinic assesses a client who has a large abdomen and
a rounded face. Which additional assessment finding would lead the nurse to
suspect that the client has Cushings syndrome rather than obesity?
A. large thighs and upper arms
B. pendulous abdomen and large hips
C. abdominal striae and ankle enlargement
D. posterior neck fat pad and thin extremities
Answer: (D) posterior neck fat pad and thin extremities . Buffalo hump is
the accumulation of fat pads over the upper back and neck. Fat may also
accumulate on the face. There is truncal obesity but the extremities are thin. All
these are noted in a client with Cushings syndrome.
28. Which statement by the client indicates understanding of the possible side
effects of Prednisone therapy?
A. I should limit my potassium intake because hyperkalemia is a side-effect of
this drug.
B. I must take this medicine exactly as my doctor ordered it. I shouldnt skip
doses.
C. This medicine will protect me from getting any colds or infection.
D. My incision will heal much faster because of this drug.
Answer: (B) I must take this medicine exactly as my doctor ordered it. I
shouldnt skip doses. The possible side effects of steroid administration are
hypokalemia, increase tendency to infection and poor wound healing. Clients on the
drug must follow strictly the doctors order since skipping the drug can lower the
drug level in the blood that can trigger acute adrenal insufficiency or Addisonian
Crisis
29. A client, who is suspected of having Pheochromocytoma, complains of sweating,
palpitation and headache. Which assessment is essential for the nurse to make
first?
A. Pupil reaction
B. Hand grips
 C. Blood pressure
D. Blood glucose
Answer: (C) Blood pressure . Pheochromocytoma is a tumor of the adrenal
medulla that causes an increase secretion of catecholamines that can elevate the
blood pressure.
30. The nurse is attending a bridal shower for a friend when another guest, who
happens to be a diabetic, starts to tremble and complains of dizziness. The next
best action for the nurse to take is to:
A. Encourage the guest to eat some baked macaroni
B. Call the guests personal physician
C. Offer the guest a cup of coffee
D. Give the guest a glass of orange juice
Answer: (D) Give the guest a glass of orange juice . In diabetic patients, the
nurse should watch out for signs of hypoglycemia manifested by dizziness, tremors,
weakness, pallor diaphoresis and tachycardia. When this occurs in a conscious
client, he should be given immediately carbohydrates in the form of fruit juice, hard
candy, honey or, if unconscious, glucagons or dextrose per IV.
31. An adult, who is newly diagnosed with Graves disease, asks the nurse, Why do
I need to take Propanolol (Inderal)? Based on the nurses understanding of the
medication and Graves disease, the best response would be:
A. The medication will limit thyroid hormone secretion.
B. The medication limit synthesis of the thyroid hormones.
C. The medication will block the cardiovascular symptoms of Graves disease.
D. The medication will increase the synthesis of thyroid hormones.
Answer: (C) The medication will block the cardiovascular symptoms of
Graves disease. Propranolol (Inderal) is a beta-adrenergic blocker that controls
the cardiovascular manifestations brought about by increased secretion of the
thyroid hormone in Graves disease.
32. During the first 24 hours after thyroid surgery, the nurse should include in her
care:
A. Checking the back and sides of the operative dressing
B. Supporting the head during mild range of motion exercise
C. Encouraging the client to ventilate her feelings about the surgery
D. Advising the client that she can resume her normal activities immediately
Answer: (A) Checking the back and sides of the operative
dressing . Following surgery of the thyroid gland, bleeding is a potential
complication. This can best be assessed by checking the back and the sides of the
operative dressing as the blood may flow towards the side and back leaving the
front dry and clear of drainage.
33. On discharge, the nurse teaches the patient to observe for signs of surgically
induced hypothyroidism. The nurse would know that the patient understands the
teaching when she states she should notify the MD if she develops:
A. Intolerance to heat
B. Dry skin and fatigue
C. Progressive weight gain
D. Insomnia and excitability
Answer: (C) Progressive weight gain . Hypothyroidism, a decrease in thyroid
hormone production, is characterized by hypometabolism that manifests itself with
weight gain.
34. What is the best reason for the nurse in instructing the client to rotate injection
sites for insulin?
A. Lipodystrophy can result and is extremely painful
B. Poor rotation technique can cause superficial hemorrhaging
C. Lipodystrophic areas can result, causing erratic insulin absorption rates from
these
D. Injection sites can never be reused
Answer: (C) Lipodystrophic areas can result, causing erratic insulin
absorption rates from these . Lipodystrophy is the development of fibrofatty
masses at the injection site caused by repeated use of an injection site. Injecting
insulin into these scarred areas can cause the insulin to be poorly absorbed and
lead to erratic reactions.
35. Which of the following would be inappropriate to include in a diabetic teaching
plan?
A. Change position hourly to increase circulation
B. Inspect feet and legs daily for any changes
C. Keep legs elevated on 2 pillows while sleeping
D. Keep the insulin not in use in the refrigerator
Answer: (C) Keep legs elevated on 2 pillows while sleeping . The client with
DM has decreased peripheral circulation caused by microangiopathy. Keeping the
legs elevated during sleep will further cause circulatory impairment.
36. Included in the plan of care for the immediate post-gastroscopy period will be:
A. Maintain NGT to intermittent suction
B. Assess gag reflex prior to administration of fluids
C. Assess for pain and medicate as ordered
D. Measure abdominal girth every 4 hours
Answer: (B) Assess gag reflex prior to administration of fluids . The client,
after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic
that has been sprayed into his throat prior to the procedure. Giving fluids and food
at this time can lead to aspiration.
37. Which description of pain would be most characteristic of a duodenal ulcer?
A. Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved
by food intake
B. RUQ pain that increases after meal
C. Sharp pain in the epigastric area that radiates to the right shoulder
D. A sensation of painful pressure in the midsternal area
Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric area
that is relieved by food intake . Duodenal ulcer is related to an increase in the
secretion of HCl. This can be buffered by food intake thus the relief of the pain that
is brought about by food intake.
38. The client underwent Billroth surgery for gastric ulcer. Post-operatively, the
drainage from his NGT is thick and the volume of secretions has dramatically
reduced in the last 2 hours and the client feels like vomiting. The most appropriate
nursing action is to:
A. Reposition the NGT by advancing it gently NSS
B. Notify the MD of your findings
C. Irrigate the NGT with 50 cc of sterile
D. Discontinue the low-intermittent suction
Answer: (B) Notify the MD of your findings . The clients feeling of vomiting
and the reduction in the volume of NGT drainage that is thick are signs of possible
abdominal distention caused by obstruction of the NGT. This should be reported
immediately to the MD to prevent tension and rupture on the site of anastomosis
caused by gastric distention.
39. After Billroth II Surgery, the client developed dumping syndrome. Which of the
following should the nurse exclude in the plan of care?
A. Sit upright for at least 30 minutes after meals
 B. Take only sips of H2O between bites of solid food
C. Eat small meals every 2-3 hours
D. Reduce the amount of simple carbohydrate in the diet
Answer: (A) Sit upright for at least 30 minutes after meals . The dumping
syndrome occurs within 30 mins after a meal due to rapid gastric emptying, causing
distention of the duodenum or jejunum produced by a bolus of food. To delay the
emptying, the client has to lie down after meals. Sitting up after meals will promote
the dumping syndrome.

40. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of
Helicobacter pylori. Which of the following statements indicate an understanding of
this data?
A. Treatment will include Ranitidine and Antibiotics
B. No treatment is necessary at this time
C. This result indicates gastric cancer caused by the organism
D. Surgical treatment is necessary
Answer: (A) Treatment will include Ranitidine and Antibiotics . One of the
causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric
and duodenal mucosa which decreases the gastric epitheliums resistance to acid
digestion. Giving antibiotics will control the infection and Ranitidine, which is a
histamine-2 blocker, will reduce acid secretion that can lead to ulcer.
41. What instructions should the client be given before undergoing a paracentesis?
A. NPO 12 hours before procedure
B. Empty bladder before procedure
C. Strict bed rest following procedure
D. Empty bowel before procedure
Answer: (B) Empty bladder before procedure . Paracentesis involves the
removal of ascitic fluid from the peritoneal cavity through a puncture made below
the umbilicus. The client needs to void before the procedure to prevent accidental
puncture of a distended bladder during the procedure.
42. The husband of a client asks the nurse about the protein-restricted diet ordered
because of advanced liver disease. What statement by the nurse would best explain
the purpose of the diet?
A. The liver cannot rid the body of ammonia that is made by the breakdown of
protein in the digestive system.
B. The liver heals better with a high carbohydrates diet rather than protein.
 C. Most people have too much protein in their diets. The amount of this diet is
better for liver healing.
D. Because of portal hyperemesis, the blood flows around the liver and
ammonia made from protein collects in the brain causing hallucinations.
Answer: (A) The liver cannot rid the body of ammonia that is made by the
breakdown of protein in the digestive system. The largest source of
ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in
the GI tract. A protein-restricted diet will therefore decrease ammonia production.
43. Which of the drug of choice for pain controls the patient with acute pancreatitis?
A. Morphine
B. NSAIDS
C. Meperidine
D. Codeine
Answer: (C) Meperidine . Pain in acute pancreatitis is caused by irritation and
edema of the inflamed pancreas as well as spasm due to obstruction of the
pancreatic ducts. Demerol is the drug of choice because it is less likely to cause
spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.
44. Immediately after cholecystectomy, the nursing action that should assume the
highest priority is:
A. encouraging the client to take adequate deep breaths by mouth
B. encouraging the client to cough and deep breathe
C. changing the dressing at least BID
D. irrigate the T-tube frequently
Answer: (B) encouraging the client to cough and deep
breathe . Cholecystectomy requires a subcostal incision. To minimize pain, clients
have a tendency to take shallow breaths which can lead to respiratory complications
like pneumonia and atelectasis. Deep breathing and coughing exercises can help
prevent such complications.
45. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding
esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of
the tube, the client complains of difficulty of breathing. The first action of the nurse
is to:
A. Deflate the esophageal balloon
B. Monitor VS
C. Encourage him to take deep breaths
D. Notify the MD
Answer: (A) Deflate the esophageal balloon . When a client with a Sengstaken-
Blakemore tube develops difficulty of breathing, it means the tube is displaced and
the inflated balloon is in the oropharynx causing airway obstruction
46. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe
abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse
should be alert for other problems associated with what disease?
A. Chrons disease
B. Ulcerative colitis
C. Diverticulitis
D. Peritonitis
Answer: (B) Ulcerative colitis . Ulcerative colitis is a chronic inflammatory
condition producing edema and ulceration affecting the entire colon. Ulcerations
lead to sloughing that causes stools as many as 10-20 times a day that is filled with
blood, pus and mucus. The other symptoms mentioned accompany the problem.
47. A client is being evaluated for cancer of the colon. In preparing the client for
barium enema, the nurse should:
A. Give laxative the night before and a cleansing enema in the morning before
the test
B. Render an oil retention enema and give laxative the night before
C. Instruct the client to swallow 6 radiopaque tablets the evening before the
study
D. Place the client on CBR a day before the study
Answer: (A) Give laxative the night before and a cleansing enema in the
morning before the test .Barium enema is the radiologic visualization of the
colon using a die. To obtain accurate results in this procedure, the bowels must be
emptied of fecal material thus the need for laxative and enema.
48. The client has a good understanding of the means to reduce the chances of
colon cancer when he states:
A. I will exercise daily.
B. I will include more red meat in my diet.
C. I will have an annual chest x-ray.
D. I will include more fresh fruits and vegetables in my diet.
Answer: (D) I will include more fresh fruits and vegetables in my diet.
Numerous aspects of diet and nutrition may contribute to the development of
cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or
lacking in the diet, slows transport of materials through the gut which has been
linked to colorectal cancer.
49. Days after abdominal surgery, the clients wound dehisces. The safest nursing
intervention when this occurs is to
A. Cover the wound with sterile, moist saline dressing
B. Approximate the wound edges with tapes
C. Irrigate the wound with sterile saline
D. Hold the abdominal contents in place with a sterile gloved hand
Answer: (A) Cover the wound with sterile, moist saline
dressing . Dehiscence is the partial or complete separation of the surgical wound
edges. When this occurs, the client is placed in low Fowlers position and instructed
to lie quietly. The wound should be covered to protect it from exposure and the
dressing must be sterile to protect it from infection and moist to prevent the
dressing from sticking to the wound which can disturb the healing process.
50. An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is
believed to have a small stone that will pass spontaneously. To increase the chance
of the stone passing, the nurse would instruct the client to force fluids and to
A. Strain all urine.
B. Ambulate.
C. Remain on bed rest.
D. Ask for medications to relax him.
Answer: (B) Ambulate. Free unattached stones in the urinary tract can be passed
out with the urine by ambulation which can mobilize the stone and by increased
fluid intake which will flush out the stone during urination.