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EXECUTIVE ORDER NO. 51 October 20, 1986 ADOPTING A NATIONAL CODE OF MARKETING OF BREASTMILK SUBSTITUTES, BREASTMILK SUPPLEMENTS AND RELATED PRODUCTS, PENALIZING VIOLATIONS THEREOF, AND FOR OTHER PURPOSES WHEREAS, in order to ensure that safe and adequate nutrition for infants is provided, there is a need to protect and promote breastfeeding and to inform the public about the proper use of breastmilk substitutes and supplements and related products through adequate, consistent and objective information and appropriate regulation of the marketing and distribution of the said substitutes, supplements and related products; WHEREAS, consistent with Article 11 of the International Code of Marketing of Breast-milk Substitutes, the present government should adopt appropriate legislation to give effect to the principles and aim of the aforesaid International Code; NOW, THEREFORE, I, CORAZON C. AQUINO, President of the Philippines, do hereby order: Sec. 1. Title. This Code shall be known and cited as the "National Code of Marketing of Breastmilk Substitutes, Breastmilk Supplements and Other Related Products". Sec. 2. Aim of the Code The aim of the Code is to contribute to the provision of safe and adequate nutrition for infants by the protection and promotion of breastfeeding and by ensuring the proper use of breastmilk substitutes and breastmilk supplements when these are necessary, on the basis of adequate information and through appropriate marketing and distribution. Sec. 3. Scope of the Code The Code applies to the marketing, and practices related thereto, of the following products: breastmilk substitutes, including infant formula; other milk products, foods and beverages, including bottle-fed complementary foods, when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breastmilk; feeding bottles and teats. It also applies to their quality and availability, and to information concerning their use. Sec. 4. Definition of Terms. For the purposes of this Code, the following definition of terms shall govern: (a) "Breastmilk Substitute" means any food being marketed or otherwise represented as a partial or total replacement for breastmilk, whether or not suitable for that purpose. (b) "Complementary Food" means any food, whether manufactured or locally prepared, suitable as a complement to breastmilk or to infant formula, when either becomes insufficient to satisfy the nutritional requirements of the infant. Such food is also commonly called "weaning food" or "breastmilk supplement." (c) "Container" means any form of packaging of products for sale as a normal retail unit, including wrappers. (d) "Distributor" means a person, corporation or any other entity in the public or private sector engaged in the business (whether directly or indirectly) of marketing at the wholesale or retail level a product within the scope of this Code. A "primary distributor" is a manufacturer's sales agent, representative, national distributor or broker.

(e) "Infant" means a person falling within the age bracket of 0-12 months. (f) "Health care system" means governmental, non-governmental or private institutions or organizations engaged, directly or indirectly, in health care for mothers, infants and pregnant women; and nurseries or child care institutions. It also includes health workers in private practice. For the purpose of this Code, the health care system does not include pharmacies or other established sales outlets. (g) "Health Worker" means a person working in a component of such health care system, whether professional or non-professional, including volunteer workers. (h) "Infant Formula" means a breastmilk substitute formulated industrially in accordance with applicable Codex Alimentarius standards to satisfy the normal nutritional requirements of infants up to between four to six months of age, and adapted to their physiological characteristics. Infant formula may also be prepared at home in which case it is described as "home-prepared". (i) "Label" means any tag, brand, mark, pictorial or other descriptive matter, written, printed, stencilled, marked, embossed or impressed on, or attached to, a container of any product within the scope of this Code. (j) "Manufacturer" means a corporation or other entity in the public or private sector engaged in the business or function (whether directly or through an agent or an entity controlled by or under contract with it) of manufacturing a product within the scope of this Code. (k) "Marketing" means product promotion, distribution, selling, advertising, product public relations, and information services. (l) "Marketing personnel" means any person whose functions involve the marketing of a product or products coming within the scope of this Code. (m) "Sample" means single or small quantities of a product provided without costs. (n) "Supplies" means quantities of a product provided for use over an extended period, free or at a low price, for social purposes, including those provided to families in need. Sec. 5. Information and Education (a) The government shall ensure that objective and consistent information is provided on infant feeding, for use by families and those involved in the field of infant nutrition. This responsibility shall cover the planning, provision, design and dissemination of information, and the control thereof, on infant nutrition. (b) Information and educational materials, whether written, audio, or visual, dealing with the feeding of infants and intended to teach pregnant women and mothers of infants, shall include clear information on all the following points: (1) the benefits and superiority of breastfeeding; (2) maternal nutrition, and the preparation for and maintenance of breastfeeding; (3) the negative effect on breastfeeding of introducing partial bottle-feeding; (4) the difficulty of reversing the decision not to breastfeed; and (5) where needed, the proper use of infant formula, whether manufactured industrially or home-prepared. When such materials contain information about the use of infant formula, they shall include the social and financial implications of its use; the health hazards of inappropriate foods or feeding methods; and, in particular, the health hazards of unnecessary or

improper use of infant formula and other breastmilk substitutes. Such materials shall not use any picture or text which may idealize the use of breastmilk substitutes. Sec. 6. The General Public and Mothers (a) No advertising, promotion or other marketing materials, whether written, audio or visual, for products, within the scope of this Code shall be printed, published, distributed, exhibited and broadcast unless such materials are duly authorized and approved by an inter-agency committee created herein pursuant to the applicable standards provided for in this Code. (b) Manufacturers and distributors shall not be permitted to give, directly, or indirectly, samples and supplies of products within the scope of this Code or gifts of any sort to any member of the general public, including members of their families, to hospitals and other health institutions, as well as to personnel within the health care system, save as otherwise provided in this Code. (c) There shall be no point-of-sale advertising, giving of samples or any other promotion devices to induce sales directly to the consumers at the retail level, such as special displays, discount coupons, premiums, special sales, bonus and tie-in sales for the products within the scope of this Code. This provision shall not restrict the establishment of pricing policies and practices intended to provide products at lower prices on a long term basis. (d) Manufacturers and distributors shall not distribute to pregnant women or mothers of infants any gifts or articles or utensils which may promote the use of breastmilk substitutes or bottle feeding, nor shall any other groups, institutions or individuals distribute such gifts, utensils or products provided by this Code. (e) Marketing personnel shall be prohibited from advertising or promoting in any other manner the products covered by this Code, either directly or indirectly, to pregnant women or with mother of infants, except as otherwise provided by this Code. (f) Nothing herein contained shall prevent donations from manufacturers and distributors of products within the scope of this Code upon request by or with the approval of the Ministry of Health. Sec. 7. Health Care System (a) The Ministry of Health shall take appropriate measures to encourage and promote breastfeeding. It shall provide objective and consistent information, training and advice to health workers on infant nutrition, and on their obligations under this Code. (b) No facility of the health care system shall be used for the purpose of promoting infant formula or other products within the scope of this Code. This Code does not, however, preclude the dissemination of information to health professionals as provided in Section 8(b). (c) Facilities of the health care system shall not be used for the display of products within the scope of this Code, or for placards or posters concerning such products. (d) The use by the health care system of "professional service" representatives, "mothercraft nurses" or similar personnel, provided or paid for by manufacturers or distributors, shall not be permitted. (e) In health education classes for mothers and the general public, health workers and community workers shall emphasize the hazards and risks of the improper use of breastmilk substitutes

particularly infant formula. Feeding with infant formula shall be demonstrated only to mothers who may not be able to breastfeed for medical or other legitimate reasons. Sec. 8. Health Workers (a) Health workers shall encourage and promote breastfeeding and shall make themselves familiar with objectives and consistent information on maternal and infant nutrition, and with their responsibilities under this Code. (b) Information provided by manufacturers and distributors to health professionals regarding products within the scope of this Code shall be restricted to scientific and factual matters and such information shall not imply or create a belief that bottlefeeding is equivalent or superior to breastfeeding. It shall also include the information specified in Section 5(b). (c) No financial or material inducements to promote products within the scope of this Code shall be offered by manufacturers or distributors to health workers or members of their families, nor shall these be accepted by the health workers or members of their families, except as otherwise provided in Section 8(e). (d) Samples of infant formulas or other products within the scope of this Code, or of equipment or utensils for their preparation or use, shall not be provided to health workers except when necessary for the purpose of professional evaluation or research in accordance with the rules and regulations promulgated by the Ministry of Health. No health workers shall give samples of infant formula to pregnant women and mothers of infants or members of their families. (e) Manufacturers and distributors of products within the scope of this Code may assist in the research, scholarships and continuing education, of health professionals, in accordance with the rules and regulations promulgated by the Ministry of Health. Sec. 9. Persons Employed by Manufacturers and Distributors Personnel employed in marketing products within the scope of this Code shall not, as part of their job responsibilities, perform educational functions in relation to pregnant women or mothers of infants. Sec. 10. Containers/Label (a) Containers and/or labels shall be designed to provide the necessary information about the appropriate use of the products, and in such a way as not to discourage breastfeeding. (b) Each container shall have a clear, conspicuous and easily readable and understandable message in Pilipino or English printed on it, or on a label, which message can not readily become separated from it, and which shall include the following points: (i) the words "Important Notice" or their equivalent; (ii) a statement of the superiority of breastfeeding; (iii) a statement that the product shall be used only on the advice of a health worker as to the need for its use and the proper methods of use; and (iv) instructions for appropriate preparation, and a warning against the health hazards of inappropriate preparation.

(c) Neither the container nor the label shall have pictures or texts which may idealize the use of infant formula. They may, however, have graphics for easy identification of the product and for illustrating methods of preparation. (d) The term "humanized", maternalized" or similar terms shall not be used. (e) Food products within the scope of this Code marketed for infant feeding, which do not meet all the requirements of an infant formula but which can be modified to do so, shall carry on the label a warning that the unmodified product should not be the sole source of nourishment of an infant. (f) The labels of food products within the scope of this Code shall, in addition to the requirements in the preceding paragraphs, conform with the rules and regulations of the Bureau of Food and Drugs. Sec. 11. Quality (a) The quality of products is an essential element for the protection of the health of infants, and therefore shall be of high recognized standard. (b) Food products within the scope of this Code shall, when sold or otherwise distributed, meet applicable standards recommended by the Codex Alimentarius Commission and also the Codex Code of Hygienic Practice for Foods for Infants and Children. (c) To prevent quality deterioration, adulteration or contamination of food products within the scope of this Code, distribution outlets, including the smallest sari-sari store, shall not be allowed to open cans and boxes for the purpose of retailing them by the cup, bag or in any other form. Sec. 12. Implementation and Monitoring (a) For purposes of Section 6(a) of this Code, an inter-agency committee composed of the following members is hereby created: Minister of Health ........................................... Chairman Minister of Trade and Industry .......................... Member Minister of Justice .......................................... Member Minister of Social Servicesl and Development ... Member The members may designate their duly authorized representative to every meeting of the Committee. The Committee shall have the following powers and functions: (1) To review and examine all advertising, promotion or other marketing materials, whether written, audio or visual, on products within the scope of this Code; (2) To approve or disapprove, delete objectionable portions from and prohibit the printing, publication, distribution, exhibition and broadcast of, all advertising promotion or other

marketing materials, whether written, audio or visual, on products within the scope of this Code; (3) To prescribe the internal and operational procedure for the exercise of its powers and functions as well as the performance of its duties and responsibilities; and (4) To promulgate such rules and regulations as are necessary or proper for the implementation of Section 6(a) of this Code. (b) The Ministry of Health shall be principally responsible for the implementation and enforcement of the provisions of this Code. For this purpose, the Ministry of Health shall have the following powers and functions: (1) To promulgate such rules and regulations as are necessary or proper for the implementation of this Code and the accomplishment of its purposes and objectives. (2) To call the assistance of government agencies and the private sector to ensure the implementation and enforcement of, and strict compliance with, the provisions of this Code and the rules and regulations promulgated in accordance herewith. (3) To cause the prosecution of the violators of this Code and other pertinent laws on products covered by this Code. (4) To exercise such other powers and functions as may be necessary for or incidental to the attainment of the purposes and objectives of this Code. Sec. 13. Sanctions (a) Any person who violates the provisions of this Code or the rules and regulations issued pursuant to this Code shall, upon conviction, be punished by a penalty of two (2) months to one (1) year imprisonment or a fine of not less than One Thousand Pesos (P1,000.00) nor more than Thirty Thousand Pesos (P30,000.00) or both. Should the offense be committed by a juridical person, the chairman of the Board of Directors, the president, general manager, or the partners and/or the persons directly responsible therefor, shall be penalized. (b) Any license, permit or authority issued by any government agency to any health worker, distributor, manufacturer, or marketing firm or personnel for the practice of their profession or occupation, or for the pursuit of their business, may, upon recommendation of the Ministry of Health, be suspended or revoked in the event of repeated violations of this Code, or of the rules and regulations issued pursuant to this Code. Sec. 14. Repealing Clause. All laws, orders, issuances, and rules and regulations or parts thereof inconsistent with this Executive Order are hereby repealed or modified accordingly. Sec. 15. Separability Clause. The provisions of this Executive Order are hereby deemed separable. If any provision thereof be declared invalid or unconstitutional, such invalidity or unconstitutionality shall not affect the other provisions which shall remain in full force and effect. Sec. 16. Effectivity This Executive Order shall take effect thirty (30) days following its publication in the Official Gazette.

Done in the City of Manila, this 20th day of October, in the year of Our Lord, nineteen hundred and eighty-six.

The Lawphil Project - Arellano Law Foundation
Here is 50-item practice test on Medical Surgical Nursing. Answers will be posted soon. Keep checking http://nclexreviewers.com for updates or Subscribe to us for free to receive updates straight on your own email. 1. The nurse is performing her admission assessment of a patient. When grading arterial pulses, a 1+ pulse indicates: 1. Above normal perfusion. 2. Absent perfusion. 3. Normal perfusion. 4. Diminished perfusion. 2. Murmurs that indicate heart disease are often accompanied by other symptoms such as: 0. Dyspnea on exertion. 1. Subcutaneous emphysema. 2. Thoracic petechiae. 3. Periorbital edema. 3. Which pregnancy-related physiologic change would place the patient with a history of cardiac disease at the greatest risk of developing severe cardiac problems? 0. Decrease heart rate 1. Decreased cardiac output 2. Increased plasma volume 3. Increased blood pressure 4. The priority nursing diagnosis for the patient with cardiomyopathy is: 0. Anxiety related to risk of declining health status. 1. Ineffective individual coping related to fear of debilitating illness 2. Fluid volume excess related to altered compensatory mechanisms. 3. Decreased cardiac output related to reduced myocardial contractility. 5. A patient with thrombophlebitis reached her expected outcomes of care. Her affected leg appears pink and warm. Her pedal pulse is palpable and there is no edema present. Which step in the nursing process is described above? 0. Planning 1. Implementation 2. Analysis 3. Evaluation 6. An elderly patient may have sustained a basilar skull fracture after slipping and falling on an icy sidewalk. The nurse knows that basilar skull factures: 0. Are the least significant type of skull fracture. 1. May have cause cerebrospinal fluid (CSF) leaks from the nose or ears. 2. Have no characteristic findings. 3. Are always surgically repaired.

7. Which of the following types of drugs might be given to control increased intracranial pressure (ICP)? 0. Barbiturates 1. Carbonic anhydrase inhibitors 2. Anticholinergics 3. Histamine receptor blockers 8. The nurse is teaching family members of a patient with a concussion about the early signs of increased intracranial pressure (ICP). Which of the following would she cite as an early sign of increased ICP? 0. Decreased systolic blood pressure 1. Headache and vomiting 2. Inability to wake the patient with noxious stimuli 3. Dilated pupils that don’t react to light 9. Jessie James is diagnosed with retinal detachment. Which intervention is the most important for this patient? 0. Admitting him to the hospital on strict bed rest 1. Patching both of his eyes 2. Referring him to an ophthalmologist 3. Preparing him for surgery 10. Dr. Bruce Owen, a chemist, sustained a chemical burn to one eye. Which intervention takes priority for a patient with a chemical burn of the eye? 0. Patch the affected eye and call the ophthalmologist. 1. Administer a cycloplegic agent to reduce ciliary spasm. 2. Immediately instill a tropical anesthetic, then irrigate the eye with saline solution. 3. Administer antibiotics to reduce the risk of infection 11. The nurse is assessing a patient and notes a Brudzinski’s sign and Kernig’s sign. These are two classic signs of which of the following disorders? 0. Cerebrovascular accident (CVA) 1. Meningitis 2. Seizure disorder 3. Parkinson’s disease 12. A patient is admitted to the hospital for a brain biopsy. The nurse knows that the most common type of primary brain tumor is: 0. Meningioma. 1. Angioma. 2. Hemangioblastoma. 3. Glioma. 13. The nurse should instruct the patient with Parkinson’s disease to avoid which of the following? 0. Walking in an indoor shopping mall 1. Sitting on the deck on a cool summer evening 2. Walking to the car on a cold winter day 3. Sitting on the beach in the sun on a summer day 14. Gary Jordan suffered a cerebrovascular accident that left her unable to comprehend speech and unable to speak. This type of aphasia is known as:

0. Receptive aphasia 1. Expressive aphasia 2. Global aphasia 3. Conduction aphasia 15. Kelly Smith complains that her headaches are occurring more frequently despite medications. Patients with a history of headaches should be taught to avoid: 0. Freshly prepared meats. 1. Citrus fruits. 2. Skim milk 3. Chocolate 16. Immediately following cerebral aneurysm rupture, the patient usually complains of: 0. Photophobia 1. Explosive headache 2. Seizures 3. Hemiparesis 17. Which of the following is a cause of embolic brain injury? 0. Persistent hypertension 1. Subarachnoid hemorrhage 2. Atrial fibrillation 3. Skull fracture 18. Although Ms. Priestly has a spinal cord injury, she can still have sexual intercourse. Discharge teaching should make her aware that: 0. She must remove indwelling urinary catheter prior to intercourse. 1. She can no longer achieve orgasm. 2. Positioning may be awkward. 3. She can still get pregnant. 19. Ivy Hopkins, age 25, suffered a cervical fracture requiring immobilization with halo traction. When caring for the patient in halo traction, the nurse must: 0. Keep a wrench taped to the halo vest for quick removal if cardiopulmonary resuscitation is necessary. 1. Remove the brace once a day to allow the patient to rest. 2. Encourage the patient to use a pillow under the ring. 3. Remove the brace so that the patient can shower. 20. The nurse asks a patient’s husband if he understands why his wife is receiving nimodipine (Nimotop), since she suffered a cerebral aneurysm rupture. Which response by the husband indicates that he understands the drug’s use? 0. “Nimodipine replaces calcium.” 1. “Nimodipine promotes growth of blood vessels in the brain.” 2. “Nimodipine reduces the brain’s demand for oxygen.” 3. “Nimodipine reduces vasospasm in the brain.” 21. Many men who suffer spinal injuries continue to be sexually active. The teaching plan for a man with a spinal cord injury should include sexually concerns. Which of the following injuries would most likely prevent erection and ejaculation? 0. C5

1. C7 2. T4 3. S4 22. Cathy Bates, age 36, is a homemaker who frequently forgets to take her carbamazepine (Tegretol). As a result, she has been experiencing seizures. How can the nurse best help the patient remember to take her medication? 0. Tell her take her medication at bedtime. 1. Instruct her to take her medication after one of her favorite television shows. 2. Explain that she should take her medication with breakfast. 3. Tell her to buy an alarm watch to remind her. 23. Richard Barnes was diagnosed with pneumococcal meningitis. What response by the patient indicates that he understands the precautions necessary with this diagnosis? 0. “I’m so depressed because I can’t have any visitors for a week.” 1. “Thank goodness, I’ll only be in isolation for 24 hours.” 2. “The nurse told me that my urine and stool are also sources of meningitis bacteria.” 3. “The doctor is a good friend of mine and won’t keep me in isolation.” 24. An early symptom associated with amyotrophic lateral sclerosis (ALS) includes: 0. Fatigue while talking 1. Change in mental status 2. Numbness of the hands and feet 3. Spontaneous fractures 25. When caring for a patient with esophageal varices, the nurse knows that bleeding in this disorder usually stems from: 0. Esophageal perforation 1. Pulmonary hypertension 2. Portal hypertension 3. Peptic ulcers 26. Tiffany Black is diagnosed with type A hepatitis. What special precautions should the nurse take when caring for this patient? 0. Put on a mask and gown before entering the patient’s room. 1. Wear gloves and a gown when removing the patient’s bedpan. 2. Prevent the droplet spread of the organism. 3. Use caution when bringing food to the patient. 27. Discharge instructions for a patient who has been operated on for colorectal cancer include irrigating the colostomy. The nurse knows her teaching is effective when the patient states he’ll contact the doctor if: 0. He experiences abdominal cramping while the irrigant is infusing 1. He has difficulty inserting the irrigation tube into the stoma 2. He expels flatus while the return is running out 3. He’s unable to complete the procedure in 1 hour 28. The nurse explains to the patient who has an abdominal perineal resection that an indwelling urinary catheter must be kept in place for several days afterward because: 0. It prevents urinary tract infection following surgery

1. It prevents urine retention and resulting pressure on the perineal wound 2. It minimizes the risk of wound contamination by the urine 3. It determines whether the surgery caused bladder trauma 29. The first day after, surgery the nurse finds no measurable fecal drainage from a patient’s colostomy stoma. What is the most appropriate nursing intervention? 0. Call the doctor immediately. 1. Obtain an order to irrigate the stoma. 2. Place the patient on bed rest and call the doctor. 3. Continue the current plan of care. 30. If a patient’s GI tract is functioning but he’s unable to take foods by mouth, the preferred method of feeding is: 0. Total parenteral nutrition 1. Peripheral parenteral nutrition 2. Enteral nutrition 3. Oral liquid supplements 31. Which type of solution causes water to shift from the cells into the plasma? 0. Hypertonic 1. Hypotonic 2. Isotonic 3. Alkaline 32. Particles move from an area of greater osmelarity to one of lesser osmolarity through: 0. Active transport 1. Osmosis 2. Diffusion 3. Filtration 33. Which assessment finding indicates dehydration? 0. Tenting of chest skin when pinched 1. Rapid filling of hand veins 2. A pulse that isn’t easily obliterated 3. Neck vein distention 34. Which nursing intervention would most likely lead to a hypo-osmolar state? 0. Performing nasogastric tube irrigation with normal saline solution 1. Weighing the patient daily 2. Administering tap water enema until the return is clear 3. Encouraging the patient with excessive perspiration to dink broth 35. Which assessment finding would indicate an extracellular fluid volume deficit? 0. Bradycardia 1. A central venous pressure of 6 mm Hg 2. Pitting edema 3. An orthostatic blood pressure change 36. A patient with metabolic acidosis has a preexisting problem with the kidneys. Which other organ helps regulate blood pH? 0. Liver

1. Pancreas 2. Lungs 3. heart 37. The nurse considers the patient anuric if the patient; 0. Voids during the nighttime hours 1. Has a urine output of less than 100 ml in 24 hours 2. Has a urine output of at least 100 ml in 2 hours 3. Has pain and burning on urination 38. Which nursing action is appropriate to prevent infection when obtaining a sterile urine specimen from an indwelling urinary catheter? 0. Aspirate urine from the tubing port using a sterile syringe and needle 1. Disconnect the catheter from the tubing and obtain urine 2. Open the drainage bag and pour out some urine 3. Wear sterile gloves when obtaining urine 39. After undergoing a transurethral resection of the prostate to treat benign prostatic hypertrophy, a patient is retuned to the room with continuous bladder irrigation in place. One day later, the patient reports bladder pain. What should the nurse do first? 0. Increase the I.V. flow rate 1. Notify the doctor immediately 2. Assess the irrigation catheter for patency and drainage 3. Administer meperidine (Demerol) as prescribed 40. A patient comes to the hospital complaining of sudden onset of sharp, severe pain originating in the lumbar region and radiating around the side and toward the bladder. The patient also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The doctor tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site? 0. Kidney 1. Ureter 2. Bladder 3. Urethra 41. A patient comes to the hospital complaining of severe pain in the right flank, nausea, and vomiting. The doctor tentatively diagnoses right ureter-olithiasis (renal calculi). When planning this patient’s care, the nurse should assign highest priority to which nursing diagnosis? 0. Pain 1. Risk of infection 2. Altered urinary elimination 3. Altered nutrition: less than body requirements 42. The nurse is reviewing the report of a patient’s routine urinalysis. Which of the following values should the nurse consider abnormal? 0. Specific gravity of 1.002 1. Urine pH of 3 2. Absence of protein 3. Absence of glucose

43. A patient with suspected renal insufficiency is scheduled for a comprehensive diagnostic work-up. After the nurse explains the diagnostic tests, the patient asks which part of the kidney “does the work.” Which answer is correct? 0. The glomerulus 1. Bowman’s capsule 2. The nephron 3. The tubular system 44. During a shock state, the renin-angiotensin-aldosterone system exerts which of the following effects on renal function? 0. Decreased urine output, increased reabsorption of sodium and water 1. Decreased urine output, decreased reabsorption of sodium and water 2. Increased urine output, increased reabsorption of sodium and water 3. Increased urine output, decreased reabsorption of sodium and water 45. While assessing a patient who complained of lower abdominal pressure, the nurse notes a firm mass extending above the symphysis pubis. The nurse suspects: 0. A urinary tract infection 1. Renal calculi 2. An enlarged kidney 3. A distended bladder 46. Gregg Lohan, age 75, is admitted to the medical-surgical floor with weakness and left-sided chest pain. The symptoms have been present for several weeks after a viral illness. Which assessment finding is most symptomatic of pericarditis? 0. Pericardial friction rub 1. Bilateral crackles auscultated at the lung bases 2. Pain unrelieved by a change in position 3. Third heart sound (S3) 47. James King is admitted to the hospital with right-side-heart failure. When assessing him for jugular vein distention, the nurse should position him: 0. Lying on his side with the head of the bed flat. 1. Sitting upright. 2. Flat on his back. 3. Lying on his back with the head of the bed elevated 30 to 45 degrees. 48. The nurse is interviewing a slightly overweight 43-year-old man with mild emphysema and borderline hypertension. He admits to smoking a pack of cigarettes per day. When developing a teaching plan, which of the following should receive highest priority to help decrease respiratory complications? 0. Weight reduction 1. Decreasing salt intake 2. Smoking cessation 3. Decreasing caffeine intake 49. What is the ratio of chest compressions to ventilations when one rescuer performs cardiopulmonary resuscitation (CPR) on an adult? 0. 15:1 1. 15:2

2. 12:1 3. 12:2 50. When assessing a patient for fluid and electrolyte balance, the nurse is aware that the organs most important in maintaining this balance are the: 0. Pituitary gland and pancreas 1. Liver and gallbladder. 2. Brain stem and heart. 3. Lungs and kidneys. View Questions 1. Answer: D A 1+ pulse indicates weak pulses and is associated with diminished perfusion. A 4+ is bounding perfusion, a 3+ is increased perfusion, a 2+ is normal perfusion, and 0 is absent perfusion. 2. Answer: A A murmur that indicates heart disease is often accompanied by dyspnea on exertion, which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest pain. Subcutaneous emphysema, thoracic petechiae, and perior-bital edema aren’t associated with murmurs and heart disease. 3. Answer: C Pregnancy increase plasma volume and expands the uterine vascular bed, possibly increasing both the heart rate and cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease, but it gradually returns to prepregnancy levels. 4. Answer: D Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a patient with cardiomyopathy. The other options can be addressed once cardiac output and myocardial contractility have been restored. 5. Answer: D Evaluation assesses the effectiveness of the treatment plan by determining if the patient has met the expected treatment outcome. Planning refers to designing a plan of action that will help the nurse deliver quality patient care. Implementation refers to all of the nursing interventions directed toward solving the patient’s nursing problems. Analysis is the process of identifying the patient’s nursing problems. 6. Answer: B A basilar skull fracture carries the risk of complications of dural tear, causing CSF leakage and damage to cranial nerves I, II, VII, and VIII. Classic findings in this type of fracture may include otorrhea, rhinorrhea, Battle’s signs, and raccoon eyes. Surgical treatment isn’t always required. 7. Answer: A Barbiturates may be used to induce a coma in a patient with increased ICP. This decreases cortical activity and cerebral metabolism, reduces cerebral blood volume, decreases cerebral edema, and reduces the brain’s need for glucose and oxygen. Carbonic anhydrase inhibitors are used to decrease ocular pressure or to decrease the serum pH in a patient with metabolic alkalosis. Anticholinergics

have many uses including reducing GI spasms. Histamine receptor blockers are used to decrease stomach acidity. 8. Answer: B Headache and projectile vomiting are early signs of increased ICP. Decreased systolic blood pressure, unconsciousness, and dilated pupils that don’t reac to light are considered late signs. 9. Answer: A Immediate bed rest is necessary to prevent further injury. Both eyes should be patched to avoid consensual eye movement and the patient should receive early referral to an ophthalmologist should treat the condition immediately. Retinal reattachment can be accomplished by surgery only. If the macula is detached or threatened, surgery is urgent; prolonged detachment of the macula results in permanent loss of central vision. 10. Answer: C A chemical burn to the eye requires immediate instillation of a topical anesthetic followed by irrigation with copious amounts of saline solution. Irrigation should be done for 5 to 10 minutes, and then the pH of the eye should be checked. Irrigation should be continued until the pH of the eye is restored to neutral (pH 7.0): Double eversion of the eyelids should be performed to look for and remove ciliary spasm, and an antibiotic ointment can be administered to reduce the risk of infection. Then the eye should be patched. Parenteral narcotic analgesia is often required for pain relief. An ophthalmologist should also be consulted. 11. Answer: B A positive response to one or both tests indicates meningeal irritation that is present with meningitis. Brudzinski’s and Kernig’s signs don’t occur in CVA, seizure disorder, or Parkinson’s disease. 12. Answer: D Gliomas account for approximately 45% of all brain tumors. Meningiomas are the second most common, with 15%. Angiomas and hemangioblastomas are types of cerebral vascular tumors that account for 3% of brain tumors. 13. Answer: D The patient with Parkinson’s disease may be hypersensitive to heat, which increases the risk of hyperthermia, and he should be instructed to avoid sun exposure during hot weather. 14. Answer: C Global aphasia occurs when all language functions are affected. Receptive aphasia, also known as Wernicke’s aphasia, affects the ability to comprehend written or spoken words. Expressive aphasia, also known as Broca’s aphasia, affected the patient’s ability to form language and express thoughts. Conduction aphasia refers to abnormalities in speech repetition. 15. Answer: D Patients with a history of headaches, especially migraines, should be taught to keep a food diary to identify potential food triggers. Typical headache triggers include alcohol, aged cheeses, processed meats, and chocolate and caffeine-containing products. 16. Answer: B An explosive headache or “the worst headache I’ve ever had” is typically the first presenting symptom of a bleeding cerebral aneurysm. Photophobia, seizures, and hemiparesis may occur later. 17. Answer: C An embolic injury, caused by a traveling clot, may result from atrial fibrillation. Blood may pool in the

fibrillating atrium and be released to travel up the cerebral artery to the brain. Persistent hypertension may place the patient at risk for a thrombotic injury to the brain. Subarachnoid hemorrhage and skull fractures aren’t associated with emboli. 18. Answer: D Women with spinal cord injuries who were sexually active may continue having sexual intercourse and must be reminded that they can still become pregnant. She may be fully capable of achieving orgasm. An indwelling urinary catheter may be left in place during sexual intercourse. Positioning will need to be adjusted to fit the patient’s needs. 19. Answer: A The nurse must have a wrench taped on the vest at all times for quick halo removal in emergent situations. The brace isn’t to be removed for any other reason until the cervical fracture is healed. Placing a pillow under the patient’s head may alter the stability of the brace. 20. Answer: D Nimodipine is a calcium channel blocker that acts on cerebral blood vessels to reduce vasospasm. The drug doesn’t increase the amount of calcium, affect cerebral vasculature growth, or reduce cerebral oxygen demand. 21. Answer: D Men with spinal cord injury should be taught that the higher the level of the lesion, the better their sexual function will be. The sacral region is the lowest area on the spinal column and injury to this area will cause more erectile dysfunction. 22. Answer: C Tegretol should be taken with food to minimize GI distress. Taking it at meals will also establish a regular routine, which should help compliance. 23. Answer: B Patient with pneumococcal meningitis require respiratory isolation for the first 24 hours after treatment is initiated. 24. Answer: A Early symptoms of ALS include fatigue while talking, dysphagia, and weakness of the hands and arms. ALS doesn’t cause a change in mental status, paresthesia, or fractures. 25. Answer: C Increased pressure within the portal veins causes them to bulge, leading to rupture and bleeding into the lower esophagus. Bleeding associated with esophageal varices doesn’t stem from esophageal perforation, pulmonary hypertension, or peptic ulcers. 26. Answer: B The nurse should wear gloves and a gown when removing the patient’s bedpan because the type A hepatitis virus occurs in stools. It may also occur in blood, nasotracheal secretions, and urine. Type A hepatitis isn’t transmitted through the air by way of droplets. Special precautions aren’t needed when feeding the patient, but disposable utensils should be used. 27. Answer: B The patient should notify the doctor if he has difficulty inserting the irrigation tube into the stoma. Difficulty with insertion may indicate stenosis of the bowel. Abdominal cramping and expulsion of flatus may normally occur with irrigation. The procedure will often take an hour to complete.

28. Answer: B An indwelling urinary catheter is kept in place several days after this surgery to prevent urine retention that could place pressure on the perineal wound. An indwelling urinary catheter may be a source of postoperative urinary tract infection. Urine won’t contaminate the wound. An indwelling urinary catheter won’t necessarily show bladder trauma. 29. Answer: D The colostomy may not function for 2 days or more (48 to 72 hours) after surgery. Therefore, the normal plan of care can be followed. Since no fecal drainage is expected for 48 to 72 hours after a colostomy (only mucous and serosanguineous), the doctor doesn’t have to be notified and the stoma shouldn’t be irrigated at this time. 30. Answer: C If the patient’s GI tract is functioning, enteral nutrition via a feeding tube is the preferred method. Peripheral and total parenteral nutrition places the patient at risk for infection. If the patient is unable to consume foods by mouth, oral liquid supplements are contraindicated. 31. Answer: A A hypertonic solution causes water to shift from the cells into the plasma because the hypertonic solution has a greater osmotic pressure than the cells. A hypotonic solution has a lower osmotic pressure than that of the cells. It causes fluid to shift into the cells, possibly resulting in rupture. An isotonic solution, which has the same osmotic pressure as the cells, wouldn’t cause any shift. A solution’s alkalinity is related to the hydrogen ion concentration, not its osmotic effect. 32. Answer: C Particles move from an area of greater osmolarity to one of lesser osmolarity through diffusion. Active transport is the movement of particles though energy expenditure from other sources such as enzymes. Osmosis is the movement of a pure solvent through a semipermeable membrane from an area of greater osmolarity to one of lesser osmolarity until equalization occurs. The membrane is impermeable to the solute but permeable to the solvent. Filtration is the process by which fluid is forced through a membrane by a difference in pressure; small molecules pass through, but large ones don’t. 33. Answer: A Tenting of chest skin when pinched indicates decreased skin elasticity due to dehydration. Hand veins fill slowly with dehydration, not rapidly. A pulse that isn’t easily obliterated and neck vein distention indicate fluid overload, not dehydration. 34. Answer: C Administering a tap water enema until return is clear would most likely contribute to a hypo-osmolar state. Because tap water is hypotonic, it would be absorbed by the body, diluting the body fluid concentration and lowering osmolarity. Weighing the patient is the easiest, most accurate method to determine fluid changes. Therefore, it helps identify rather than contribute to fluid imbalance. Nasogastric tube irrigation with normal saline solution wouldn’t cause a shift in fluid balance. Drinking broth wouldn’t contribute to a hypo-osmolar state because it doesn’t replace sodium and water lost through excessive perspiration. 35. Answer: D An orthostatic blood pressure indicates an extracellular fluid volume deficit. (The extracellular compartment consists of both the intravascular compartment and interstitial space.) A fluid volume

deficit within the intravascular compartment would cause tachycardia, not bradycardia or orthostatic blood pressure change. A central venous pressure of 6 mm Hg is in the high normal range, indicating adequate hydration. Pitting edema indicates fluid volume overload. 36. Answer: C The respiratory and renal systems act as compensatory mechanisms to counteract-base imbalances. The lungs alter the carbon dioxide levels in the blood by increasing or decreasing the rate and depth of respirations, thereby increasing or decreasing carbon dioxide elimination. The liver, pancreas, and heart play no part in compensating for acid-base imbalances. 37. Answer: B Anuria refers to a urine output of less than 100 ml in 24 hours. The baseline for urine output and renal function is 30 ml of urine per hour. A urine output of at least 100 ml in 2 hours is within normal limits. Voiding at night is called nocturia. Pain and burning on urination is called dysuria. 38. Answer: A To obtain urine properly, the nurse should aspirate it from a port, using a sterile syringe after cleaning the port. Opening a closed urine drainage system increases the risk of urinary tract infection. Standard precautions specify the use of gloves during contract with body fluids; however, sterile gloves aren’t necessary. 39. Answer: C Although postoperative pain is expected, the nurse should ensure that other factors, such as an obstructed irrigation catheter, aren’t the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic such as meperidine as prescribed. Increasing the I.V. flow rate may worse the pain. Notifying the doctor isn’t necessary unless the pain is severe or unrelieved by the prescribed medication. 40. Answer: A Renal calculi most commonly from in the kidney. They may remain there or become lodged anywhere along the urinary tract. The ureter, bladder, and urethra are less common sites of renal calculi formation. 41. Answer: A Ureterolithiasis typically causes such acute, severe pain that the patient can’t rest and becomes increasingly anxious. Therefore, the nursing diagnosis of pain takes highest priority. Risk for infection and altered urinary elimination are appropriate once the patient’s pain is controlled. Altered nutrition: less than body requirements isn’t appropriate at this time. 42. Answer: B Normal urine pH is 4.5 to 8; therefore, a urine pH of 3 is abnormal and may indicate such conditions as renal tuberculosis, pyrexia, phenylketonuria, alkaptonuria, and acidosis. Urine specific gravity normally ranges from 1.002 to 1.032, making the patient’s value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. 43. Answer: C The nephron is the kidney’s functioning unit. The glomerulus, Bowman’s capsule, and tubular system are components of the nephron. 44. Answer: A As a response to shock, the renin-angiotensin-aldosterone system alters renal function by decreasing

urine output and increasing reabsorption of sodium and water. Reduced renal perfusion stimulates the renin-angiotensin-aldosterone system in an effort to conserve circulating volume. 45. Answer: D The bladder isn’t usually palpable unless it is distended. The feeling of pressure is usually relieved with urination. Reduced bladder tone due to general anesthesia is a common postoperative complication that causes difficulty in voiding. A urinary tract infection and renal calculi aren’t palpable. The kidneys aren’t palpable above the symphysis pubis. 46. Answer: A A pericardial friction rub may be present with the pericardial effusion of pericarditis. The lungs are typically clear when auscultated. Sitting up and leaning forward often relieves pericarditis pain. An S3 indicates left-sided heart failure and isn’t usually present with pericarditis. 47. Answer: D Assessing jugular vein distention should be done when the patient is in semi-Fowler’s position (head of the bed elevated 30 to 45 degrees). If the patient lies flat, the veins will be more distended; if he sits upright, the veins will be flat. 48. Answer: C Smoking should receive highest priority when trying to reduce risk factors for with respiratory complications. Losing weight and decreasing salt and caffeine intake can help to decrease risk factors for hypertension. 49. Answer: B The correct ratio of compressions to ventilations when one rescuer performs CPR is 15:2 50. Answer: D The lungs and kidneys are the body’s regulators of homeostasis. The lungs are responsible for removing fluid and carbon dioxide; the kidneys maintain a balance of fluid and electrolytes. The other organs play secondary roles in maintaining homeostasis. 1.51.
1. A female client is admitted with a diagnosis of acute renal failure. She is awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature 100.4°F (38°C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance?

2.52.

A. Hyponatremia

B. Hyperkalemia C. Hyperphosphatemia D. Hypercalcemia

3.53.
in a

2. Assessing the laboratory findings, which result would the nurse most likely expect to find

client with chronic renal failure?

4.54.

A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl

B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased serum calcium

5.55.

3. Treatment with hemodialysis is ordered for a client and an external shunt is created.

Which nursing action would be of highest priority with regard to the external shunt?

6.56.

A. Heparinize it daily.

B. Avoid taking blood pressure measurements or blood samples from the affected arm. C. Change the Silastic tube daily. D. Instruct the client not to use the affected arm.

7.57.

4. Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic

hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching?

8.58.

A. TURP is the most common operation for BPH.

B. Explain the purpose and function of a two-way irrigation system. C. Expect bloody urine, which will clear as healing takes place. D. He will be pain free.

9.59.

5. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On physical

examination, the nurse should be looking for tenderness on palpation at McBurney‟s point, which is located in the

10.60.

A. left lower quadrant

B. left upper quadrant C. right lower quadrant D. right upper quadrant

11.61. 12.62.

6. Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge teaching A. telling him to avoid heavy lifting for 4 to 6 weeks

should include B. instructing him to have a soft bland diet for two weeks C. telling him to resume his previous daily activities without limitations D. recommending him to drink eight glasses of water daily

13.63.

7. A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe

burns of the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned?

14.64.
B. 22% C. 31% D. 40%

A. 18%

15.65. 16.66.

8. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are A. An increase in the total volume of intracranial plasma

characterized by: B. Excessive renal perfusion with diuresis C. Fluid shift from interstitial space D. Fluid shift from intravascular space to the interstitial space

17.67. 18.68.

9. If a client has severe bums on the upper torso, which item would be a primary concern? A. Debriding and covering the wounds

B. Administering antibiotics C. Frequently observing for hoarseness, stridor, and dyspnea D. Establishing a patent IV line for fluid replacement

19.69.

10. Contractures are among the most serious long-term complications of severe burns. If a

burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures?

20.70.

A. Changing the location of the bed or the TV set, or both, daily

B. Encouraging the client to chew gum and blow up balloons C. Avoiding the use of a pillow for sleep, or placing the head in a position of hyperextension D. Helping the client to rest in the position of maximal comfort

21.71. 22.72.

11. An adult is receiving Total Parenteral Nutrition (TPN). Which of the following assessment A. evaluation of the peripheral IV site

is essential? B. confirmation that the tube is in the stomach C. assess the bowel sound D. fluid and electrolyte monitoring

23.73. 24.74.

12. Which drug would be least effective in lowering a client‟s serum potassium level? A. Glucose and insulin

B. Polystyrene sulfonate (Kayexalate) C. Calcium glucomite D. Aluminum hydroxide

25.75. 26.76.
C. D5W

13. A nurse is directed to administer a hypotonic intravenous solution. Looking at the A. 0.45% NaCl

following labeled solutions, she should choose B. 0.9% NaCl D. D5NSS

27.77.
EXCEPT

14. A patient is hemorrhaging from multiple trauma sites. The nurse expects that

compensatory mechanisms associated with hypovolemia would cause all of the following symptoms

28.78.

A. hypertension

B. oliguria C. tachycardia D. tachypnea

29.79.

15. Maria Sison, 40 years old, single, was admitted to the hospital with a diagnosis of Breast

Cancer. She was scheduled for radical mastectomy. Nursing care during the preoperative period should consist of

30.80.

A. assuring Maria that she will be cured of cancer

B. assessing Maria’s expectations and doubts C. maintaining a cheerful and optimistic environment D. keeping Maria’s visitors to a minimum so she can have time for herself

31.81. 32.82.

16. Maria refuses to acknowledge that her breast was removed. She believes that her breast A. call the MD to change the dressing so Kathy can see the incision

is intact under the dressing. The nurse should B. recognize that Kathy is experiencing denial, a normal stage of the grieving process

C. reinforce Kathy’s belief for several days until her body can adjust to stress of surgery. D. remind Kathy that she needs to accept her diagnosis so that she can begin rehabilitation exercises.

33.83. 34.84.

17. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of A. it is a local treatment affecting only tumor cells

the ff. statements about chemotherapy is true? B. it affects both normal and tumor cells C. it has been proven as a complete cure for cancer D. it is often used as a palliative measure.

35.85. 36.86.

18. Which is an incorrect statement pertaining to the following procedures for cancer A. Biopsy is the removal of suspicious tissue and the only definitive method to diagnose cancer

diagnostics? B. Ultrasonography detects tissue density changes difficult to observe by X-ray via sound waves.

37.87. 38.88. tumor

C. CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of

D. Endoscopy provides direct view of a body cavity to detect abnormality. 39.89. 40.90.
19. A post-operative complication of mastectomy is lymphedema. This can be prevented by A. ensuring patency of wound drainage tube

B. placing the arm on the affected side in a dependent position C. restricting movement of the affected arm D. frequently elevating the arm of the affected side above the level of the heart.

41.91. 42.92.

20. Which statement by the client indicates to the nurse that the patient understands A. “I should get out of bed and walk around in my room.”

precautions necessary during internal radiation therapy for cancer of the cervix? B. “My 7 year old twins should not come to visit me while I’m receiving treatment.” C. “I will try not to cough, because the force might make me expel the application.” D. “I know that my primary nurse has to wear one of those badges like the people in the x-ray department, but they are not necessary for anyone else who comes in here.”

43.93. 44.94.

21. High uric acid levels may develop in clients who are receiving chemotherapy. This is A. The inability of the kidneys to excrete the drug metabolites

caused by: B. Rapid cell catabolism C. Toxic effect of the antibiotic that are given concurrently D. The altered blood ph from the acid medium of the drugs

45.95.
cervical

22. Which of the following interventions would be included in the care of plan in a client with

implant?

46.96.

A. Frequent ambulation

B. Unlimited visitors C. Low residue diet D. Vaginal irrigation every shift

47.97. 48.98.

23. Which nursing measure would avoid constriction on the affected arm immediately after A. Avoid BP measurement and constricting clothing on the affected arm

mastectomy? B. Active range of motion exercises of the arms once a day. C. Discourage feeding, washing or combing with the affected

49.99. 50.100. 51.101.

arm the affected arm in a dependent position, below the level of the heart
24. A client suffering from acute renal failure has an unexpected increase in urinary output

D. Place

to 150ml/hr. The nurse assesses that the client has entered the second phase of acute renal failure. Nursing actions throughout this phase include observation for signs and symptoms of

52.102.

A. Hypervolemia, hypokalemia, and hypernatremia.

B. Hypervolemia, hyperkalemia, and hypernatremia. C. Hypovolemia, wide fluctuations in serum sodium and potassium levels. D. Hypovolemia, no fluctuation in serum sodium and potassium levels.

53.103.

25. An adult has just been brought in by ambulance after a motor vehicle accident. When

assessing the client, the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation?

54.104.

A. A rapid pulse and increased RR

B. Decreased physiologic functioning C. Rigid posture and altered perceptual focus D. Increased awareness and attention

55.105. 56.106.

26. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced A. placing her in a trendeleburg position

with a graft. When she arrives in the RR she is still in shock. The nurse‟s priority should be B. putting several warm blankets on her C. monitoring her hourly urine output D. assessing her VS especially her RR

57.107. 58.108.

27. A major goal for the client during the first 48 hours after a severe bum is to prevent A. Elevated hematocrit levels.

hypovolemic shock. The best indicator of adequate fluid balance during this period is B. Urine output of 30 to 50 ml/hr. C. Change in level of consciousness. D. Estimate of fluid loss through the burn eschar.

59.109.

28. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood

and fluids is administered intravenously (IV), but the client‟s vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following?

60.110.

A. Spontaneous pneumothorax

B. Ruptured diaphragm C. Hemothorax D. Pericardial tamponade

61.111.
except

29. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following A. administering an irritant that will stimulate vomiting

62.112.

B. aspirating secretions from the pharynx if respirations are affected C. neutralizing the chemical D. washing the esophagus with large volumes of water via gastric lavage

63.113. 64.114.

30. Which initial nursing assessment finding would best indicate that a client has been A. Skin warm and dry

successfully resuscitated after a cardio-respiratory arrest? B. Pupils equal and react to light C. Palpable carotid pulse D. Positive Babinski’s reflex

65.115. 66.116.

31. Chemical burn of the eye are treated with A. local anesthetics and antibacterial drops for 24 – 36 hrs.

B. hot compresses applied at 15-minute intervals C. Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water D. cleansing the conjunctiva with a small cotton-tipped applicator

67.117. 68.118.

32. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to: A. Force air out of the lungs

B. Increase systemic circulation C. Induce emptying of the stomach D. Put pressure on the apex of the heart

69.119. 70.120.
freely

33. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced A. ask them to stay in the waiting area until she can spend time alone with them

dead on arrival. When his parents arrive at the hospital, the nurse should: B. speak to both parents together and encourage them to support each other and express their emotions C. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other D. ask the MD to medicate the parents so they can stay calm to deal with their son’s death.

71.121. 72.122.

34. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given A. increase BP

hypodermically. This is given to: B. decrease mucosal swelling C. relax the bronchial smooth muscle D. decrease bronchial secretions

73.123. 74.124.

35. A nurse is performing CPR on an adult patient. When performing chest compressions, A. upper half of the sternum

the nurse understands the correct hand placement is located over the B. upper third of the sternum C. lower half of the sternum D. lower third of the sternum

75.125.
is:

36. The nurse is performing an eye examination on an elderly client. The client states „My

vision is blurred, and I don‟t easily see clearly when I get into a dark room.” The nurse best response

76.126.

A. “You should be grateful you are not blind.”

B. “As one ages, visual changes are noted as part of degenerative changes. This is normal.” C. “You should rest your eyes frequently.” D. “You maybe able to improve you vision if you move slowly.”

77.127. 78.128.

37. Which of the following activities is not encouraged in a patient after an eye surgery? A. sneezing, coughing and blowing the nose

B. straining to have a bowel movement C. wearing tight shirt collars D. sexual intercourse

79.129.
client?

38. Which of the following indicates poor practice in communicating with a hearing-impaired A. Use appropriate hand motions

80.130.

B. Keep hands and other objects away from your mouth when talking to the client C. Speak clearly in a loud voice or shout to be heard D. Converse in a quiet room with minimal distractions

81.131. 82.132.

39. A client is to undergo lumbar puncture. Which is least important information about LP? A. Specimens obtained should be labeled in their proper sequence.

B. It may be used to inject air, dye or drugs into the spinal canal. C. Assess movements and sensation in the lower extremities after the D. Force fluids before and after the procedure.

83.133. 84.134.

40. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. A. Inform the client that a warm, flushed feeling and a salty taste may be

Nursing care of the client includes the following EXCEPT B. Maintain pressure dressing over the site of puncture and check for C. Check pulse, color and temperature of the extremity distal to the site of D. Kept the extremity used as puncture site flexed to prevent bleeding.

85.135. 86.136.

41. Which is considered as the earliest sign of increased ICP that the nurse should closely A. abnormal respiratory pattern

observed for? B. rising systolic and widening pulse pressure C. contralateral hemiparesis and ipsilateral dilation of the pupils D. progression from restlessness to confusion and disorientation to lethargy

87.137. 88.138.

42. Which is irrelevant in the pharmacologic management of a client with CVA? A. Osmotic diuretics and corticosteroids are given to decrease cerebral edema

B. Anticonvulsants are given to prevent seizures C. Thrombolytics are most useful within three hours of an occlusive CVA D. Aspirin is used in the acute management of a completed stroke.

89.139.

43. What would be the MOST therapeutic nursing action when a client‟s expressive aphasia

is severe?

90.140.

A. Anticipate the client wishes so she will not need to talk

B. Communicate by means of questions that can be answered by the client shaking the head C. Keep us a steady flow rank to minimize silence D. Encourage the client to speak at every possible opportunity.

91.141. 92.142.

44. A client with head injury is confused, drowsy and has unequal pupils. Which of the A. altered level of cognitive function

following nursing diagnosis is most important at this time? B. high risk for injury C. altered cerebral tissue perfusion D. sensory perceptual alteration

93.143. 94.144.

45. Which nursing diagnosis is of the highest priority when caring for a client with A. Pain

myasthenia gravis? B. High risk for injury related to muscle weakness C. Ineffective coping related to illness D. Ineffective airway clearance related to muscle weakness

95.145. 96.146.

46. The client has clear drainage from the nose and ears after a head injury. How can the A. Measure the ph of the fluid

nurse determine if the drainage is CSF? B. Measure the specific gravity of the fluid C. Test for glucose D. Test for chlorides

97.147. 98.148.

47. The nurse includes the important measures for stump care in the teaching plan for a A. Wash, dry, and inspect the stump daily.

client with an amputation. Which measure would be excluded from the teaching plan? B. Treat superficial abrasions and blisters promptly. C. Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. D. Toughen the stump by pushing it against a progressively harder substance (e.g., pillow on a foot-stool).

99.149.

48. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall

and weighs 180 pounds. Her major complaint is pain in her joints. She is retired and has had to give up her volunteer work because of her discomfort. She was told her diagnosis was osteoarthritis about 5 years ago. Which would be excluded from the clinical pathway for this client?

100.150.

A. Decrease the calorie count of her daily diet.

B. Take warm baths when arising. C. Slide items across the floor rather than lift them.

101.151. 102.152. 103.153.

D. Place items so that it is necessary to bend or stretch to reach them.
49. A client is admitted from the emergency department with severe-pain and edema in the

right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have the highest priority?

104.154.

A. Apply hot compresses to the affected joints.

B. Stress the importance of maintaining good posture to prevent deformities.

C. Administer salicylates to minimize the inflammatory reaction. D. Ensure an intake of at least 3000 ml of fluid per day.

105.155. 106.156.
legs.

50. A client had a laminectomy and spinal fusion yesterday. Which statement is to be A. Before log rolling, place a pillow under the client’s head and a pillow between the client’s legs.

excluded from your plan of care? B. Before log rolling, remove the pillow from under the client’s head and use no pillows between the client’s C. Keep the knees slightly flexed while the client is lying in a semi-Fowler’s position in bed. D. Keep a pillow under the client’s head as needed for comfort.

107.157.

1.

Answer: (A) Hyponatremia

The normal serum sodium level is 135 – 145 mEq/L. The client’s serum sodium is below normal. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting

108.158.

2.

Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L

Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate, potassium and hydrogen ions are retained.

109.159.

3.

Answer: (B) Avoid taking blood pressure measurements or blood samples from the

affected arm. In the client with an external shunt, don’t use the arm with the vascular access site to take blood pressure readings, draw blood, insert IV lines, or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt.

110.160.

4.

Answer: (D) He will be pain free.

Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance.

111.161.

5.

Answer: (C) right lower quadrant

To be exact, the appendix is anatomically located at the Mc Burney’s point at the right iliac area of the right lower quadrant.

112.162.

6.

Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks

The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. There is no special diet required. The fluid intake of eight glasses a day is good advice but is not a priority in this case.

113.163.

7.

Answer: (C) 31%

Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9% – head; 9% – each upper extremity; 18%- front chest and abdomen; 18% – entire back; 18% – each lower extremity and 1% – perineum.

114.164.

8.

Answer: (D) Fluid shift from intravascular space to the interstitial space

This period is the burn shock stage or the hypovolemic phase. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output.

115.165.

9.

Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea

Burns located in the upper torso, especially resulting from thermal injury related to fires can lead to

inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a patent airway is a primary concern.

116.166.

10. Answer: (D) Helping the client to rest in the position of maximal comfort

Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort. But this approach can lead to contracture deformities and other complications.

117.167.

11. Answer: (D) fluid and electrolyte monitoring

Total parenteral nutrition is a method of providing nutrients to the body by an IV route. The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and sterile water based on individual client needs. It is intended to improve the clients nutritional status. Because of its composition, it is important to monitor the clients fluid intake and output including electrolytes, blood glucose and weight.

118.168.

12. Answer: (D) Aluminum hydroxide

Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. All the other medications mentioned help treat hyperkalemia and its effects.

119.169.

13. Answer: (A) 0.45% NaCl

Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and D5W are isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic with a higher tonicity thab the blood.

120.170.

14. Answer: (A) hypertension

In hypovolemia, one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria.

121.171.

15. Answer: (B) assessing Maria‟s expectations and doubts

Assessing the client’s expectations and doubts will help lessen her fears and anxieties. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed.

122.172.
process

16. Answer: (B) recognize that Kathy is experiencing denial, a normal stage of the grieving

A person grieves to a loss of a significant object. The initial stage in the grieving process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patient’s feelings and encourage verbalization.

123.173.

17. Answer: (B) it affects both normal and tumor cells

Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow, thus the effect of bone marrow depression.

124.174.

18. Answer: (C) CTscanning uses magnetic fields and radio frequencies to provide cross-

sectional view of tumor CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic fields and radio frequencies to detect tumors.

125.175.
heart.

19. Answer: (D) frequently elevating the arm of the affected side above the level of the

Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling.

126.176.

20. Answer: (B) “My 7 year old twins should not come to visit me while I‟m receiving

treatment.” Children have cells that are normally actively dividing in the process of growth. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself.

127.177.

21. Answer: (B) Rapid cell catabolism

One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction of large number of tumor cells. . Intracellular contents are released, including potassium and purines, into the bloodstream faster than the body can eliminate them. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. They can precipitate in the kidneys and block the tubules causing acute renal failure.

128.178.

22. Answer: (C) Low residue diet

It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions

129.179.

23. Answer: (A) Avoid BP measurement and constricting clothing on the affected arm

A BP cuff constricts the blood vessels where it is applied. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm

130.180.

24. Answer: (C) Hypovolemia, wide fluctuations in serum sodium and potassium levels.

The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur.

131.181.

25. Answer: (A) A rapid pulse and increased RR

The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for survival.

132.182.

26. Answer: (D) assessing her VS especially her RR

Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications.

133.183.

27. Answer: (B) Urine output of 30 to 50 ml/hr.

Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue perfusion to the different organs of the body. Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Normal renal perfusion should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance.

134.184.

28. Answer: (D) Pericardial tamponade

Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal.

135.185.

29. Answer: (A) administering an irritant that will stimulate vomiting

Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its absorption. For corrosive

poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric lavage and the administration of activated charcoal to absorb the poison. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is swallowed.

136.186.

30. Answer: (C) Palpable carotid pulse

Presence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of CPR. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be noted after.

137.187.
water

31. Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or preferably sterile

Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done.

138.188.

32. Answer: (A) Force air out of the lungs

The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material.

139.189.

33. Answer: (B) speak to both parents together and encourage them to support each other

and express their emotions freely Sudden death of a family member creates a state of shock on the family. They go into a stage of denial and anger in their grieving. Assisting them with information they need to know, answering their questions and listening to them will provide the needed support for them to move on and be of support to one another.

140.190.

34. Answer: (C) relax the bronchial smooth muscle

Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles.

141.191.

35. Answer: (C) lower half of the sternum

The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration.

142.192.

36. Answer: (B) “As one ages, visual changes are noted as part of degenerative changes.

This is normal.” Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision.

143.193.

37. Answer: (D) sexual intercourse

To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP.

144.194.

38. Answer: (C) Speak clearly in a loud voice or shout to be heard

Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. It is enough for the nurse to speak clearly and slowly.

145.195.

39. Answer: (D) Force fluids before and after the procedure.

LP involves the removal of some amount of spinal fluid. To facilitate CSF production, the client is instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after the procedure.

146.196.

40. Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding.

Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the procedure. Ice bag can be applied intermittently to the puncture site.

147.197.

41. Answer: (D) progression from restlessness to confusion and disorientation to lethargy

The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. This is initially manifested by restlessness.

148.198.

42. Answer: (D) Aspirin is used in the acute management of a completed stroke.

The primary goal in the management of CVA is to improve cerebral tissue perfusion. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but is not used in the acute management of a completed stroke as it may lead to bleeding.

149.199.

43. Answer: (D) Encourage the client to speak at every possible opportunity.

Expressive or motor aphasia is a result of damage in the Broca’s area of the frontal lobe. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively.

150.200.

44. Answer: (C) altered cerebral tissue perfusion

The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage.

151.201.

45. Answer: (D) Ineffective airway clearance related to muscle weakness

Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. This leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation.

152.202.

46. Answer: (C) Test for glucose

The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result with the drainage indicate CSF leakage.

153.203.

47. Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal end of

the affected limb. The “shrinker” bandage is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow.

154.204.

48. Answer: (D) Place items so that it is necessary to bend or stretch to reach them.

Patients with osteoarthritis have decreased mobility caused by joint pain. Over-reaching and stretching to get an object are to be avoided as this can cause more pain and can even lead to falls. The nurse should see to it therefore that objects are within easy reach of the patient.

155.205.

49. Answer: (D) Ensure an intake of at least 3000 ml of fluid per day.

Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones.

156.206.

50. Answer: (B) Before log rolling, remove the pillow from under the client‟s head and use

no pillows between the client‟s legs. Following a laminectomy and spinal fusion, it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing.

157.207. 158.208.

1. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. A. providing emotional support to decrease fear

The nurse would incorporate which of the ff. as a priority in the plan of care? B. protecting the client from infection C. encouraging discussion about lifestyle changes D. identifying factors that decreased the immune function

159.209. 160.210.

2. Joy, an obese 32 year old, is admitted to the hospital after an automobile accident. She

has a fractured hip and is brought to the OR for surgery.

After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin)

300 mg in 50 ml of D5W. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the piggyback to flow at: 161.211.
A. 25 gtt/min B. 30 gtt/min C. 35 gtt/min D. 45 gtt/min

162.212. 163.213.

3. The day after her surgery Joy asks the nurse how she might lose weight. Before A. Fats are controlled in the diet

answering her question, the nurse should bear in mind that long-term weight loss best occurs when: B. Eating habits are altered C. Carbohydrates are regulated D. Exercise is part of the program

164.214.

4. The nurse teaches Joy, an obese client, the value of aerobic exercises in her weight

reduction program. The nurse would know that this teaching was effective when Joy says that exercise will:

165.215.

A. Increase her lean body mass

B. Lower her metabolic rate C. Decrease her appetite D. Raise her heart rate

166.216.

5. The physician orders non-weight bearing with crutches for Joy, who had surgery for a

fractured hip. The most important activity to facilitate walking with crutches before ambulation begun is:

167.217.

A. Exercising the triceps, finger flexors, and elbow extensors

B. Sitting up at the edge of the bed to help strengthen back muscles C. Doing isometric exercises on the unaffected leg D. Using the trapeze frequently for pull-ups to strengthen the biceps muscles

168.218. 169.219.

6. The nurse recognizes that a client understood the demonstration of crutch walking when A. The palms and axillary regions

she places her weight on: B. Both feet placed wide apart C. The palms of her hands D. Her axillary regions

170.220.

7. Joey is a 46 year-old radio technician who is admitted because of mild chest pain. He is 5

feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed.

171.221. 172.222.

The physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is
A. 8 minims

labeled 1 ml/ 10 mg. The nurse should administer:
B. 10 minims C. 12 minims D. 15 minims

173.223. 174.224.

8. Joey asks the nurse why he is receiving the injection of Morphine after he was A. Will help prevent erratic heart beats

hospitalized for severe anginal pain. The nurse replies that it: B. Relieves pain and decreases level of anxiety C. Decreases anxiety D. Dilates coronary blood vessels

175.225.
9. Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. The nurse institutes safety precautions in the room because oxygen:

176.226.

A. Converts to an alternate form of matter

B. Has unstable properties C. Supports combustion D. Is flammable

177.227. 178.228.
B. LDH

10. Myra is ordered laboratory tests after she is admitted to the hospital for angina. The A. SGPT

isoenzyme test that is the most reliable early indicator of myocardial insult is:

C. CK-MB D. AST

179.229. 180.230. 181.231. 182.232.

11. An early finding in the EKG of a client with an infarcted mycardium would be: A. Disappearance of Q waves

B. Elevated ST segments

C. Absence of P wave D. Flattened T waves 183.233.
12. Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to:

184.234.

A. Allow him to release his feelings and then leave him alone to allow him to regain his composure

B. Refocus the conversation on his fears, frustrations and anger about his condition C. Explain how his being upset dangerously disturbs his need for rest D. Attempt to explain the purpose of different hospital routines

185.235. 186.236.

13. Twenty four hours after admission for an Acute MI, Jose‟s temperature is noted at 39.3 A. Shortness of breath

C. The nurse monitors him for other adaptations related to the pyrexia, including: B. Chest pain C. Elevated blood pressure D. Increased pulse rate

187.237.

14. Jose, who is admitted to the hospital for chest pain, asks the nurse, “Is it still possible

for me to have another heart attack if I watch my diet religiously and avoid stress?” The most appropriate initial response would be for the nurse to:

188.238.

A. Suggest he discuss his feelings of vulnerability with his physician.

B. Tell him that he certainly needs to be especially careful about his diet and lifestyle. C. Avoid giving him direct information and help him explore his feelings D. Recognize that he is frightened and suggest he talk with the psychiatrist or counselor.

189.239.

15. Ana, 55 years old, is admitted to the hospital to rule out pernicious anemia. A Schilling

test is ordered for Ana. The nurse recognizes that the primary purpose of the Schilling test is to determine the client‟s ability to:

190.240.

A. Store vitamin B12

B. Digest vitamin B12 C. Absorb vitamin B12 D. Produce vitamin B12

191.241.

16. Ana is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of

Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer:

192.242.
B. 1.0 ml

A. 0.5 ml

C. 1.5 ml D. 2.0 ml

193.243. 194.244.

17. Health teachings to be given to a client with Pernicious Anemia regarding her A. Oral tablets of Vitamin B12 will control her symptoms

therapeutic regimen concerning Vit. B12 will include: B. IM injections are required for daily control C. IM injections once a month will maintain control D. Weekly Z-track injections provide needed control

195.245. 196.246.

18. The nurse knows that a client with Pernicious Anemia understands the teaching A. When she feels fatigued

regarding the vitamin B12 injections when she states that she must take it: B. During exacerbations of anemia C. Until her symptoms subside D. For the rest of her life

197.247.

19. Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and

colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as:

198.248.

A. Reaction Formation

B. Sublimation C. Intellectualization D. Projection

199.249. 200.250.

20. When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse A. When the client would have normally had a bowel movement

should plan to perform the procedure: B. After the client accepts he had a bowel movement C. Before breakfast and morning care D. At least 2 hours before visitors arrive

201.251. 202.252.

21. When observing an ostomate do a return demonstration of the colostomy irrigation, the A. Stops the flow of fluid when he feels uncomfortable

nurse notes that he needs more teaching if he: B. Lubricates the tip of the catheter before inserting it into the stoma C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion D. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled

203.253. 204.254.

22. When doing colostomy irrigation at home, a client with colostomy should be instructed A. Abdominal cramps during fluid inflow

to report to his physician : B. Difficulty in inserting the irrigating tube C. Passage of flatus during expulsion of feces D. Inability to complete the procedure in half an hour

205.255.

23. A client with colostomy refuses to allow his wife to see the incision or stoma and

ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:

206.256.

A. A reaction formation to his recent altered body image.

B. A difficult time accepting reality and is in a state of denial. C. Impotency due to the surgery and needs sexual counseling D. Suicide thoughts and should be seen by psychiatrist

207.257. 208.258.

24. The nurse would know that dietary teaching had been effective for a client with A. Food low in fiber so that there is less stool

colostomy when he states that he will eat: B. Everything he ate before the operation but will avoid those foods that cause gas C. Bland foods so that his intestines do not become irritated D. Soft foods that are more easily digested and absorbed by the large intestines

209.259.

25. Eddie, 40 years old, is brought to the emergency room after the crash of his private

plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated.

210.260. 211.261.

When Eddie arrives in the emergency room, the assessment that assume the
A. Level of consciousness and pupil size

greatest priority are:
B. Abdominal contusions and other wounds C. Pain, Respiratory rate and blood pressure D. Quality of respirations and presence of pulsesQuality of respirations and presence of pulses

212.262. 213.263.

26. Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure A. Facilitate his verbal communication

ventilation. The most immediate nursing intervention for him at this time would be to: B. Maintain sterility of the ventilation system C. Assess his response to the equipment D. Prepare him for emergency surgery

214.264.

27. A chest tube with water seal drainage is inserted to a client following a multiple chest

injury. A few hours later, the client‟s chest tube seems to be obstructed. The most appropriate nursing action would be to

215.265.

A. Prepare for chest tube removal

B. Milk the tube toward the collection container as ordered C. Arrange for a stat Chest x-ray film. D. Clam the tube immediately

216.266. 217.267.

28. The observation that indicates a desired response to thoracostomy drainage of a client A. Increased breath sounds

with chest injury is: B. Constant bubbling in the drainage chamber C. Crepitus detected on palpation of chest D. Increased respiratory rate

218.268. 219.269.

29. In the evaluation of a client‟s response to fluid replacement therapy, the observation that A. Urinary output is 30 ml in an hour

indicates adequate tissue perfusion to vital organs is: B. Central venous pressure reading of 2 cm H2O C. Pulse rates of 120 and 110 in a 15 minute period D. Blood pressure readings of 50/30 and 70/40 within 30 minutes

220.270.

30. A client with multiple injury following a vehicular accident is transferred to the critical

care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the:

221.271.

A. Complete safety of the procedure

B. Expectation of postoperative bleeding C. Risk of the procedure with his other injuries D. Presence of abdominal drains for several days after surgery

222.272. 223.273.

31. To promote continued improvement in the respiratory status of a client following chest A. Encourage bed rest with active and passive range of motion exercises

tube removal after a chest surgery for multiple rib fracture, the nurse should: B. Encourage frequent coughing and deep breathing

C. Turn him from side to side at least every 2 hours D. Continue observing for dyspnea and crepitus

224.274.

32. A client undergoes below the knee amputation following a vehicular accident. Three

days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to:

225.275.

A. Give him explanations of why there is a need to quickly increase his activity

B. Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle C. Appear cheerful and non-critical regardless of his response to attempts at intervention D. Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving

226.276. 227.277.

33. The key factor in accurately assessing how body image changes will be dealt with by the A. Extent of body change present

client is the: B. Suddenness of the change C. Obviousness of the change D. Client’s perception of the change

228.278.

34. Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for

chemotherapy. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that Larry is using the defense mechanism known as:

229.279.

A. Reaction formation

B. Sublimation C. Intellectualization D. Projection

230.280. 231.281.

35. The laboratory results of the client with leukemia indicate bone marrow depression. The A. Increase his activity level and ambulate frequently

nurse should encourage the client to: B. Sleep with the head of his bed slightly elevated C. Drink citrus juices frequently for nourishment D. Use a soft toothbrush and electric razor

232.282. 233.283.

36. Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. A. An anaphylactic transfusion reaction

The nurse recognizes that Dennis is probably experiencing: B. An allergic transfusion reaction C. A hemolytic transfusion reaction D. A pyrogenic transfusion reaction

234.284. 235.285.

37. A client jokes about his leukemia even though he is becoming sicker and weaker. The A. “Your laugher is a cover for your fear.”

nurse‟s most therapeutic response would be: B. “He who laughs on the outside, cries on the inside.” C. “Why are you always laughing?” D. “Does it help you to joke about your illness?”

236.286.

38. In dealing with a dying client who is in the denial stage of grief, the best nursing

approach is to:

237.287.

A. Agree with and encourage the client’s denial

B. Reassure the client that everything will be okay C. Allow the denial but be available to discuss death D. Leave the client alone to discuss the loss

238.288. 239.289.

39. During and 8 hour shift, Mario drinks two 6 oz. cups of tea and vomits 125 ml of fluid. A. +55 ml

During this 8 hour period, his fluid balance would be: B. +137 ml C. +235 ml D. +485 ml

240.290. 241.291.

40. Mr. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. In the A. Crushing chest pain

assessment, the nurse should expect to find: B. Dyspnea on exertion C. Extensive peripheral edema D. Jugular vein distention

242.292. 243.293.

41. The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and A. Distal tubule

furosemide (Lasix). The nurse understands Lasix exerts is effects in the: B. Collecting duct C. Glomerulus of the nephron D. Ascending limb of the loop of Henle

244.294. 245.295.
B. 1.0 L C. 2.0 L D. 3.5 L

42. Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he A. 0.5 L

weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:

246.296.

43. Mr. Ong, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a

vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes that his pulse rate is most likely the result of the:

247.297.

A. Diuretic

B. Vasodilator C. Bed-rest regimen D. Cardiac glycoside

248.298. 249.299.

44. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g A. 2200 calories

of fat and 100 g of protein. The nurse understands that this diet contains approximately: B. 2000 calories C. 2800 calories D. 1600 calories

250.300.

45. After the acute phase of congestive heart failure, the nurse should expect the dietary

management of the client to include the restriction of:

251.301.

A. Magnesium

B. Sodium C. Potassium D. Calcium

252.302. 253.303.

46. Jude develops GI bleeding and is admitted to the hospital. An important etiologic clue A. The medications he has been taking

for the nurse to explore while taking his history would be: B. Any recent foreign travel C. His usual dietary pattern D. His working patterns

254.304. 255.305.

47. The meal pattern that would probably be most appropriate for a client recovering from GI A. Three large meals large enough to supply adequate energy.

bleeding is: B. Regular meals and snacks to limit gastric discomfort C. Limited food and fluid intake when he has pain D. A flexible plan according to his appetite

256.306.

48. A client with a history of recurrent GI bleeding is admitted to the hospital for a

gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by:

257.307.

A. Increasing HCO3

B. Decreasing PCO2 C. Decreasing pH D. Decreasing PO2

258.308.

49. Routine postoperative IV fluids are designed to supply hydration and electrolyte and

only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately:

259.309.

A. 400 Kilocalories

B. 600 Kilocalories C. 800 Kilocalories D. 1000 Kilocalories

260.310. 261.311.

50. Thrombus formation is a danger for all postoperative clients. The nurse should act A. Encouraging adequate fluids

independently to prevent this complication by: B. Applying elastic stockings C. Massaging gently the legs with lotion D. Performing active-assistive leg exercises

262.312.

51. An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is

inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by:

263.313.

A. Emptying the drainage bag frequently

B. Collecting a weekly urine specimen

C. Maintaining the ordered hydration D. Assessing urine specific gravity

264.314. 265.315.

52. The nurse performs full range of motion on a bedridden client‟s extremities. When A. Flexion, extension and left and right rotation

putting his ankle through range of motion, the nurse must perform: B. Abduction, flexion, adduction and extension C. Pronation, supination, rotation, and extension D. Dorsiflexion, plantar flexion, eversion and inversion

266.316. 267.317.

53. A client has been in a coma for 2 months. The nurse understands that to prevent the A. 30 degrees

effects of shearing force on the skin, the head of the bed should be at an angle of: B. 45 degrees C. 60 degrees D. 90 degrees

268.318.
surgery:

54. Rene, age 62, is scheduled for a TURP after being diagnosed with a Benign Prostatic

Hyperplasia (BPH). As part of the preoperative teaching, the nurse should tell the client that after

269.319.

A. Urinary control may be permanently lost to some degree

B. Urinary drainage will be dependent on a urethral catheter for 24 hours C. Frequency and burning on urination will last while the cystotomy tube is in place D. His ability to perform sexually will be permanently impaired

270.320.
55. The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care should include:

271.321.

A. Changing the abdominal dressing

B. Maintaining patency of the cystotomy tube C. Maintaining patency of a three-way Foley catheter for cystoclysis D. Observing for hemorrhage and wound infection

272.322. 273.323.

56. In the early postoperative period following a transurethral surgery, the most common A. Sepsis

complication the nurse should observe for is: B. Hemorrhage C. Leakage around the catheter D. Urinary retention with overflow

274.324. 275.325.

57. Following prostate surgery, the retention catheter is secured to the client‟s leg causing A. Limit discomfort

slight traction of the inflatable balloon against the prostatic fossa. This is done to: B. Provide hemostasis C. Reduce bladder spasms D. Promote urinary drainage

276.326.
be to:

58. Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal

discomfort. The nurse notes that the catheter drainage has stopped. The nurse‟s initial action should

277.327.

A. Irrigate the catheter with saline

B. Milk the catheter tubing C. Remove the catheter D. Notify the physician

278.328. 279.329.

59. The nurse would know that a post-TURP client understood his discharge teaching when A. Get out of bed into a chair for several hours daily

he says “I should:” B. Call the physician if my urinary stream decreases C. Attempt to void every 3 hours when I’m awake D. Avoid vigorous exercise for 6 months after surgery

280.330. 281.331.

60. Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with A. Lethargy, weight gain, and forgetfulness

Grave‟s Disease. When assessing Lucy, the nurse would expect to find: B. Weight loss, protruding eyeballs, and lethargy C. Weight loss, exopthalmos and restlessness D. Constipation, dry skin, and weight gain

282.332. 283.333.

61. Lucy undergoes Subtotal Thyroidectomy for Grave‟s Disease. In planning for the client‟s A. The entire thyroid gland is removed

return from the OR, the nurse would consider that in a subtotal thyroidectomy: B. A small part of the gland is left intact C. One parathyroid gland is also removed D. A portion of the thyroid and four parathyroids are removed

284.334. 285.335.

62. Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to A. A crash cart with bed board

set up emergency equipment, which should include: B. A tracheostomy set and oxygen C. An airway and rebreathing mask D. Two ampules of sodium bicarbonate

286.336. 287.337.

63. When a post-thyroidectomy client returns from surgery the nurse assesses her for A. Observing for signs of tetany

unilateral injury of the laryngeal nerve every 30 to 60 minutes by: B. Checking her throat for swelling C. Asking her to state her name out loud D. Palpating the side of her neck for blood seepage

288.338.

64. On a post-thyroidectomy client‟s discharge, the nurse teaches her to observe for signs

of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops:

289.339.

A. Intolerance to heat

B. Dry skin and fatigue C. Progressive weight loss D. Insomnia and excitability

290.340.

65. A client‟s exopthalmos continues inspite of thyroidectomy for Grave‟s Disease. The

nurse teaches her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client understands the teaching when she says: “I should:

291.341.

A. Elevate the head of my bed at night

B. Avoid moving my extra-ocular muscles C. Avoid using a sleeping mask at night D. Avoid excessive blinking

292.342.

66. Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness

burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious.

293.343. 294.344.
B. 9% C. 18 %

Performing an immediate appraisal, using the rule of nines, the nurse estimates
A. 4.5%

the percent of Clara‟s body surface that is burned is:

D. 22.5%

295.345.

67. The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and

third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will:

296.346.

A. Inhibit bacterial growth

B. Relieve pain from the burn C. Prevent scar tissue formation D. Provide chemical debridement

297.347.
provide:

68. Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid

to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to

298.348.

A. 18 gtt/min

B. 28 gtt/min C. 32 gtt/min D. 36 gtt/min

299.349. 300.350.

69. Clara, a burn client, receives a temporary heterograft (pig skin) on some of her burns. A. Debride necrotic epithelium

These grafts will: B. Be sutured in place for better adherence C. Relieve pain and promote rapid epithelialization D. Frequently be used concurrently with topical antimicrobials.

301.351. 302.352.

70. A client with burns on the chest has periodic episodes of dyspnea. The position that A. Semi-fowler’s position

would provide for the greatest respiratory capacity would be the: B. Sims’ position C. Orthopneic position D. Supine position

303.353.

71. Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis

of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:

304.354.

A. Brief exaggeration of symptoms

B. Prolonged symptomatic improvement C. Rapid but brief symptomatic improvement D. Symptomatic improvement of just the ptosis

305.355. 306.356.

72. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase A. Develop a teaching plan

of her hospitalization would be to: B. Facilitate psychologic adjustment C. Maintain the present muscle strength D. Prepare for the appearance of myasthenic crisis

307.357. 308.358.

73. The most significant initial nursing observations that need to be made about a client A. Ability to chew and speak distinctly

with myasthenia include: B. Degree of anxiety about her diagnosis C. Ability to smile an to close her eyelids D. Respiratory exchange and ability to swallow

309.359.

74. Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon)

therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse‟s priority intervention is to:

310.360.

A. Administer the medication exactly on time

B. Administer the medication with food or mild C. Evaluate the client’s muscle strength hourly after medication D. Evaluate the client’s emotional side effects between doses

311.361.
to:

75. Helen, a client with myasthenia gravis, begins to experience increased difficulty in

swallowing. To prevent aspiration of food, the nursing action that would be most effective would be

312.362.

A. Change her diet order from soft foods to clear liquids

313.363. 314.364.

B. Place an emergency tracheostomy set in her room

C. Assess her respiratory status before and after meals D. Coordinate her meal schedule with the peak effect of her medication, Mestinon 315.365. View the questions of NCLEX Practice Test for Medical Surgical Nursing 3. 316.366.
1. Answer: (B) protecting the client from infection Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection.

317.367.

2.

Answer: (A) 25 gtt/min

To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20)

318.368.

3.

Answer: (B) Eating habits are altered

For weight reduction to occur and be maintained, a new dietary program, with a balance of foods from the basic four food groups, must be established and continued

319.369. 320.370.

4. 5.

Answer: (A) Increase her lean body mass Answer: (A) Exercising the triceps, finger flexors, and elbow extensors

Increased exercise builds skeletal muscle mass and reduces excess fatty tissue. These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation.

321.371. 322.372.

6. 7.

Answer: (C) The palms of her hands Answer: (C) 12 minims

The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus) Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate

323.373.

8.

Answer: (B) Relieves pain and decreases level of anxiety

Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand.

324.374.

9.

Answer: (C) Supports combustion

The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use.

325.375.

10. Answer: (C) CK-MB

The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage.

326.376.

11. Answer: (B) Elevated STsegments

This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI.

327.377.

12. Answer: (B) Refocus the conversation on his fears, frustrations and anger about his

condition This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.

328.378.

13. Answer: (D) Increased pulse rate

Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.

329.379.

14. Answer: (C) Avoid giving him direct information and help him explore his feelings

To help the patient verbalize and explore his feelings, the nurse must reflect and analyze the feelings that

are implied in the client’s question. The focus should be on collecting data to minister to the client’s psychosocial needs.

330.380.

15. Answer: (C) Absorb vitamin B12

Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine.

331.381.

16. Answer: (D) 2.0 ml

First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.

332.382.

17. Answer: (C) IM injections once a month will maintain control

Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow

333.383.

18. Answer: (D) For the rest of her life

Since the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client’s life.

334.384.

19. Answer: (D) Projection

Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.

335.385.

20. Answer: (A) When the client would have normally had a bowel movement

Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.

336.386.

21. Answer: (C) Hangs the bag on a clothes hook on the bathroom door during fluid

insertion The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.

337.387.

22. Answer: (B) Difficulty in inserting the irrigating tube

Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.

338.388.

23. Answer: (B) A difficult time accepting reality and is in a state of denial.

As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported

339.389.

24. Answer: (B) Everything he ate before the operation but will avoid those foods that

cause gas There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.

340.390.

25. Answer: (D) Quality of respirations and presence of pulsesQuality of respirations and

presence of pulses Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished

341.391.

26. Answer: (C) Assess his response to the equipment

It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding

342.392.

27. Answer: (B) Milk the tube toward the collection container as ordered

This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber

343.393.

28. Answer: (A) Increased breath sounds

The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function

344.394. 345.395.

29. Answer: (A) Urinary output is 30 ml in an hour 30. Answer: (D) Presence of abdominal drains for several days after surgery

A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain. Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.

346.396.

31. Answer: (B) Encourage frequent coughing and deep breathing

This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.

347.397.

32. Answer: (D) Accept and acknowledge that his withdrawal is an initially normal and

necessary part of grieving The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention.

348.398.

33. Answer: (D) Client‟s perception of the change

It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings.

349.399.

34. Answer: (C) Intellectualization

People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.

350.400.

35. Answer: (D) Use a soft toothbrush and electric razor

Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.

351.401.

36. Answer: (C) A hemolytic transfusion reaction

This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations.

352.402. 353.403.

37. Answer: (D) “Does it help you to joke about your illness?” 38. Answer: (C) Allow the denial but be available to discuss death

This non-judgmentally on the part of the nurse points out the client’s behavior. This does not take away the client’s only way of coping, and it permits future movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages.

354.404.

39. Answer: (C) +235 ml

The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake

355.405.

40. Answer: (B) Dyspnea on exertion

Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion.

356.406. 357.407. 358.408.

41. Answer: (D) Ascending limb of the loop of Henle 42. Answer: (C) 2.0 L 43. Answer: (D) Cardiac glycoside

This is the site of action of Lasix being a potent loop diuretic. One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters. A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate.

359.409. 360.410. 361.411.

44. Answer: (B) 2000 calories 45. Answer: (B) Sodium 46. Answer: (A) The medications he has been taking

There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein Restriction of sodium reduces the amount of water retention that reduces the cardiac workload Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use

362.412.

47. Answer: (B) Regular meals and snacks to limit gastric discomfort

Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.

363.413.

48. Answer: (B) Decreasing PCO2

Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.

364.414.

49. Answer: (B) 600 Kilocalories

Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need.

365.415.

50. Answer: (D) Performing active-assistive leg exercises

Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon

366.416.

51. Answer: (C) Maintaining the ordered hydration

Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection

367.417. 368.418.

52. Answer: (D) Dorsiflexion, plantar flexion, eversion and inversion 53. Answer: (A) 30 degrees

These movements include all possible range of motion for the ankle joint Shearing force occurs when 2 surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores.

369.419.

54. Answer: (B) Urinary drainage will be dependent on a urethral catheter for 24 hours

An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.

370.420.

55. Answer: (C) Maintaining patency of a three-way Foley catheter for cystoclysis

Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis

371.421.

56. Answer: (B) Hemorrhage

After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.

372.422.

57. Answer: (B) Provide hemostasis

The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding.

373.423.

58. Answer: (B) Milk the catheter tubing

Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency.

374.424.

59. Answer: (B) Call the physician if my urinary stream decreases

Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction.

375.425.

60. Answer: (C) Weight loss, exopthalmos and restlessness

Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.

376.426.

61. Answer: (B) A small part of the gland is left intact

Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.

377.427.

62. Answer: (B) A tracheostomy set and oxygen

Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.

378.428.

63. Answer: (C) Asking her to state her name out loud

If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.

379.429.

64. Answer: (B) Dry skin and fatigue

Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism.

380.430. 381.431.
of 22.5%

65. Answer: (C) Avoid using a sleeping mask at night 66. Answer: (D) 22.5%

The mask may irritate or scratch the eye if the client turns and lies on it during the night. The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total

382.432.

67. Answer: (A) Inhibit bacterial growth

Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes

383.433.

68. Answer: (B) 28 gtt/min

This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)

384.434.

69. Answer: (C) Relieve pain and promote rapid epithelialization

The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.

385.435. 386.436.
minutes.

70. Answer: (C) Orthopneic position 71. Answer: (C) Rapid but brief symptomatic improvement

The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several

387.437.
atrophy

72. Answer: (C) Maintain the present muscle strength

Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle

388.438.

73. Answer: (D) Respiratory exchange and ability to swallow

Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration

389.439.

74. Answer: (C) Evaluate the client‟s muscle strength hourly after medication Peakresponse

occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.

390.440.

75. Answer: (D) Coordinate her meal schedule with the peak effect of her medication,

Mestinon Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.