stress nursing

8/13/2019 stress nursing

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1. The nurse is assisting in planning care for a client with a diagnosis of immunedeficiency. The nurse would incorporate which of the ff. as a priority in the plan ofcare?

A. providing emotional support to decrease fearB. protecting the client from infection

C. encouraging discussion about lifestyle changesD. identifying factors that decreased the immune function

2. oy! an obese "2 year old! is admitted to the hospital after an automobileaccident. #he has a fractured hip and is brought to the $% for surgery.After surgery oy is to receive a piggy&bac' of Clindamycin phosphate (Cleocin)"** mg in +* ml of D+,. The piggybac' is to infuse in 2* minutes. The dropfactor of the - set is 1* gtt/ml. The nurse should set the piggybac' to flow at0

A. 2+ gtt/minB. "* gtt/min

C. "+ gtt/min

D. + gtt/min

". The day after her surgery oy as's the nurse how she might lose weight.Before answering her uestion! the nurse should bear in mind that long&termweight loss best occurs when0

A. 3ats are controlled in the diet

B. 4ating habits are altered

C. Carbohydrates are regulatedD. 45ercise is part of the program

. The nurse teaches oy! an obese client! the value of aerobic e5ercises in herweight reduction program. The nurse would 'now that this teaching was effectivewhen oy says that e5ercise will0

A. -ncrease her lean body mass

B. 6ower her metabolic rate

C. Decrease her appetiteD. %aise her heart rate

+. The physician orders non&weight bearing with crutches for oy! who hadsurgery for a fractured hip. The most important activity to facilitate wal'ing withcrutches before ambulation begun is0

A. 45ercising the triceps! finger fle5ors! and elbow e5tensors

B. #itting up at the edge of the bed to help strengthen bac' muscles

C. Doing isometric e5ercises on the unaffected legD. 7sing the trape8e freuently for pull&ups to strengthen the biceps

muscles

9. The nurse recogni8es that a client understood the demonstration of crutch


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wal'ing when she places her weight on0

A. The palms and a5illary regionsB. Both feet placed wide apart

C. The palms of her hands

D. :er a5illary regions

;. oey is a 9 year&old radio technician who is admitted because of mild chestpain. :e is + feet! < inches tall and weighs 1=* pounds. :e is diagnosed with a

myocardial infarct. >orphine sulfate! Dia8epam (alium) and 6idocaine areprescribed.The physician orders < mg of >orphine #ulfate to be given -. The vial on hand islabeled 1 ml/ 1* mg. The nurse should administer0

A. < minims

B. 1* minimsC. 12 minims

D. 1+ minims


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12. ose! who had a myocardial infarction 2 days earlier! has been complaining tothe nurse about issues related to his hospital stay. The best initial nursingresponse would be to0

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

B. %efocus the conversation on his fears! frustrations and anger about hiscondition

C. 45plain how his being upset dangerously disturbs his need for restD. Attempt to e5plain the purpose of different hospital routines

1". Twenty four hours after admission for an Acute >-! oses temperature isnoted at "=." C. The nurse monitors him for other adaptations related to the

pyre5ia! including0

A. #hortness of breathB. Chest pain

C. 4levated blood pressureD. -ncreased pulse rate

1. ose! who is admitted to the hospital for chest pain! as's the nurse! E-s it stillpossible for me to have another heart attac' if - watch my diet religiously and

avoid stress?F The most appropriate initial response would be for the nurse to0

A. #uggest 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 e5plore his feelings

D. %ecogni8e that he is frightened and suggest he tal' with the psychiatrist

or counselor.

1+. Ana! ++ years old! is admitted to the hospital to rule out pernicious anemia. A#chilling test is ordered for Ana. The nurse recogni8es that the primary purpose of

the #chilling test is to determine the clients ability to0

A. #tore vitamin B12B. Digest vitamin B12

C. Absorb vitamin B12D. roduce vitamin B12

19. Ana is diagnosed to have ernicious anemia. The physician orders *.2 mg ofCyanocobalamin (itamin B12) ->. Available is a vial of the drug labeled 1 mlG

1** mcg. The nurse should administer0

A. *.+ mlB. 1.* ml

C. 1.+ ml

D. 2.* ml

1;. :ealth teachings to be given to a client with ernicious Anemia regarding her


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therapeutic regimen concerning it. B12 will include0

A. $ral tablets of itamin B12 will control her symptomsB. -> inections are reuired for daily control

C. -> inections once a month will maintain control

D. ,ee'ly H&trac' inections provide needed control

1r. Cru8 accuses the nurse of being uncomfortableduring a dressing change! because his Ewound loo's terrible.F The nurse

recogni8es that the client is using the defense mechanism 'nown as0

A. %eaction 3ormation

B. #ublimation

C. -ntellectuali8ation

D. roection

2*. ,hen preparing to teach a client with colostomy how to irrigate his

colostomy! the nurse should plan to perform the procedure0

A. ,hen the client would have normally had a bowel movementB. After the client accepts he had a bowel movement

C. Before brea'fast and morning careD. At least 2 hours before visitors arrive

21. ,hen observing an ostomate do a return demonstration of the colostomyirrigation! the nurse notes that he needs more teaching if he0

A. #tops the flow of fluid when he feels uncomfortable

B. 6ubricates the tip of the catheter before inserting it into the stomaC. :angs the bag on a clothes hoo' on the bathroom door during fluid

insertion

D. Discontinues the insertion of fluid after only +** ml of fluid has been

instilled

22. ,hen doing colostomy irrigation at home! a client with colostomy should be

instructed to report to his physician 0

A. Abdominal cramps during fluid inflow

B. Difficulty in inserting the irrigating tube

C. assage of flatus during e5pulsion of feces

D. -nability to complete the procedure in half an hour


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2". A client with colostomy refuses to allow his wife to see the incision or stomaand ignores most of his dietary instructions. The nurse on assessing this data!can assume that the client is e5periencing0

A. A reaction formation to his recent altered body image.B. A difficult time accepting reality and is in a state of denial.

C. -mpotency due to the surgery and needs se5ual counselingD. #uicide thoughts and should be seen by psychiatrist

2. The nurse would 'now that dietary teaching had been effective for a clientwith colostomy when he states that he will eat0

A. 3ood low in fiber so that there is less stool

B. 4verything he ate before the operation but will avoid those foods thatcause gas

C. Bland foods so that his intestines do not become irritatedD. #oft foods that are more easily digested and absorbed by the large

intestines

2+. 4ddie! * years old! is brought to the emergency room after the crash of his

private plane. :e has suffered multiple crushing wounds of the chest! abdomenand legs. -t is feared his leg may have to be amputated. ,hen 4ddie arrives in

the emergency room! the assessment that assume the greatest priority are0

A. 6evel of consciousness and pupil si8eB. Abdominal contusions and other wounds

C. ain! %espiratory rate and blood pressureD. uality of respirations and presence of pulsesuality of respirations and

presence of pulses

29. 4ddie! a plane crash victim! undergoes endotracheal intubation and positive

pressure ventilation. The most immediate nursing intervention for him at thistime would be to0

A. 3acilitate his verbal communication

B. >aintain sterility of the ventilation systemC. Assess his response to the euipment

D. repare him for emergency surgery

2;. A chest tube with water seal drainage is inserted to a client following a

multiple chest inury. A few hours later! the clients chest tube seems to beobstructed. The most appropriate nursing action would be to

A. repare for chest tube removal

B. >il' the tube toward the collection container as orderedC. Arrange for a stat Chest 5&ray film.

D. Clam the tube immediately

2


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of a client with chest inury is0

A. -ncreased breath soundsB. Constant bubbling in the drainage chamber

C. Crepitus detected on palpation of chest

D. -ncreased respiratory rate

2=. -n the evaluation of a clients response to fluid replacement therapy! theobservation that indicates adeuate tissue perfusion to vital organs is0

A. 7rinary output is "* ml in an hour

B. Central venous pressure reading of 2 cm :2$C. ulse rates of 12* and 11* in a 1+ minute period

D. Blood pressure readings of +*/"* and ;*/* within "* minutes

"*. A client with multiple inury following a vehicular accident is transferred to the

critical care unit. :e begins to complain of increased abdominal pain in the leftupper uadrant. A ruptured spleen is diagnosed and he is scheduled for

emergency splenectomy. -n preparing the client for surgery! the nurse shouldemphasi8e in his teaching plan the0

A. Complete safety of the procedure

B. 45pectation of postoperative bleedingC. %is' of the procedure with his other inuries

D. resence of abdominal drains for several days after surgery

"1. To promote continued improvement in the respiratory status of a client

following chest tube removal after a chest surgery for multiple rib fracture! thenurse should0

A. 4ncourage bed rest with active and passive range of motion e5ercises

B. 4ncourage freuent coughing and deep breathingC. Turn him from side to side at least every 2 hours

D. Continue observing for dyspnea and crepitus

"2. A client undergoes below the 'nee amputation following a vehicular accident.

Three days postoperatively! the client is refusing to eat! tal' or perform anyrehabilitative activities. The best initial nursing approach would be to0

A. @ive him e5planations of why there is a need to uic'ly increase his

activityB. 4mphasi8e 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 ac'nowledge that his withdrawal is an initially normal and

necessary part of grieving

"". The 'ey factor in accurately assessing how body image changes will be dealtwith by the client is the0


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A. 45tent of body change presentB. #uddenness of the change

C. $bviousness of the change

D. Clients perception of the change

". 6arry is diagnosed as having myelocytic leu'emia and is admitted to thehospital for chemotherapy. 6arry discusses his recent diagnosis of leu'emia by

referring to statistical facts and figures. The nurse recogni8es that 6arry is usingthe defense mechanism 'nown as0

A. %eaction formation

B. #ublimationC. -ntellectuali8ation

D. roection

"+. The laboratory results of the client with leu'emia indicate bone marrow

depression. The nurse should encourage the client to0

A. -ncrease his activity level and ambulate freuentlyB. #leep with the head of his bed slightly elevated

C. Drin' citrus uices freuently for nourishment

D. 7se a soft toothbrush and electric ra8or

"9. Dennis receives a blood transfusion and develops flan' pain! chills! fever andhematuria. The nurse recogni8es that Dennis is probably e5periencing0

A. An anaphylactic transfusion reaction

B. An allergic transfusion reactionC. A hemolytic transfusion reaction

D. A pyrogenic transfusion reaction

";. A client o'es about his leu'emia even though he is becoming sic'er andwea'er. The nurses most therapeutic response would be0

A. EIour laugher is a cover for your fear.F

B. E:e who laughs on the outside! cries on the inside.F

C. E,hy are you always laughing?F

D. EDoes it help you to o'e about your illness?F

"


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A. J++ mlB. J1"; ml

C. J2"+ ml

D. Jr. $ng is admitted to the hospital with a diagnosis of 6eft&sided C:3. -n theassessment! the nurse should e5pect to find0

A. Crushing chest pain

B. Dyspnea on e5ertion

C. 45tensive peripheral edema

D. ugular vein distention

1. The physician orders on a client with C:3 a cardiac glycoside! a vasodilator!and furosemide (6asi5). The nurse understands 6asi5 e5erts is effects in the0

A. Distal tubuleB. Collecting duct

C. @lomerulus of the nephron

D. Ascending limb of the loop of :enle

2. >r. $ng weighs 21* lbs on admission to the hospital. After 2 days of diuretictherapy he weighs 2*+.+ lbs. The nurse could estimate that the amount of fluidhe has lost is0

A. *.+ 6

B. 1.* 6

C. 2.* 6D. ".+ 6

". >r. $ng! a client with C:3! has been receiving a cardiac glycoside! a diuretic!and a vasodilator drug. :is apical pulse rate is and he is on bed rest. Thenurse concludes that his pulse rate is most li'ely the result of the0

A. Diuretic

B. asodilator

C. Bed&rest regimen

D. Cardiac glycoside

. The diet ordered for a client with C:3 permits him to have a 1=* g ofcarbohydrates! =* g of fat and 1** g of protein. The nurse understands that thisdiet contains appro5imately0

A. 22** calories

B. 2*** calories

C. 2


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A. >agnesiumB. #odium

C. otassium

D. Calcium

9. ude develops @- bleeding and is admitted to the hospital. An importantetiologic clue for the nurse to e5plore while ta'ing his history would be0

A. The medications he has been ta'ing

B. Any recent foreign travel

C. :is usual dietary pattern

D. :is wor'ing patterns

;. The meal pattern that would probably be most appropriate for a clientrecovering from @- bleeding is0

A. Three large meals large enough to supply adeuate energy.B. %egular meals and snac's to limit gastric discomfort

C. 6imited food and fluid inta'e when he has pain

D. A fle5ible plan according to his appetite


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danger. The nurse can best plan to avoid this problem by0

A. 4mptying the drainage bag freuentlyB. Collecting a wee'ly urine specimen

C. >aintaining the ordered hydration

D. Assessing urine specific gravity

+2. The nurse performs full range of motion on a bedridden clients e5tremities.,hen putting his an'le through range of motion! the nurse must perform0

A. 3le5ion! e5tension and left and right rotation

B. Abduction! fle5ion! adduction and e5tensionC. ronation! supination! rotation! and e5tension

D. Dorsifle5ion! plantar fle5ion! eversion and inversion

+". A client has been in a coma for 2 months. The nurse understands that to

prevent the effects of shearing force on the s'in! the head of the bed should be atan angle of0

A. "* degrees

B. + degreesC. 9* degrees

D. =* degrees

+. %ene! age 92! is scheduled for a T7% after being diagnosed with a Benign

rostatic :yperplasia (B:). As part of the preoperative teaching! the nurseshould tell the client that after surgery0

A. 7rinary control may be permanently lost to some degree

B. 7rinary drainage will be dependent on a urethral catheter for 2 hours

C. 3reuency and burning on urination will last while the cystotomy tube is

in place

D. :is ability to perform se5ually will be permanently impaired

++. The transurethral resection of the prostate is performed on a client with B:.3ollowing surgery! nursing care should include0

A. Changing the abdominal dressing

B. >aintaining patency of the cystotomy tubeC. >aintaining patency of a three&way 3oley catheter for cystoclysis

D. $bserving for hemorrhage and wound infection

+9. -n the early postoperative period following a transurethral surgery! the mostcommon complication the nurse should observe for is0

A. #epsis

B. :emorrhage

C. 6ea'age around the catheterD. 7rinary retention with overflow

+;. 3ollowing prostate surgery! the retention catheter is secured to the clients leg


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causing slight traction of the inflatable balloon against the prostatic fossa. This isdone to0

A. 6imit discomfort

B. rovide hemostasisC. %educe bladder spasms

D. romote urinary drainage

+il' the catheter tubingC. %emove the catheter

D. Lotify the physician

+=. The nurse would 'now that a post&T7% client understood his discharge

teaching when he says E- should0F

A. @et out of bed into a chair for several hours dailyB. Call the physician if my urinary stream decreases

C. Attempt to void every " hours when -m awa'e

D. Avoid vigorous e5ercise for 9 months after surgery

9*. 6ucy is admitted to the surgical unit for a subtotal thyroidectomy. #he isdiagnosed with @raves Disease. ,hen assessing 6ucy! the nurse would e5pect to

find0

A. 6ethargy! weight gain! and forgetfulnessB. ,eight loss! protruding eyeballs! and lethargy

C. ,eight loss! e5opthalmos and restlessness

D. Constipation! dry s'in! and weight gain

91. 6ucy undergoes #ubtotal Thyroidectomy for @raves Disease. -n planning forthe clients return from the $%! the nurse would consider that in a subtotal

thyroidectomy0

A. The entire thyroid gland is removedB. A small part of the gland is left intact

C. $ne parathyroid gland is also removed

D. A portion of the thyroid and four parathyroids are removed

92. Before a post& thyroidectomy client returns to her room from the $%! thenurse plans to set up emergency euipment! which should include0

A. A crash cart with bed board

B. A tracheostomy set and o5ygen

C. An airway and rebreathing mas'

D. Two ampules of sodium bicarbonate


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9". ,hen a post&thyroidectomy client returns from surgery the nurse assessesher for unilateral inury of the laryngeal nerve every "* to 9* minutes by0

A. $bserving for signs of tetany

B. Chec'ing her throat for swellingC. As'ing her to state her name out loud

D. alpating the side of her nec' for blood seepage

9. $n a post&thyroidectomy clients discharge! the nurse teaches her to observe

for signs of surgically induced hypothyroidism. The nurse would 'now that theclient understands the teaching when she states she should notify the physician ifshe develops0

A. -ntolerance to heatB. Dry s'in and fatigue

C. rogressive weight lossD. -nsomnia and e5citability

9+. A clients e5opthalmos continues inspite of thyroidectomy for @raves Disease.The nurse teaches her how to reduce discomfort and prevent corneal ulceration.The nurse recogni8es that the client understands the teaching when she says0 E-should0

A. 4levate the head of my bed at night

B. Avoid moving my e5tra&ocular musclesC. Avoid using a sleeping mas' at night

D. Avoid e5cessive blin'ing

99. Clara is a ";&year old coo'. #he is admitted for treatment of partial and full&thic'ness burns of her entire right lower e5tremity and the anterior portion of herright upper e5tremity. :er respiratory status is compromised! and she is in painand an5ious. erforming an immediate appraisal! using the rule of nines! thenurse estimates the percent of Claras body surface that is burned is0

A. .+K

B. =K

C. 1< K

D. 22.+K

9;. The nurse applies mafenide acetate (#ulfamylon cream) to Clara! who hassecond and third degree burns on the right upper and lower e5tremities! asordered by the physician. This medication will0

A. -nhibit bacterial growth

B. %elieve pain from the burn

C. revent scar tissue formation

D. rovide chemical debridement

9


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A. 1< gtt/minB. 2< gtt/min

C. "2 gtt/min

D. "9 gtt/min

9=. Clara! a burn client! receives a temporary heterograft (pig s'in) on some ofher burns. These grafts will0

A. Debride necrotic epithelium

B. Be sutured in place for better adherence

C. %elieve pain and promote rapid epitheliali8ation

D. 3reuently be used concurrently with topical antimicrobials.

;*. A client with burns on the chest has periodic episodes of dyspnea. Theposition that would provide for the greatest respiratory capacity would be the0

A. #emi&fowlers positionB. #ims position

C. $rthopneic position

D. #upine position

;1. ane! a 2*& year old college student is admiited to the hospital with a

tentative diagnosis of myasthenia gravis. #he is scheduled to have a series ofdiagnostic studies for myasthenia gravis! including a Tensilon test. -n preparingher for this procedure! the nurse e5plains that her response to the medication willconfirm the diagnosis if Tensilon produces0

A. Brief e5aggeration of symptomsB. rolonged symptomatic improvementC. %apid but brief symptomatic improvement

D. #ymptomatic improvement of ust the ptosis

;2. The initial nursing goal for a client with myasthenia gravis during thediagnostic phase of her hospitali8ation would be to0

A. Develop a teaching plan

B. 3acilitate psychologic adustment

C. >aintain the present muscle strength

D. repare for the appearance of myasthenic crisis

;". The most significant initial nursing observations that need to be made about aclient with myasthenia include0

A. Ability to chew and spea' distinctly

B. Degree of an5iety about her diagnosisC. Ability to smile an to close her eyelids

D. %espiratory e5change and ability to swallow

;. :elen is diagnosed with myasthenia gravis and pyridostigmine bromide

(>estinon) therapy is started. The >estinon dosage is freuently changed duringthe first wee'. ,hile the dosage is being adusted! the nurses priority


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intervention is to0

A. Administer the medication e5actly on timeB. Administer the medication with food or mild

C. 4valuate the clients muscle strength hourly after medication

D. 4valuate the clients emotional side effects between doses

;+. :elen! a client with myasthenia gravis! begins to e5perience increaseddifficulty in swallowing. To prevent aspiration of food! the nursing action that

would be most effective would be to0

A. Change her diet order from soft foods to clear liuidsB. lace an emergency tracheostomy set in her room

C. Assess her respiratory status before and after meals

D. Coordinate her meal schedule with the pea' effect of her medication!

>estinon

Answer and rational

1. Answer: (B) protecting the client from infection

-mmunodeficiency is an absent or depressed immune response that

increases susceptibility to infection. #o it is the nurses primary

responsibility to protect the patient from infection.

2. Answer: (A) 25 gtt/min

To get the correct flow rate0 multiply the amount to be infused (+* ml) by

the drop factor (1*) and divide the result by the amount of time in minutes

(2*)

". Answer: (B) Eating habits are altered

3or 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

. Answer: (A) Increase her lean body mass

-ncreased e5ercise builds s'eletal muscle mass and reduces e5cess fatty

tissue.

+. Answer: (A) Exercising the triceps finger flexors

and elbow extensors

These sets of muscles are used when wal'ing with crutches and therefore

need strengthening prior to ambulation.

9. Answer: (!) "he palms of her hands

The palms should bear the clients weight to avoid damage to the nerves in

the a5illa (brachial ple5us)

;. Answer: (!) #2 minims

7sing ratio and proportion < mg/1* mg G M minims/1+ minims 1* MG 12*

M G 12 minims The nurse will administer 12 minims intravenously

euivalent to orphine #ulfate

orphine is a specific central nervous system depressant used to relieve


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the pain associated with myocardial infarction. -t also decreases an5iety

and apprehension and prevents cardiogenic shoc' by decreasing

myocardial o5ygen demand.

=. Answer: (!) &'pports comb'stion

The nurse should 'now that $5ygen is necessary to produce fire! thus

precautionary measures are important regarding its use.

1*. Answer: (!) !*B

The cardiac mar'er! Creatinine phospho'inase (C) isoen8yme levels!

especially the >B sub&unit which is cardio&specific! begin to rise in "&9

hours! pea' in 12&1< hours and are elevated < hours after the occurrence

of the infarct. They are therefore most reliable in assisting with early

diagnosis. The cardiac mar'ers elevate as a result of myocardial tissue

damage.

11. Answer: (B) Ele%ated &"segments

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

12. Answer: (B) $efoc's the con%ersation on his fears

fr'strations and anger abo't his condition

This provides the opportunity for the client to verbali8e feelings underlying

behavior and helpful in relieving an5iety. An5iety can be a stressor which

can activate the sympathoadrenal response causing the release of

catecholamines that can increase cardiac contractility and wor'load that

can further increase myocardial o5ygen demand.

1". Answer: (+) Increased p'lse rate

3ever causes an increase in the bodys metabolism! which results in anincrease in o5ygen consumption and demand. This need for o5ygen

increases the heart rate! which is reflected in the increased pulse rate.

-ncreased B! chest pain and shortness of breath are not typically noted in

fever.

1. Answer: (!) A%oid gi%ing him direct information and help him

explore his feelings

To help the patient verbali8e and e5plore his feelings! the nurse must

reflect and analy8e the feelings that are implied in the clients uestion.

The focus should be on collecting data to minister to the clients

psychosocial needs.

1+. Answer: (!) Absorb %itamin B#2

ernicious anemia is caused by the inability to absorb vitamin B12 in the

stomach due to a lac' of intrinsic factor in the gastric uices. -n the

#chilling test! radioactive vitamin B12 is administered and its absorption

and e5cretion can be ascertained through the urine.

19. Answer: (+) 2,- ml

3irst convert milligrams to micrograms and then use ratio and proportion

(*.2 mgG 2** mcg) 2** mcg 0 1** mcgG M ml 0 ml 1** MG 2** M G 2 ml.

-nect 2 ml. to give *.2 mg of Cyanocobalamin.

1;. Answer: (!) I* in.ections once a month will maintain controlDeep -> inections bypass B12 absorption defect in the stomach due to


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lac' of intrinsic factor! the transport carrier component of gastric uices. A

monthly dose is usually sufficient since it is stored in active body tissues

such as the liver! 'idney! heart! muscles! blood and bone marrow

1


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2;. Answer: (B) *il3 the t'be toward the collection container as

ordered

This assists in moving blood! fluid or air! which may be obstructing

drainage! toward the collection chamber

2


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"

$ne liter of fluid weighs appro5imately 2.2 lbs. Therefore a .+ lbs weight

loss euals appro5imately 2 6iters.

". Answer: (+) !ardiac glycoside

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.

. Answer: (B) 2--- calories

There are = calories in each gram of fat and calories in each gram ofcarbohydrate and protein

+. Answer: (B) &odi'm

%estriction of sodium reduces the amount of water retention that reduces

the cardiac wor'load

9. Answer: (A) "he medications he has been ta3ing

#ome medications! such as aspirin and prednisone! irritate the stomach

lining and may cause bleeding with prolonged use

;. Answer: (B) $eg'lar meals and snac3s to limit gastric

discomfort

resence of food in the stomach at regular intervals interacts with :Cl

limiting acid mucosal irritation. >ucosal irritation can lead to bleeding.


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against the veins! all of which lead to thrombus formation. 4arly

ambulation or e5ercise of the lower e5tremities reduces the occurrence of

this phenomenon

+1. Answer: (!) *aintaining the ordered hydration

romoting hydration! maintains urine production at a higher rate! which

flushes the bladder and prevents urinary stasis and possible infection

+2. Answer: (+) +orsiflexion plantar flexion e%ersion and

in%ersion

These movements include all possible range of motion for the an'le oint

+". Answer: (A) 7- degrees

#hearing force occurs when 2 surfaces move against each otherN when the

bed is at an angle greater than "* degrees! the torso tends to slide and

causes this phenomenon. #hearing forces are good contributory factors of

pressure sores.

+. Answer: (B) 6rinary drainage will be dependent on a 'rethral

catheter for 2 ho'rs

An indwelling urethral catheter is used! because surgical trauma can cause

urinary retention leading to further complications such as bleeding.

++. Answer: (!) *aintaining patency of a threeway oley catheter

for cystoclysis

atency of the catheter promotes bladder decompression! which prevents

distention and bleeding. Continuous flow of fluid through the bladder limits

clot formation and promotes hemostasis

+9. Answer: (B) emorrhageAfter transurethral surgery! hemorrhage is common because of venous

oo8ing and bleeding from many small arteries in the prostatic bed.

+;. Answer: (B) 0ro%ide hemostasis

The pressure of the balloon against the small blood vessels of the prostate

creates a tampon&li'e effect that causes them to constrict thereby

preventing bleeding.

+


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

%emaining thyroid tissue may provide enough hormone for normal

function. Total thyroidectomy is generally done in clients with Thyroid Ca.

92. 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.

9". Answer: (!) As3ing her to state her name o't lo'd

-f the recurrent laryngeal nerve is damaged during surgery! the client will

be hoarse and have difficult spea'ing.

9. Answer: (B) +ry s3in and fatig'e

Dry s'in is most li'ely caused by decreased glandular function and fatigue

caused by decreased metabolic rate. Body functions and metabolism are

decreased in hypothyroidism.

9+. Answer: (!) A%oid 'sing a sleeping mas3 at night

The mas' may irritate or scratch the eye if the client turns and lies on it

during the night.

99. Answer: (+) 22,5

The entire right lower e5tremity is 1


21/21

;. Answer: (!) E%al'ate the client8s m'scle strength ho'rly after

medication ea' response occurs 1 hour after administration and lasts up

to < hoursN the response will influence dosage levels.

;+. Answer: (+) !oordinate her meal sched'le with the pea3

effect of her medication *estinon

Dysphagia should be minimi8ed during pea' effect of >estinon! thereby

decreasing the probability of aspiration. >estinon can increase her muscle

strength including her ability to swallow.

stress nursing

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