The nurse can quickly assess volume depletion in a patient with ulcerative colitis by: Measuring the quantity and specific gravity of the patient's urine output. Taking the patient's blood pressure first supine, then sitting, noting any changes. Comparing the patient's present weight with weight on a previous admission. Administering the oral water test. Postural blood pressure readings are an excellent mode for assessing volume depletion. If the systolic blood pressure decreases more than 10 mm Hg and there is a concurrent increase in the pulse rate, a volume depletion problem is indicated. Urine output and specific gravity (Answer 1) are better measures of the adequacy of fluid volume replacement than of fluid volume depletion. Comparing the prior and present weight of the patient (Answer 3) will give the nurse an estimate of the slow catabolism of body stores that occurs with ulcerative colitis. There is no oral water test (Answer 4). Key words are "quickly" (something the nurse can do without a great deal of equipment and something that can be done easily) and "volume depletion." Physical assessment of a patient admitted for a bronchoscopy revealed a thin, muscular man with wheezes in the left lung and some wheezes in the right lower lobe. Wheezes are due to: Total obstruction of small bronchioles. Partial obstruction of bronchi and bronchioles. Fluid in the alveoli. Inflammation of the pleura. Wheezes occur when there is partial obstruction of the bronchi or bronchioles. Sounds are due to the increased vibration of air molecules as they pass over these obstructions.Answer 1 is incorrect because total obstruction would produce no sounds. Answer 3 is incorrect because the soundsproduced by fluid in the alveoli are the finer, less harsh sounds generally referred to as crackles. Answer 4 is incorrect because inflammation of the pleura creates a grating sound referred to as a friction rub. The question is looking for the reasons why these sounds occur. With a wheeze, think "squeeze"— air through a narrow tube. Which of the following best describes the metabolic functions of the liver? Detoxification of endogenous and exogenous substances. Fluid volume control and acid-base balance. Erythrocyte and leukocyte breakdown. Concentration and storage of bile. Liver functions are many and varied, including detoxification of chemicals (estrogen, adrenocorticoids, aldosterone,drugs, poisons, and heavy metals); synthesis of plasma proteins (albumin, fibrinogen, globulin) and several clotting factors (prothrombin, factor VII); storage of glycogen, iron, and vitamins (A, D, E, K, and B12); gluconeogenesis (glucose from amino acids and fats); and deamination of amino acids. Fluid volume and acid-base balance are functions of the kidney(Answer 2). Most erythrocyte and leukocyte breakdown occurs in the spleen (Answer 3). The gallbladder concentrates and stores bile (Answer 4), and the liver is involved with synthesis and secretion of bile. The question is focusing on what is the liver supposed to do, what is the normal physiology of the liver. The key words "best describes" are asking for the most accurate and complete answer. Clue—look for a "metabolic" process. In response to a patient's questions regarding the cause of glomerulonephritis, the nurse explains that acute glomerulonephritis is the result of: Acute infection of the kidney by gram-negative bacteria. An immune response of the glomerular membrane to protein of the beta-hemolytic streptococcus. Destruction of the glomerular membrane by gram-positive streptococci. Ischemia of glomerular capillary and vasa recta. Acute glomerulonephritis is an autoimmune response to an antigen produced by beta-hemolytic streptococci. Antibodies produced to fight the antigen also react against the glomerular tissue. This causes proliferation and swelling of endothelial cells in the glomerular capillary wall and results in passage of blood cells and protein into the glomerular filtrate. Acute glomerular nephritis is not the result of direct infection (Answers 1 and 3) or of hypoxia (Answer 4). The key word is "cause" of glomerulonephritis. The question is asking for an explanation of the pathophysiology of the disease. Look for a pattern—three options are direct infections. A patient who is scheduled for repair of bilateral inguinal hernias has a history of obesity, smoker's cough, and heavy lifting following a previous inguinal hernia repair. The most likely cause for the herniation is: Intestinal obstruction. Failure of resected muscles in previous operations to heal properly. Chronic cough and vigorous exercise. Obesity. Coughing, vigorous exercise, and straining or lifting increase intra-abdominal pressures, which tend to extrude the intestines through weakened areas of the abdominal wall. This patient's history includes all of the above. Other causes of hernia include combinations of Answers 1,2, and 4; alone they are less likely causes. Patient history identifies several risk factors/behaviors. Select the answer that is most inclusive, the one that lists more than one risk. The nurse knows that the function of the gallbladder is to: Synthesize and manufacture bile. Collect, concentrate, and store bile. Collect and dilute bile. Regulate bile flow into the duodenum. The functions of the gallbladder are to collect, concentrate, and store bile, which is produced by the liver, not by the gallbladder (Answer 1). Bile reaches the gallbladder via the hepatic duct, which later joins the cystic duct emanating from the gallbladder to form the common bile Hurt. The common bile duct joins the pancreatic duct, which opens into the duodenum.Bile is not diluted (Answer 3). Answer 4 is incorrect because contraction of the gallbladder and therefore flow of bile are stimulated by the hormone cholecystokinin, which is secreted by the duodenal mucosa when food enters the duodenum. This question is looking for knowledge of physiology of the gallbladder. What does the gallbladder do under normal circumstances? Be cautious of all statements in the options because some may be correct but are placed with some that are incorrect. Look at each word or phrase and decide right or wrong for each part of the option. The most accurate description the nurse could give a colleague about a thyroid scan is that it: Assists in differentiating between primary and secondary hypothyroidism. Demonstrates increased uptake of radioactive iodine in areas of possible malignancy. Demonstrates decreased uptake of radioactive iodine in areas of possible malignancy. Measures the effect of TSH on thyroid function. A thyroid scan utilizes the uptake of ¹³¹I by the thyroid gland to determine the size, shape, and function of the gland.Also identified are areas of increased uptake (hot areas), indicating increased metabolic function, as in hyperthyroidism, not malignancy (Answer 2), and areas of decreased or no up take (cold areas), which are associated with malignancy. Answers 1 and 4 both describe the TSH stimulation test. The question is asking for the most accurate description of a thyroid scan. This test uses iodine uptake to identify normal and abnormal findings. A stat cesarean birth is ordered for a woman in labor; her husband is with her. The primary priority of the nurse at this time would be to: Obtain an operation permit. Attempt to alleviate the couple's anxiety. Monitor maternal and fetal signs closely. Provide emotional and physiological support. This is the most appropriate response because it attempts to provide total intervention for all parties involved. Answer 1 is essentially the physician's role. It would be almost impossible to alleviate the couple's anxiety at this time (Answer 2). The most appropriate intervention is to assist the couple to cope with their anxiety as effectively as possible. Answer 3 is essential, but it neglects the psychological needs of the woman and her family. Focus on the nurse's roles/responsibilities in the operating room when caring for patients undergoing cesarean birth, not the MD's (1). When two options are good, (3,4) choose the more inclusive option (physiological plus psychological). The nurse knows that a decreased hematocrit occurs in chronic renal failure because: Secretion of erythropoietin factor by the diseased kidney is decreased. Chronic hypertension tends to suppress bone marrow centers. Metabolic alkalosis tends to increase red blood cell fragility. Excretion of red blood cells in the urine is increased. The kidneys secrete the erythropoietin factor, which stimulates the bone marrow to produce red blood cells. In chronic kidney disease, secretion of this factor decreases as greater portions of the kidney are destroyed by the disease process. Hypertension does not suppress bone marrow centers (Answer 2), because local blood flow regulators tend to compensate over the long run by supplying tissue with adequate blood flow for metabolic purposes. Unlike metabolic acidosis, metabolic alkalosis does not increase RBC fragility(Answer 3). Frank bleeding into the urine is uncommon in chronic renal disease (Answer 4). Take each option by itself and determine if it is correct or incorrect in relation to the normal or abnormal kidney function seen in chronic failure. A routine preoperative assessment for the patient having vein ligation and stripping would include the following laboratory studies: VDRL, NA, K, CI. Prothrombin time, ALT (SGOT), VDRL. UA, CBC, prothrombin time. WBC, VDRL, serum glucose. For patients having elective surgery, routine preoperative laboratory studies generally include a complete blood count, urinalysis, and prothrombin time. Some institutions also require a VDRL. The urinalysis provides information about specific gravity (indicating the ability of the kidney to concentrate and dilute urine); the presence of albumin or pus, indicating renal infection; and the presence of sugar and acetone. The CBC detects the presence of anemia, infection, allergy, and leukemia. Prothrombin time (increased) may indicate a need for preoperative vitamin K therapy. Electrolytes (Answer 1), enzymes such as ALT (SGOT), (Answer 2), and serum glucose (Answer 4) are ordered only if the patient's history or physical condition warrants a more complete workup. Key word in this question is "routine" for each patient having surgery. The incorrect options all suggest an underlying medical problem, but none is discussed in the stem (e.g., VDRL). The nurse finds a marijuana joint under an adolescent patient's pillow. After being confronted, the patient promises not to smoke marijuana again if the nurse will not report the incident. The nurse fears that the patient is being manipulative. The most therapeutic nursing intervention when working with manipulative patients is to: Make decisions for them. Reinforce use of alternative behaviors. Set rigid limits. Confront them in front of others. Many times, patients who are manipulative are not aware of any other mechanisms for fulfilling their needs. Teaching them to identify manipulative behaviors may help them to avoid being manipulative and to eventually adopt more appropriate means for meeting their needs. The patients should be involved in the decision-making process (Answer 1). Limits must be realistically established (Answer 3). Public confrontation (Answer 4) may only exacerbate the power struggle. Therapeutic nursing process calls for supportive care (e.g., reinforce), not a dominant, controlling approach (e.g., rigid, confronting). A multiparous woman is admitted to the birth unit for induction of labor. The nurse performing Leopold's maneuvers notes that uterine tonicity is normal and the presenting part (the sacrum) is high, not engaged. The nurse expects that medical management will probably consist of: Delaying induction until the presenting part is at 0 station. Piper forceps-assisted vaginal birth. Spontaneous, vaginal birth. Cesarean birth. For this woman, a cesarean birth may be expected. With the fetus in breech presentation, there is a risk of prolapsed cord if membranes rupture in early labor (the presenting part is not engaged as yet). Induction (Answer 1) may not be considered since the presenting part is the sacrum and it is high.Vaginal birth (Answer 2) may not be considered; however, if breech birth is vaginal, Piper forceps are used to assist in the birth of the after-coming head. Spontaneous vaginal birth (Answer 3) may not be possible for this woman. Note the fetal presentation (high), and eliminate two options that call for vaginal delivery (Answer 1 also implies probable vaginal). Choose the option that is different from the others (i.e., nonvaginal). The nurse knows the acetonuria develops in diabetes due to: Excessive oxidation of fatty acids for energy, which increases ketones in glomerular filtrate. Osmotic diuresis, accompanying elevation in serum-glucose levels, which decreases exchange of electrolytes in renal tubules. Failure of sodium-hydrogen ion exchange mechanism in the renal tubules to secrete excess hydrogen ions. Increased volatile H+ ions and decreased nonvolatile H+ ions in the glomerular filtrate. When excessive quantities of fatty acids are oxidized, blood buffer systems may become exhausted. Ketoacidosis develops and acetone bodies are excreted in the urine. In an emergency room situation, diabetic acidosis can be recognized not only by the increased rate and depth of respirations (Kussmaul's respirations) but also by the odor of acetone on the breath. Neither osmotic diuresis (Answer 2) nor failure in the sodium-hydrogen ion exchange (Answer 3) causes acetonuria. In the latter case, failure to excrete excess hydrogen ions would decrease urinary acids. Volatile hydrogen ions (C02) are excreted by the lungs; a decrease in nonvolatile hydrogen ions in the glomerular filtrate (Answer 4)would move the pH of the urine toward the alkaline side. The word "acetonuria" tells you something is evident in the urine. Improper fat metabolism produces acetonuria. A woman experienced an incomplete spontaneous abortion. After evacuation of the uterus, an oxytocic agent is ordered to prevent hemorrhage. An ergot product (e.g., ergonovine) is ordered. The nurse knows that ergot products are contraindicated: Until the uterus is emptied. When the woman is normotensive. If her religion proscribes the use of blood products. If she is a candidate for receiving Rh0(D) immune globulin. Ergot products such as ergonovine, which contract the uterus and cervix, are contraindicated until the uterus is emptied to avoid retention of placental fragments or tissue. Retained fragments predispose to uterine relaxation and puerperal infection. Answer 2 is incorrect because ergot products are not given to women if they are hypertensive because of the vasoconstrictive properties of these products. Ergot products are not blood products (Answer 3). Answer 4 is incorrect because ergot products are not contraindicated if she is also a candidate for Rh0(D) immune globulin (i.e., she is Rh negative and Coombs negative.) The stem asks for when not to administer ergot. Focus on risk factors and eliminate those that do not apply (2,4). Eliminate Answer 3 because ergot is not related to a blood product. A woman who is diabetic gives birth to an 8-pound 11-ounce boy at 38 weeks. On her first postpartum day she is eating a full diet and her insulin has been cut to one-third of the dosage during pregnancy. The night nurse is making rounds and wants to assess the sleeping woman for signs indicating her response to the lowered insulin dosage. Which indicates this woman is hyperglycemic: A flash of light in her face does not elicit a squint or turn of the head. She seems restless, her face is flushed, her pulse is rapid, and her respirations are deep. She is perspiring profusely. She awakens with a headache. The woman who seems restless, with flushed face, rapid pulse, and rapid deep respirations, is exhibiting signs of hyperglycemia. Answer 1 is incorrect because failure to react to a flash of light in the face is associated with an insulin reaction(hypoglycemia). Answer 3 is wrong because diaphoresis during sleep is associated with insulin reactions. Answer 4 is wrong because headaches are associated with insulin reactions. Recognize that three of the options describe insulin reaction (hypoglycemia) and therefore do not meet the condition in the stem (hyperglycemia). Review signs and symptoms of hypoglycemia and hyperglycemia. Understand the expected changes in glucose levels and insulin requirements in the immediate postpartum period. The nurse expects hyperkalemia on assessment to occur in chronic renal dysfunction because: As metabolic acidosis increases, the kidneys selectively secrete more H+ than K+ in exchange for Na+. As edema forms, sodium diffuses into the interstitial space and is balanced by increased serum potassium. Respiratory compensation for metabolic acidosis tends to increase K+ reabsorption by the kidneys. The nausea and vomiting that occur with metabolic acidosis tend to increase serum potassium to compensate for chloride losses. Hyperkalemia tends to develop in renal dysfunction for two reasons: In the kidneys, more hydrogen ions than potassium ions are selectively secreted in exchange for sodium ions, and decreasing glomerular filtration and urine output tends to decrease the excretion of all electrolytes and waste products of metabolism. Potassium does not move out of the cell to balance sodium shifts in edema (Answer 2), nor does respiratory alkalosis affect potassium reabsorption in the kidneys (Answer 3). Nausea and vomiting (Answer 4) cause hypokalemia. Know the role of potassium in the body and the pathophysiology of chronic renal failure. A patient has second-degree burns of the left leg and thigh. The nurse plans to help prevent contractures in the burned leg by: Maintaining abduction of the left leg, extension of the left knee, and flexion of the left ankle. Maintaining adduction of the left leg and extension of the left knee and ankle. Maintaining abduction of the left leg and flexion of the left knee and ankle. Maintaining adduction of the left leg, flexion of the left knee, and extension of the left ankle. To prevent contractures, the affected limb is kept straight(knee extension) and slightly abducted (to prevent pressure in hip joint), and the foot is supported (ankle flexion) to prevent footdrop. Answers 2,3, and 4 are incorrect because all or part of each response could produce a contracture. Key word is "contractures." Look for anything that is suggested to extend the limb or keep it straight. A truss is a pad of firm material that is placed over a hernial opening and held in place with a belt. When should the nurse apply a hernia truss on a patient? After the patient gets out of bed but before engaging in strenuous activity. After the hernia has been reduced, with the patient lying down with feet elevated. At any time, whether or not the hernia has been reduced, to prevent further extrusion of the bowel. Not at all, for physicians no longer recommend the use of a truss, because athletic supporters are sufficient in preventing further herniation. A truss should be applied before the patient gets out of bed or after the hernia has been reduced, by having the patient lie down with the feet elevated in bed or in the bath.If the hernia cannot be reduced, the truss should not be applied (Answers 1 and 3). Although the truss is not a cure for a hernia and its use is not as common as it once was, it is far more effective in keeping a hernia reduced than is an athletic supporter (Answer 4). A truss keeps the internal organs from protruding through the herniated area. Look for the best time. To correctly administer a tuberculin skin test, the nurse would inject 5 TU (tuberculin units) of PPD (purified protein derivative) of tuberculin: Intradermally. Subcutaneously. Intramuscularly. Subdermally. The PPD for the tuberculin skin test is injected intradermally on the polar aspect of the forearm. If the test is correctly administered, a pale elevation similar to a mosquito bite should be apparent. Answers 2,3, and 4 are not used for this test. Correct technique is just under the skin. Only one option will produce a bubble. You want to be able to see results from the administration of this injection, so you do not want to give deep injections. If bile flow into the duodenum is obstructed, absorption of fat-soluble vitamins is reduced. Which complication would the nurse therefore observe? Peripheral neuritis. Scurvy. Increased bleeding tendencies. Macrocytic anemia. Fat-soluble vitamins, particularly vitamin K, are poorly absorbed in the absence of bile. Decreased absorption of vitamin K results in decreased levels of circulating prothrombin, thus reducing normal clotting levels. Peripheral neuritis (Answer 1) occurs with vitamin B6 deficiencies, and scurvy(Answer 2) occurs with deficiency in vitamin C; these are water-soluble vitamins. Macrocytic anemia (Answer 4) is consistent with a vitamin B12 deficiency, which may be due to lack of intrinsic factor in the stomach. Need to know fat-soluble vitamins (A, D, E and K). Associate vitamin K with increased bleeding tendencies. The preoperative nursing care plan for a patient having cataract surgery includes: Keeping the patient flat in bed. Applying eye patches to both eyes. Orienting the patient to the environment and nursing personnel. Teaching the patient eyedrop instillation. Even though the patient will have only one eye patched after surgery, familiarization with the physical environment and with nursing personnel will decrease the occurrence of disorientation (this is especially important with elderly patients). It is not necessary to keep the patient flat in bed before or after surgery (Answer 1). Patches (Answer 2) are not generally applied to both eyes. Eye-drop instillations (Answer 4) are part of the postoperative or pre-discharge teaching plan. The key word is "preoperative." Orienting the patient to prevent injuries in the post-op period is priority. Following a thyroid scan with ¹³¹I for a thyroid nodule, the nurse should plan for: No special radiation precautions. Full radiation precautions to be instituted, including segregating the patient in a private room. Radiation precautions that are limited to urine and feces. Full radiation precautions to be instituted for 8 hours (the half-life of ¹³¹I). Following an injection of the small dose of ¹³¹I used in a thyroid scan, no radiation precautions arc necessary. Full radiation precautions (Answer 2) are utilized for radium implants. Answer 3 may be employed when ¹³¹I therapy is utilized to and reduce hypersecretion by the thyroid(hyperthyroidism). Answer 4 is not an example of normal radiation therapy policy. There is no identification of treatment with radioactive substance, just a scan. Look for a pattern— three of the options are inappropriate precautions. To prevent displacement of radium implants in the cervix, the nurse should position the patient: With the foot of the bed elevated. Flat in bed. With the head elevated 45 degrees (semi-Fowler's). On the side only. Patients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The patient may roll to the side for meals, but the upper body should not be raised more than 20 degrees.Answers 1, 3, and 4 are incorrect because these positions are more likely to change the position of the cobalt seeds. Radium implants are localized treatment for known cancer; therefore it is important that they remain in the correct position. The best option to maintain the implants in the correct position is to have the patient lie flat in bed. Visualize the patient in each position. Which one would have no effect on placement of implant? A woman in labor is moved into the Cesarean room. Her husband enters the room and appears anxious. The nurse should ask him: How are you feeling? Are you feeling up to this? Would you rather wait outside? Can I get you anything? This is an open-ended question that allows the husband to identify what his needs are at this time. Answer 2 is too threatening. Answer 3 assumes he cannot tolerate the situation, which is unfair. Answer 4 is unrealistic because the nurse has many responsibilities at this time. In addition, the husband would have to leave the room anyway to drink or take anything. Choose an open-ended question. Notice that three of the options can be answered with a "yes-no" response that closes communication. The parents of a newborn who has a unilateral cleft lip and palate are anxious to have surgery performed as soon as possible to repair the deformities. The most appropriate response to the couple's questions about when the surgery may be performed would be to Reinforce what the physicians have told the parents. Inform the parents that the baby's lip may be repaired during the first few weeks of life and the palate repaired at 12-18 months, before speech develops. Refer the couple to the surgeon. Tell the couple that a complete repair may be performed when their baby weighs at least 10 pounds. This answer provides the parents with accurate information specific to the questions they have asked. Answer 1 is incorrect because the nurse may or may not be fully informed as to what the physicians may have told the parents.Answer 3 is incorrect because it avoids answering their questions and may actually increase their anxiety. Answer 4 is incorrect because the palate repair is generally not done until the infant is at least 1 year of age, when the infant should be well over 10 pounds. This delay allows for the growth of thebony structures of the jaw and mouth, but is done before theinfant begins to use speech. Use process of elimination; omit the two options referring to MD; select the more complete, precise, factually correct answer. A total thyroidectomy is ordered following discovery of a cold nodule. In this case of hyperthyroidism versus malignancy, the nurse anticipates that the patient will have: A complete thyroidectomy also. A partial thyroidectomy (approximately one-half of the thyroid is removed). A partial thyroidectomy (approximately five-sixths of the thyroid is removed). Administration of thyroid medication. Surgical treatment of hyperthyroidism involves a subtotal thyroidectomy in which approximately five-sixths of the thyroid tissue is removed. While this procedure does not cure hyperthyroidism, it reduces the amount of circulating thyroid hormone by reducing the amount of functioning tissue. Answer 1, complete or total thyroidectomy, is rarely done for hyperthyroidism today but is indicated for thyroid malignancy. Answer 2, removal of half of the thyroid, would leave enough functioning hyperactive tissue to prevent diminution of symptoms in the patient. Answer 4 is incorrect because the patient with hyperthyroidism needs no additional thyroid hormone; he or she receives antithyroid medications such as propylthiouracil (PRU) or methimazole(Tapazole) to reduce both circulating and stored thyroid hormone. When you have two good choices, select the one that includes the other. Besides jaundice of the sclera and skin, what other clinical parameters might indicate biliary obstruction in the patient? Increased systolic and diastolic pressures. Frequent eructation between meals. Darkened urine and clay-colored stools. Longitudinal ridging of the fingernails. Obstruction of the bile duct will cause elevated serum and urine bilirubin (dark urine) as well as a decreased amount of urobilinogen in the feces (clay-colored stools). Bilirubin is an end product of hemoglobin breakdown. Normally it is conjugated in the liver and secreted, in thebile, into the intestines, where it is converted into urobilinogen and excreted in the stools. Answer 1 is incorrect because biliary obstruction itself does not directly affect blood pressure. However, if the obstruction is acute and accompanied by pain, changes in blood pressure in response to increased sympathetic tone can be expected. Answer 2 is incorrect because between-meal eructation is a symptom of ulcer disease. Eructation in gallbladder disease occurs after eating, particularly if large amounts of fat have been ingested. Answer 4 is also incorrect; longitudinal ridging of the fingernails is a sign seen frequently in anemia. The question is focused on what would you see when there is an obstruction of the bile duct. If bile cannot be excreted into the intestines, the bile goes to the serum and urine. The lack of bile in the intestines will cause the stools to be lighter in color. It is bile that gives stool its normal color. A patient who has a long-term history of smoking and a smoker's cough is scheduled for bilateral herniorrhaphy. Which preoperative nursing action will be a priority? Explanation of the surgical procedure. Respiratory hygiene measures and instructions in deep breathing. Discussion of postoperative nursing care measures. Assurance that pain medication will be available whenever needed. This patient's smoking history and history of chronic cough necessitate directing preoperative nursing measures toward clearing the respiratory tract of excess secretions that might lead to postoperative complications. Besides oral hygiene, the following may be instituted or ordered before surgery: postural drainage, incentive spirometers, IPPB, and mucolytic agent. Because postoperative coughing is contraindicated with hernia repairs, removal of secretions is a priority, as is instruction in deep-breathing techniques. Answers 1, 3, and 4, though not top priority, are correct and should also be included in the preoperativeteaching plan. This is a priority question. The patient is at greater risk for respiratory infection and complications. A patient has been NPO for the last 12 hours in preparation for an intravenous pyelogram (IVP) and has been complaining of thirst. The specific gravity of the patient's urine has been averaging 1.008. The nurse's explanation for these signs and symptoms is: The hypothalamus is stimulating increased secretion of ADH. Extracellular fluid has become hypo-osmolar. The kidneys are no longer able to concentrate urine, making the extracellular fluid hyperosmolar. Most patients complain of thirst after fluid restriction. This patient's urine specific gravity indicates that the kidneys have lost their ability to concentrate urine. Therefore the patient has a greater water loss than would normally be expected. ADH secretion (Answer 1) would produce an elevated specific gravity. Answer 2 is incorrect because water loss without concomitant electrolyte loss causes the extracellular fluids to become hyperosmolar (that is, the patient is dehydrated). Answer 4 is incorrect because hyperosmolarity of ECF causes the thirst receptors in the hypothalamus to shrink (which stimulates the thirst mechanism). Know what is normal. It is normal to be thirsty and have a dry mouth after 12 hours, but it is not normal to have a specific gravity of 1.008 (normal is 1.010-1.020). Focus attention on the kidneys. Which contributes to the development of ascites in cirrhosis of the liver? Portal hypertension, venous dilation, and stasis. Increased hepatic synthesis of albumin. Decreased serum levels of aldosterone and ADH. Increased blood volume causing increased blood hydrostatic pressure in the capillary bed. The portal system becomes obstructed, causing a rise in portal venous pressure and portal hypertension, venous dilation, and stasis. In cirrhosis, there is decreased hepatic synthesis of albumin, not increased (Answer 2), and increased levels of aldosterone, not decreased (Answer 3). Blood volumes are decreased, not increased (Answer 4), while total body fluid is increased due to the physiological effects of hypoproteinemia (decreased serum proteins). These factors, plus increasing obstruction of the portal vein, cause fluids, electrolytes, and serum proteins to move out of the vascular compartment and into the intestines. The abdomen providesa large space for the accumulation of these fluids. Know where ascites is found and how fluid is able to shift (some type of intravascular problem). The nurse explains to a patient that a bronchoscopy is: An x-ray procedure that allows for multiple views of the lungs. A procedure utilizing a lighted mirror lens to observe the walls of the trachea, mainstem bronchus, and major bronchial tubes. A diagnostic test during which a radiopaque substance is inserted into the tracheobronchial tree for clear visualization. A needle puncture of the lung mass, identified on an x-ray with aspiration of cells for microscopic examination. Bronchoscopy provides direct visualization of the airways by utilizing a long, slender, hollow instrument through which a light is reflected. Bronchoscopy can be utilized for diagnostic purposes, for removal of foreign objects, for removal of mucous plugs, or for obtaining a biopsy orbronchial washings for cytology. Answer 1 is an example or a fluoroscopic exam. Answer 3 characterizes a bronchogram, and Answer 4, a lung biopsy. Try to take words apart: "bronch" means lungs and "scope" means use an instrument to look into a body part or cavity. The other options use x-ray or needle biopsy as the method of making a diagnosis. With severe diarrhea, electrolytes as well as fluids are lost. The nurse would conclude that the patient is experiencing hypokalemia if which of the following were observed? Spasms, high T waves on ECG, irregular pulse. Kussmaul breathing, thirst, furrowed tongue. Apathy, weakness, GI disturbance. Pitting edema, confusion, bounding pulse. Potassium deficit leads to decreased muscular function, causing muscle weakness, decreased intestinal motility, and a variety of GI symptoms (vomiting, abdominal distention, flatulence). There is also decreased neuromuscular irritability, which contributes to apathy, lethargy, and mental confusion. Answer 1 is partially correct (spasms or tetany and irregular pulse), but high T waves occur in hyperkalemia; low flat waves occur in hypokalemia. Answer 2 is incorrect because the symptoms indicated would likely be seen in metabolic acidosis and dehydration. Hyperkalemia would be expected. Pitting edema and bounding pulse (Answer 4) are seen in fluid overload, which would be consistent with hyperkalemia and renal impairment. Confusion does occur in hypokalemia. Know the influences of potassium on tissues and body functioning. Understanding that potassium is lost in severe diarrhea, you would be looking for low potassium levels and symptoms caused by hypokalemia, not hyperkalemia. Look carefully at each option. Often one correct statement is combined with an incorrect statement. A woman anticipating a stat cesarean birth expresses some concern over feeling the incision and experiencing pain. The most appropriate response would be: You will feel nothing at all. You may feel some pressure in the area during surgery. You may feel slight pain when the incision is made. If you feel any pain, it is only your imagination. The effect of the anesthesia will be closely checked prior to making the incision, and the level of anesthesia will be monitored throughout the procedure. Many times thewoman will complain of tightness or pressure in the area where the physician is working (Answer 1). No significant pain should be felt as long as the anesthesia is closely monitored and maintained (Answer 3). Answer 4 is inappropriate because it makes her feel that she should not complain about pain even if she actually does feel it. Look at some key words in the options: "feel nothing" (1); "pain when incision" (3); "only your imagination"^). Eliminate: Answer 4 because it is demeaning; Answer 3 because there should be no pain during surgery/ anesthesia; Answer 1 because pressure sensations do exist. After discharge following ileostomy surgery, a patient calls the nurse at the hospital to report the sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. What should the nurse advise? Call the physician if symptoms persist for 24 hours. Take 30 ml of m.o.m. (milk of magnesia). NPO until vomiting stops. Call the physician immediately. Abdominal cramps, vomiting, and watery or no discharge are signs of intestinal obstruction, a complication that requires immediate medical intervention. Answers 1,2,and 3 are incorrect, not only because they can delay appropriate medical intervention but also because they increase the risk of severe fluid and electrolyte imbalance. Although obstruction of an ileostomy is a rare problem, a very small stoma or one that is contracted may need to be dilated regularly so that the little finger can be inserted easily. The key word is "sudden." Suspect something serious with onset of multiple symptoms. Look for a pattern—three options delay diagnosis. To safely transport a patient who has chest tube drainage to the x-ray department to assess the degree of lung reexpansion, the nurse would: Remove the chest tubes, immediately covering the incision site with a sterile petrolatum gauze to prevent air from entering the chest. Disconnect the drainage bottles from the chest tubes, covering the catheter tip with a sterile dressing to prevent contamination. Send the patient to x-ray with the chest tube clamped but still attached to the drainage system to prevent air from entering the chest wall if the bottles are accidentally broken. Send the patient to x-ray with the chest tube attached to the drainage system, taking precautions to prevent interruption in the system. Normal functioning of chest tubes is maintained, and the drainage system is transported below the level of the chest.Chest tubes are not removed (Answer 1) to facilitate transportation of the patient; they are removed only after the physician is satisfied with the degree of reexpansion. Removing the chest tubes from the suction drainage system (Answer 2) will result in an equalization of intrapleural pressures with atmospheric pressures, thus also increasing the risk of pneumothorax. Current practice precludes the clamping of the chest tubes (Answer 3). It is believed that clamping increases the risk of a tension pneumothorax because air may enter the intrapleural space during inspiration but cannot escape during expiration. The reason why chest tubes are inserted is to re-expand the lung. Avoid any option that would interfere with the purpose of the chest tube. Look for the independent nursing action—nurses do not "remove," "disconnect," or "clamp" routinely. Which statement would the nurse make to differentiate ketoacidosis from insulin shock? Deep and rapid respirations are characteristic of ketoacidosis, whereas slow, shallow respirations are characteristic of insulin shock. Acetone breath characterizes ketoacidosis, whereas the breath of the patient in insulin shock is frequently fetid. Warm, dry, flushed skin and loss of turgor characterize the patient with ketoacidosis, whereas the skin of the patient with insulin shock is usually pale, cool, and diaphoretic. Apprehension, irritability, and combative behavior occur with ketoacidosis, whereas the patient in insulin shock is more likely to be confused, lethargic, or comatose. Hypoglycemic or insulin reactions are the result of decreased circulatory serum glucose to the brain. This stimulates epinephrine release. Early symptoms include cold, clammy skin, nervousness, tremors, numbness of the hands or around the lips, and cardiac palpitations. Later symptoms may mimic alcoholic intoxication, such as staggering gait, slurring of words, combative behavior, or uncontrolled weeping. As hypoglycemia deepens, the patient may develop convulsions and coma. Answer 1 is incorrect, in that respirations in insulin shock, though shallow, are increased. Answer 2 is incorrect because the breath of the patient in insulin shock is noncontributory, not fetid. Fetid breath may occur with liver failure or poor dental hygiene. Behavioral responses in Answer 4 are switched; that is, confusion and lethargy are common with ketoacidosis, and apprehension and irritability is consistent with insulin shock. Look for the signs and symptoms of insulin shock. Consider each sign or symptom individually; eliminate those options with incorrect signs and symptoms. The nurse explains to the patient and family that because of excessive bleeding, an emergency hysterectomy will need to be performed: Upon completion of the necessary surgical preparation. Immediately. Within 24 hours. At the start of the next surgical day. Emergency surgery must be performed to save the life of the patient, save the function of an organ or limb, remove a damaged organ or limb, or stop hemorrhage. Few emergency situations are so urgent as to require immediate response (Answer 2), eliminating the necessary laboratory data to evaluate the patient's physiologic response to the situation. Surgical preparation would be completed within 24 hours (Answer 3), but this is not the best answer. True emergency situations cannot be postponed to the following surgical day (Answer 4). Emergency means "right away;" however, important things need to be done before the surgery can begin. There are preliminary measures such as establishing baseline assessment data, establishing IV lines, determining allergies, and having blood on hand for replacement if necessary. Consider what is best for patient. The nurse can anticipate a marked improvement in the patient's prognosis if a hepatic coma lasts no longer than: 24 hours. 36 hours. 48 hours. 72 hours. Prognosis is generally poor if hepatic coma lasts longer than 24 hours. Other measures that have been utilized to decrease serum ammonia and allow for regeneration of hepatocytes include hemodialysis, exchange blood transfusions,and administration of lactalose, which, when degraded in the large bowel, decreases the pH of the feces, thus preventing formation of ammonia and promoting its excretion. Answers 2,3, and 4 all exceed the 24-hour threshold. The longer the patient is in the coma, the more complications will increase in number and effect. The effectiveness of peritoneal dialysis will be measured by: Serum potassium less than 3.5 mEq/L and serum sodium greater than 148 mEq/L. Unchanged quantity and specific gravity of urine. BUN less than 20 mg/dL, serum creatinine less than 1.2 mg/dL. Moderately soft abdomen and dullness on percussion. A BUN of less than 20 mg/dL and serum creatinine less than 1.2 mg/dl would be optimal outcome measures for this patient (that is, within normal range). Answers 1, 2, and 4 are incorrect because a serum K+ of less than 3.5 mEq/L would be indicative of hypokalemia and a serum Na* above 148 mEq/L indicates hypernatremia (Answer 1); quantity of urine output should increase to over 500 mL/24 hours (Answer 2); and the abdomen should be soft and tympanic to percussion; so dullness to percussion in the abdomen is consistent with fluid excess (Answer 4). The key word is "effectiveness." How well is the dialysis working? The closer to normal the values are, the more effective the treatment. Know normal lab values. After explaining peritoneal dialysis procedures to a patient and the family and obtaining a signed operative permit, the nurse's next action is to: Have the patient empty the bladder. Position the patient in a comfortable supine position. Weigh the patient and record vital signs. Cleanse and drape the abdomen. Before the dialysis procedure is started, baseline information needs to be collected so that the therapy can be accurately evaluated. Baseline information will include vital signs, body temperature, weight, FCG, and electrolyte levels. If the patient does not have a Foley catheter (often by this time he or she does because of the need to assess hourly outputs), then the patient is asked to void. Following voiding,the patient is positioned in a supine or low Fowler's position and the abdomen is prepared and draped. Answers 1,2, and 4 are actions subsequent to Answer 3. With renal problems, weight is often the correct answer. Of the following activities of daily living, which should the nurse recommend that a patient (who has had a bilateral hernia repair) avoid after discharge? Driving to and from work. Walking 3 miles a day. Washing and polishing the car. Carrying out the garbage cans. All straining and lifting should be avoided for at least 3 weeks to prevent undue stress on the sutures. Other less strenuous activities, such as Answers 1, 2, and 3, are appropriate, though good body mechanics should be reviewed with the patient. Look at all the activities and determine which one would be the most strenuous for the patient. A patient has had a spinal anesthetic. In the recovery room, it will be important that the nurse immediately position this patient: On the side to prevent obstruction of airway by tongue. Flat on the back. On the back, with knees flexed 15 degrees. Hat on the stomach, with head turned to side. To avoid the complication of a painful spinal headache that can last for several days, the patient is kept flat in a supine position for approximately 4-12 hours postoperatively. Headaches are believed to be due to the seepage of cerebral spinal fluid from the puncture site. By keeping the patient flat, cerebral spinal fluid pressures are equalized,which avoids trauma to the neurons. Answer 1 is the position for patients having general anesthesia. Answer 3 is in correct because knees are flexed. Answer 4 is the position for patients with head traumas. When a question is asked about the recovery room, you know that this is the immediate postoperative period. Select the position that would be used first and would prevent spinal headache. After positioning a patient who has had spinal anesthesia, the recovery room nurse initially should make which observation: Status of reflexes. Vital signs. Patient's level of consciousness. Integrity of airway. Patients who have had spinal anesthesia have varying degrees of hypotension due to the vasodepressor effect of the anesthetic agent on the autonomic nervous system. Reflexes (Answer 1) will be depressed in the lower extremities because of the anesthetic and should be checked after circulatory status. However, sensory impulses remain blocked longer than motor activity, so safety measures should be instituted to prevent injury from bedding, poor positioning, or sources of heat. Because the patient is awake with a spinal anesthetic, level of consciousness (Answer 3) and airway integrity (Answer 4) are lower priorities than circulatory status. Think baseline data in the postoperative period. You need to know what the vitals were and how they progress over time. With spinal anesthetic, circulatory problems are more likely. While giving diet instructions after a cholecystectomy, the nurse would inform the patient that: The diet will not include fatty food for at least 1 year. After approximately 3 months polyunsaturated fats can be added to the diet. There are no specific dietary restrictions in the postoperative period, but the patient will be more comfortable if large, fatty meals are avoided. The diet will be limited to 20 g of fat per day. There are no specific dietary restrictions following cholecystectomy. Patients are advised, however, to avoid foods highin fats. Most patients tend to avoid these foods anyway because they are more comfortable if they do so. Generally, after about 3 months, patients may begin to experiment with certain foods to ascertain their tolerance to them. Answer 1 is incorrect because some fat is allowed in the diet at all times. Answer 2 is incorrect because fats are not limited to those classified as polyunsaturates. Answer 4 is incorrect because fats are allowed in the post-cholecystectomy diet, to tolerance. Understand the purpose of the gallbladder and why it needed to be removed. Bile is stored in the gallbladder and sent out of the gallbladder when fat needs to be digested. Fatty foods are avoided when there is gallbladder disease because of the pain that occurs when there is a demand but the gallbladder is not able to respond. The obstruction or inflammation has been solved with the removal of the gallbladder. Most patients are fearful of the return of severe pain and are hesitant to eat a fatty meal initially. While assisting a patient who has had a thyroidectomy to dangle at the bedside on the first postoperative evening, the most appropriate nursing action would be to Support the patient under the axilla while bringing the feet over the bedside. Bring the patient's feet to the side of the bed and support the back of the neck while assisting the patient to assume a sitting position. Allow the patient to assume the sitting position at the patient's own pace, unassisted unless necessary. Bring the patient's feet to the side of the bed, then pull the patient forward. The patient who has had thyroid surgery should be assisted in supporting the head and neck whenever the position is changed during the first 3 postoperative days. Supporting the head is particularly important during early ambulation procedures, when sudden movement may result in hyperextension of the neck. Answers 1, 3, and 4 are incorrect because none of these responses takes into account the need to prevent hyperextension of the neck. Think of where the surgical incision is for this surgery. Support the head to prevent any trauma to the incision. New parents of a baby with a cleft lip and palate are experiencing a reactive depression in response to the birth of their infant, who is in the high-risk newborn nursery. The primary difference between a reactive (situational) depression and major depressive disorder melancholic type (endogenous depression) is that in a reactive depression: There is substantial weight loss, usually over 10 pounds. The individual does not respond to environmental stimuli. The individual generally feels worse as the day progresses. The precipitating event is usually difficult to identify. This diurnal variation is characteristic of a reactive (situational) depression. The individuals experiencing a melancholic type depression usually feel worse in the morning but better as the day progresses. In reactive depression there is usually a weight loss of less than 10 pounds (Answer 1). The individuals usually do respond to environmental stimuli(Answer 2). The precipitating event is usually an identifiable stressor, such as the birth of an unhealthy baby (Answer 4). Knowing the difference between reactive depression (situational) and melancholia will point to the correct answer. You can also eliminate Answers 2 and 4 because of similarity of terms, such as "reactive" (situational); you would expect a response (reaction) to environment and external stressors (events). An Apgar score of 4 at 1 and 5 minutes indicates that the neonate's condition is: Excellent. Good. Fair. Poor. An Apgar score of 4-6 indicates the infant is in fair condition. "Excellent" (Answer 1) is not a category in the Apgar score. "Good" (Answer 2) is a score of 7-10. "Poor"(Answer 4) is a score of 0-3. Review the five areas of assessment and scoring for Apgar. Use this acronym to help remember theory in selecting the answer: A—Appearance; P—Pulse; G—Grimace; A—Activity; R—Respiratory effort. A toddler who fractured the right femur in a car accident is placed in Bryant's traction and admitted to the hospital. During the first night in the hospital, the toddler lies still in the crib, sucks a thumb, and occasionally sobs quietly in a monotone voice. The nurse should interpret these behaviors to mean that the toddler: Wants his or her mother. Might prefer to sleep in a bed. Probably does not sleep through the night at home. May be experiencing painful muscle spasms due to the fracture. Toddlers will most likely experience separation anxiety when separated from parents. In the "despair" phase, the child appears to be mourning the apparent loss of the parent, as evidenced by nonverbal behavior cues such as monotone crying,regressive behavior (thumb sucking), and sleep disturbances. If this child were experiencing muscle spasms due to her fracture (Answer 4), she would most likely cry out in severe pain intermittently. The other explanations for her behavior (Answers 2 and 3) do not take her developmental level into account. Know age-typical (toddler) behavior in relation to the concept of separation anxiety. Most accidental pregnancies in couples using "natural" family planning methods have been related to unprotected intercourse before ovulation. Which factor explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period: Spermatozoal viability. Ovum viability. Tubal motility. Secretory endometrium. Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result. Answer 2 is incorrect because the ovum is present only after ovulation. Answer 3 is wrong because tubal motility is important in the union of ovum and sperm (and transport of the zygote) after ovulation. Answer 4 is wrong because the uterine endometrium becomes secretory postovulation. The question asks for when pregnancy might occur preovulation; three of the answers focus on postovulation. Parents of an infant with deformities may use which of the following defense mechanisms in attempting to cope with their anxiety? Fixation. Displacement. Conversion. Sublimation. Both parents will probably attempt to place the blame for their infant's deformities on someone or something else, such as "inadequate prenatal care," "bad counseling," or "God's wish." Answer 1 involves a state in which personality development is arrested in one or more aspects at a level short of maturity. Answer 3 involves unconsciously translating emotional problems into physical symptoms. Answer 4 involves channeling a destructive or instinctual impulse that is socially unacceptable into a socially acceptable behavior, such as coping with anger by participating in sports that require the release of a lot of energy. Know definitions of common defense mechanisms. The parents of an infant born with a cleft lip and palate express concern about caring for their infant. They are especially worried about paying excessive hospital bills because insurance has set limits. The most appropriate nursing action would be to: Refer the couple to a social worker. Validate the couple's perceived needs. Discuss alternatives with the couple. Implement health teaching regarding the physical care of the infant. It is important to assess and validate the parents' perceived needs in order to plan care effectively. The parents may need a social worker as well as a public health nurse,speech pathologist, audiologist, etc. Therefore it is essential to first make an accurate and continual assessment of the family's needs before referral (Answer 1). Alternatives (Answer 3) may be more appropriately identified after performing a total assessment. Health teaching (Answer 4) is necessary, but it must be based on an assessment and validationof the family's needs as well as of their level of readiness. Assessment ("validate") comes before referral (1), discussing alternatives (3), or doing health teaching (4). The nurse suggests that premenopausal breast self-examinations are best carried out: During the middle of the menstrual cycle. On the first day of each month. One week after the onset of menses. The week before the onset of menses. Breast self-examination are best done the week following onset of menses. The breasts are then the softest, and any lumps not associated with hormonal changes are more evident. Answer 1 is incorrect because breast changes due to hormonal changes, such as fullness or tenderness, may occur at this time, obscuring possible pathology. Answer 2 is a good idea (that is, having a regular time or pattern for examination), but does not take into account the normal breast-tissue changes during the menstrual cycle. Answer 4 is incorrect for the same reason as Answer 1. The question asks for the best time period—before, during, or after menses. Key factor is to avoid hormonal influence; therefore, eliminate Answer 1 (middle), Answer 2 (first day), Answer 4 (week before). In preparing a patient for an IV cholangiogram, it is important for the nurse to ascertain: If the patient has ever had the procedure before. If the patient has any known allergies, particularly to fish or other iodine-containing substances. If the patient's epigastric discomfort occurs only with fatty-food ingestion. If there is a family history of gallstones. The contrast medium utilized in IV cholangiograms, like that used in intravenous pyelograms, contains iodine. It is important to ascertain before the test whether the patient is aware of any allergy to iodine. Saltwater fish generally leave a high iodine content, so it is helpful to ascertain if the patient has an allergy to fish, and if so, to what kind. Answer 1 is helpful in planning patient teaching. Answers 3 and 4 are less specific responses that provide interesting, though not essential, data. Priority for any diagnostic study using a contrast medium is to determine if the patient has an allergy to the substance being used. The nurse suspects abdominal wound dehiscence, and lifts the edges of the patient's dressings. The nurse notes that the wound edges are entirely separated. What is the next nursing action? Tell the patient to remain quiet and not to cough. Offer the patient a warm drink to promote relaxation. Position the patient in a chair with the feet elevated. Apply a scultetus bandage. The patient should remain quiet in a low Fowler's or horizontal position. He or she should be cautioned not to cough so as not to extrude any intestines by increasing intra-abdominal pressures. The physician should be notified next. Remain with the patient; reassuring him or her, monitoring vital signs, and having others bring equipment such as IV setup, nasogastric tube, and suction equipment. The surgeon should also be notified that the patient will be returning to the operating room. The patient should be kept NPO (Answer 2) in the above position (Answer 3) and the dressing left in place to prevent evisceration (Answer 4). This is an emergency situation. Look for the answer that will not add to the damage. Getting the patient out of bed to a chair may cause the entire wound to open and all contents of the cavity to eviscerate. This new wound will need surgical correction, so patient should be kept NPO. Which of the following signs and symptoms are least likely to occur during peritoneal dialysis if fluid drainage is inadequate? A negative balance between the amount drained and the amount instilled. Confusion, lethargy, and coma. Moist crackles and rhonchi. Flattened neck veins in a supine position. Flattened neck veins in a supine position are characteristic of hypovolemia. Inadequate drainage would result in fluid retention and hypervolemia. Indications of fluid retention include inadequate fluid drainage (greater intake than output), increased blood pressure, and signs of congestive heart failure, for example, distended neck veins, increased dependent edema, crackles, and decreased mentation(Answers 1,2, and 3). The key word is "least likely"; this could also be rephrased by saying what will not happen. Look for fluid volume excess, not deficit. Which nursing action is designed to reduce ammonia intoxication in a patient with bleeding esophageal varices who is jaundiced, edematous, and in a hepatic coma? Active and passive range-of-motion exercises to prevent venous stasis. Tap-water enemas to remove blood that may still be in the gut from the bleeding esophageal varices. Administration of insulin and glucagon to reduce serum-potassium levels. Holding all antibiotic medications so that the action of the intestinal bacteria on protein is enhanced. Ammonia is formed in the intestines by the action of intestinal bacteria on proteins. Tap-water enemas may be given to remove protein-rich blood that has resulted from bleeding esophageal varices. Because ammonia is formed during muscle contraction, active range-of-motion exercises are contraindicated (Answer 1). To prevent skin breakdown in a patient who is jaundiced and edematous, passive exercises,turning, and frequent skin care are indicated. In an effort to reduce serum-ammonia levels, potassium levels need to be increased, not reduced (Answer 3), because potassium is necessary for cerebral metabolism of ammonia. Antibiotics that are poorly absorbed by the intestines, such as neomycin, are given, rather than withheld (Answer 4), to decrease the intestinal flora that manufacture ammonia. Only one option includes an intervention for a possible cause for an ammonia increase—blood. In analyzing the BBT record of a woman who has a normal 30-day cycle, on which of the following days would the nurse expect to find evidence of ovulation? Day 5 or 6. Day 13 or 14. Day 16 or 17. Day 28 or 29. Ovulation occurs most commonly 14 days before the next menstrual period. In a 30-day cycle, this would be day 16 or 17. Answers 1 and 2 are incorrect because they describe a time prior to normal ovulation; Answer 4 is wrong because ovulation occurs before the last week of the menstrual cycle. Understand the phases of a woman's menstrual cycle and the fertile period. Answers 1 and 2 describe a time prior to ovulation; Answer 4 occurs at the end of the menstrual cycle. Think middle of the month, middle option, a midpoint number (i.e., 16-1/) among the options. The nurse explains to a patient's family that the surgical treatment most often implemented for excessive vaginal bleeding due to uterine fibroids is: Panabdominal hysterectomy. Vaginal hysterectomy. Dilation and curettage. Abdominal hysterectomy. An abdominal hysterectomy is generally the treatment of choice for uterine fibroids with excessive vaginal bleeding. If the ovaries are not pathologic, there is no reason for surgical removal. Answer 1, panabdominal hysterectomy involves the removal of the uterus, fallopian tubes, and ovaries and is usually performed for extensive endometriosis or carcinoma. A vaginal hysterectomy (Answer 2) is the treatment of choice for a prolapsed uterus, and a D & C (Answer 3) is primarily a diagnostic tool, not a measure to excessive uterine bleeding. The key word is "fibroids," which do not require extensive removal of tubes, ovaries and uterus. Thus, eliminate 1. The difference between Answer 2 (vaginal) and Answer 4 (abdominal) is that Answer 2 is done for a prolapsed uterus, not for excessive vaginal bleeding from fibroids. Following surgery, a patient with diabetes complains of nausea and appears lethargic and flushed. BP 108/78, P 100, R 24 and deep. The first nursing action should be: Call the attending physician. Check the patient's blood glucose. Administer an antiemetic. Decrease the patient's IV infusion rate. Before notifying the physician (Answer 1), it is necessary to collect the data, blood sugar and urine sugar and acetone, on which the physician will base the insulin order. The physician should also be notified of the patient's vital signs and intake and output. Generally, urinary output is depressed for about 36 hours after surgery due to increased circulating levels of ADH. Given that the patient has also had insensible water loss (respirations and perspiration), the assessment data strongly indicate dehydration or hypovolemia. An antiemetic (Answer 3) may be administered if nausea persists after blood sugar and fluid balance are rectified. The physician may order an increase in the amount and rate of intravenous fluids (contrary to Answer 4). The key consideration here is that the patient is a diabetic. During surgery the normal routine of the diabetic patient is interrupted. The first thing the nurse should do in this situation is to get baseline information, which includes glucose level for a diabetic patient. Then the nurse has accurate assessment data to report. Choose the first step of the nursing process—assess. Passive arm exercises are instituted on a patient's left arm 4 hours after lobectomy surgery. The nurse assists with these exercises to prevent which dysfunction? Hyperflexion of the wrist. Ankylosis of the shoulder. Flexion of the elbow. Spasticity of the intercostal muscles. Arm exercises are initiated to prevent ankylosis of the shoulder. Most patients tend to splint incisional discomfort by limiting movement on the affected side. This protective mechanism may lead to "frozen shoulder," or ankylosis. Therefore, it is important to initiate movement early to maintain muscle tone and joint integrity. Answer 1 is an example of wristdrop due to poor positioning of wrist joints. Answer 3 is usually a normal finding, although it may occur with improper positioning with upper motor neuron lesions. Intercostal muscle spasticity (Answer 4) is rare and is not due to positioning. Visualize the incision. It is natural to protect an area (to splint) to reduce the pain. The shoulder will lose mobility very quickly if passive range of motion does not begin in the early postoperative phase. The nurse initiates ileostomy teaching with a patient during the early postoperative period. The primary objective of this procedure is: To facilitate maintenance of intake and output records. To control unpleasant odors. To prevent excoriation of the skin around the stoma. To reduce the risk of postoperative wound infection. The primary objective of stoma care is to prevent skin irritation and excoriation. The surrounding skin should be washed with mild soap and water, rinsed thoroughly, and patted dry. The ostomy appliance should be fitted close to the stoma to further prevent skin irritation. Although fecal material is measured as output (Answer 1), this procedure is secondary to control of skin damage. A tight-fitting seal on the drainage bag and a well-ventilated room will decrease odor problems (Answer 2). Likewise, a tight-fitting appliance will prevent contamination of the abdominal incision (Answer 4). The key words are "primary objective." Focus on prevention of skin excoriation. The gastric enzymes in the ileostomy drainage are very irritating to the tissue surrounding the stoma. When teaching families about cleft lip and palate, the nurse would need to be aware that Cleft lip occurs most frequently in girls. Cleft palate occurs most frequently in boys. Cleft lip and palate almost always occur simultaneously. Cleft lip and palate are both influenced by hereditary factors. The exact cause of the failure of the embryonic structures of the face to form a union is unclear. However, there is a significant familial pattern, and a hereditary factor is involved. Cleft palate is seen more frequently in girls, whereas cleft lip is seen more frequently in boys (Answers 1 and 2). Although cleft lip and palate sometimes do occur together (Answer 3), in many cases they occur independently. Choose the more general "heredity" response than gender-specific responses (1,2); eliminate the option with "always" in the stem. A pregnant woman was instructed to report signs and symptoms of preterm labor. The nurse knows that the woman failed to follow instructions about evaluating her signs and symptoms when she telephoned before she: Waited to see if uterine contractions were occurring every 10 minutes. Assessed that her contractions continued after she emptied her bladder. Drank a glass of water for hydration. Rested in bed on her side for 1 hour. The woman should have waited to telephone until she had assessed her signs and symptoms after drinking three to four 8 oz glasses of water for hydration. She is correct to call when her contractions are every 10 minutes (Answer 1), to call after she emptied her bladder (Answer 2), and to call after she rested in bed for 1 hour (Answer 4). The question asks for the action that the patient should do first (but did not do) before calling the health care provider. Hydration will often stop uterine irritability. The other answers would be appropriate for her to contact the provider. The Trendelenburg test is frequently used to evaluate the competence of venous valves. Prior to administering the test, the nurse tells the patient that this test will consist of: Walking back and forth so the nurse can observe venous changes during walking. Injecting a contrast medium into the veins and taking multiple x rays as the dye flows in the veins. Stripping a superficial vein, occluding flow, and then releasing the vein and observing the direction of filling. Elevating the involved leg to empty the veins, applying a tourniquet to the upper thigh while the patient is first lying down and then standing, and then removing the tourniquet to observe the filling of the superficial veins. The Trendelenburg test evaluates the competency of the superficial veins. While lying down, the patient is asked to elevate the involved leg to empty the veins. A tourniquet is then applied lightly to occlude the superficial veins. The patient is then asked to stand, the tourniquet is removed, and the direction and degree of vein-filling are observed.Answer 1 is also a test of venous competence: Ordinarily, distended veins decrease markedly during walking because muscular contractions facilitate venous flow in deeper veins.Answer 2 describes a phlebography, and Answer 3 is a test generally used on the jugular vein when pump failure is suspected. The key phrase is "competence of the venous valves." To do such a test, you need to empty the veins as best you can (lying down), obstruct the blood flow (tourniquet), have patient stand to have the impact of gravity on the blood flow (competent valves will prevent blood from flowing backwards). As you visualize each option, look for the one that will empty the vein first. A woman who is anticipating a stat cesarean birth for a fetus in transverse lie questions the nurse about the type of incision the physician will use in her operation. The nurse should realize that this woman's primary concern involves the possibility of: Infection. Bleeding. Scarring. Rupture. Usually with a transverse lie the classic or longitudinal incision is used, and the woman is concerned about her body image. Answers 1,2, and 4 may be concerns, but they are not usually primary in the woman's mind. Compare the answers given here, and determine which could cause the patient to be concerned about body image. Answers 1,2, and 4 do not relate to body image. A patient asks the nurse whether marijuana is addictive. The most appropriate response by the nurse would be: It is addictive. It causes a psychological dependence. It is not addictive. It is physiologically addictive. There is a physical tolerance, but the dependence is purely psychological. Answers 1 and 3 are imprecise; and Answer 4 is incorrect because this drug is not physiologically addictive. Know what is the effect of marijuana in relation to dependency/addiction. Following the insertion of a catheter into the abdominal cavity, warmed dialyzing solution is allowed to run rapidly (10-20 minutes) into the abdominal cavity. The nurse warmed the solution to body temperature to prevent abdominal pain and to: Expand the molecules and increase the osmotic gradient. Increase dilation of the peritoneal vessels, thereby increasing urea clearance. Decrease the likelihood of peritonitis due to constriction of peritoneal vessels. Expedite the movement of the dialyzing solute into the abdomen. The dialysate is warmed to body temperature before administration to minimize discomfort and optimize clearance of waste products. Warming the fluid tends to dilate the peritoneal vessels, increasing the amount of urea that passes through the membrane. It has little effect on the osmotic gradient (Answer 1), does not prevent peritonitis, which is secondary to infection (Answer 3), and does not speed infusion time (Answer 4), although it does make it more comfortable. The purpose of dialysis is to act as a filtration when the kidneys are unable to function correctly. Know the effect of "warming"—improves blood flow to an area. Preoperative teaching measures unique to the patient having a thyroidectomy should encompass: Active flexion exercise of the neck, special coughing instructions, voice rest, and antithyroid medications postoperatively. Active flexion and extension neck exercises, deep breathing and coughing, and thyroid replacement when necessary. Instruction on supporting the back of the neck when repositioning and ambulating, and avoiding hyperextension and flexion of the neck when coughing. Instruction on supporting the back of the neck when ambulating and repositioning and active flexion exercises of the neck. To prevent undue stress on the suture line and underlying surgical repair, the patient is taught to support the back of the neck when repositioning and to avoid both hyperextension and flexion of the neck. Answer 1 is incorrect because active flexion of the neck is avoided and because after a total thyroidectomy the patient will receive thyroid medications to prevent hypothyroidism and to maintain a euthyroid state. Answer 2 is also incorrect due to the focus on active flexion and extension neck exercises, which would put undue stress on the suture line. Answer 4 is partially correct;however, again, active flexion exercises are contraindicated. Visualize the incision line. Only one option supports the head in a neutral position. The nurse will plan to read the reaction to an intradermal tuberculin test in: 6-12 hours. 12-24 hours. 24-48 hours. 48-72 hours. The intradermal tuberculin test is read in 48-72 hours. Color is observed, and the injection site is palpated for in duration. Reading the test in less than 48 hours may lead to inaccurate interpretation (Answers 1, 2, and 3). It takes time for a reaction (more than 2 days). Which are precautionary nursing measures to be used when caring for a patient being treated with internal radioisotopes Maintain strict patient isolation, and limit professional contact with patient. Limit exposure, and maximize distance between patient, professional, and family. Position the patient in a prone position, and restrict turning to mealtimes only. Maintain the legs in a flexed position to decrease the likelihood of dislodgement. It is not necessary to isolate a patient with radioactive implants (Answer 1), but to prevent undue exposure to radiation contacts, contact time should be brief and distance between the patient and others maximized. Specific instructions as to the amount of time permitted with the patient and the safe distance should be posted. Answers 3 and 4 are incorrect because the best position for the patient is supine. It is important to maintain patient position so that the implant is in the correct position; but none of these options describes the correct position (lying flat on back). The other important consideration is to protect the staff and family visitor from unnecessary exposure. Patients who have radiation implants have active radiation ongoing for a number of hours. Know the concepts of time (as short a time of exposure to others as possible), distance (stay as far away as possible from the source of radiation), and shielding (protect with a lead barrier such as apron) when dealing with radiation therapy. The nurse explains to a patient who is diagnosed with cirrhosis that the anemia is the result of: Increased RBC fragility due to folic acid deficiencies from inadequate dietary intake. Decreased efficiency of Kupffer cells in the liver. Increased blood-ammonia levels. Decreased amino acid breakdown and synthesis. Anemia occurs in cirrhosis due to (a) erythrocyte destruction in the engorged spleen, (b) gastrointestinal blood losses, and (c) folic acid deficiencies from inadequate dietary intake. Kupffer cells (Answer 2) line the venous sinusoids in the liver and are primarily macrophagic Answers 3 and 4are incorrect because decreased amino acid breakdown and synthesis result in increasing serum-ammonia levels, which may further inhibit dietary intake. Use process of elimination and a clue from the stem—anemia; look for low RBCs. Postoperative vital signs for a patient with diabetes are BP 108/78, pulse 100, respirations 24 and deep. IV intake has been 2100 mL and urine output 2000 mL. The nurse recognizes that the patient is experiencing: Increased ADH release in response to physiological stress of surgery. Decreased extracellular fluid (ECF) volume due to osmotic diuresis. A hypo-osmolar fluid imbalance. Circulatory overload. The patient's vital signs and urine output reflect a decrease in extracellular volume secondary to osmotic diuresis. Increased ADH release decreases urinary output (Answer 1).A hypo-osmolar fluid imbalance is one in which there is more water than solute in the extracellular fluid compartment (Answer 3). Like circulatory overload (Answer 4),symptoms of a hypo-osmolar imbalance include widened pulse pressure, increased blood pressure, distended neck veins, and respiratory crackles. Blood pressure is low and pulse is fast in fluid volume deficit. Following bronchoscopy, what is the nurse's most important observation? Blood pressure, pulse, and temperature. Color and consistency of sputum. Function of the tenth cranial nerve. Presence of urticaria. After bronchoscopy the patient generally produces a large amount of sputum that must be observed carefully for signs of hemorrhage, particularly if a biopsy specimen has been taken during the procedure. Although the sputum is generally bloodstreaked, any pronounced bleeding should be reported immediately. Patency of the airway is the first priority. Answers 1 and 3 are also observations made after a bronchoscopy. Vital signs are observed until stable, and food and fluids are with held until the gag reflex returns. Answer 4, urticaria, does not occur following bronchoscopy, though it may after a bronchogram if the patient reacts to the iodine-based dye. Think of the organ just examined and look for any signs and symptoms that identify a problem in that organ or system. Priority—assessment of system affected by procedure (e.g., patency of airway). The nurse knows that emergency procedures increase the surgical risk to the patient because: The surgery is performed immediately. There is little time for psychological/physical preparation. There is decreased physiological stress. The anesthesia of choice is different for emergency surgery. Few surgeries warrant immediate treatment (Answer 1); however, the urgency of the situation does decrease preparation time. Consequently, the patient's physiologic stress will increase, not decrease (Answer 3), placing greater demands on metabolic functions and increasing the risk of complications. Emergency surgery does not compromise the use of general anesthesia (Answer 4). It is imperative to ascertain before an emergency surgery the time, type, and amount of the last oral intake, as gastric lavage or suctioning may be necessary to prevent aspiration during the surgery. Generally patients are NPO 12 hours before surgery. When more than one answer looks good look for an answer that is broad and includes another option. Care of the patient on peritoneal dialysis must allow a dwell time, or equilibration period, of the dialyzing fluid, which is normally: 10-15 minutes. 20-30 minutes. 50-60 minutes. More than 1 hour. Generally, the dwell time of the dialysate is 20-30 minutes, occasionally longer. The dwell time as well as the instillation and outflow times are prescribed by the physician according to the patient's needs. Ten to 15 minutes (Answer 1) is too short a time to allow for diffusion of waste products. Equilibrium between dialysate and body fluids occurs in 15-30 minutes. Longer times (Answers 3 and 4) are not necessary. Think about what is happening in the procedure and determine how long it would take to be effective. The Billings method (or cervical mucus method) of natural family planning incorporates patient examination of cervical mucus. Which characteristics are typical of the cervical mucus during the "fertile" period of the menstrual cycle: Thick, cloudy. Thin, clear, good spinnbarkeit. Yellow, sticky. Absence of ferning. Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and clastic (spinnbarkeit), facilitating sperm passage. Answer 1 is incorrect because cervical mucus becomes thicker and opaque under progesterone stimulation after ovulation. Answer 3 is wrong because cervical mucus is essentially colorless, and postovulation, under progesterone stimulation, it becomes thick and sticky. Answer 4 is wrong because ferning is absent during the postovulatory period. The question asks for characteristics of the fertile period (i.e., during high estrogen level). Eliminate three of these answers, because they indicate characteristics during postovulation (under progesterone simulation). Compare the signs of fertile mucus versus nonfertile periods of a woman's menstrual cycle. An elderly patient asks about the type of anesthesia used for cataract surgery. The nurse replies that this surgery is generally performed using a: Local. General. Intravenous. Rectal. Local anesthesia is used in cataract surgery, not only because this surgery is a short procedure but also because mostpatients are elderly, with one chronic disease or more, which may be exacerbated by general anesthesia (Answer 2). Intravenous anesthesia (Answer 3) with thiopental sodium (Pentothal) is most frequently used when unconsciousness is desirable for short procedures or when an anesthetic induction is desired for general anesthesia. Rectal anesthesia (Answer 4), though rarely used today, has been employed to induce short-term anesthesia in children. The procedure is fast, and the eye is easily anesthetized. Most patients are elderly, and are high risk with general anesthesia. A patient has frequent stools, with poor oral intake of both fluids and solids. While administering the ordered parenteral hyperalimentation, it is important to remember that hyperalimentation solutions are: Hypotonic solutions used primarily for hydration when hemoconcentration is present. Hypertonic solutions used primarily to increase osmotic pressure of blood plasma. Alkalyzing solutions used to treat metabolic acidosis, thus reducing cellular swelling. Hyperosmolar solutions used primarily to reverse negative nitrogen balance. Parenteral hyperalimentation solutions are hyperosmolar solutions containing amino acids, 10-25% glucose, multivitamins, and electrolytes. These solutions are administered through large veins such as the subclavian to avoid the inflammation or thrombosis that these hyperosmolar solutions tend to cause in peripheral veins. These solutions are given to patients with disturbances to ingestion, digestion, or absorption that are combined with excessive catabolism. Hypotonic solutions (Answer 1) have osmolality less than blood plasma osmotic pressures and cause fluids to enter the cells. They are used for fluid replacement when some sodium is also necessary. Answer 2 is partially correct, in that hyperalimentation solutions are hypertonic; that is, they have an osmolarity greater than that of the plasma. However, the goal of hyperalimentation is not to reduce cellular swelling but to reverse negative nitrogen balance. Hypertonic solutions utilized to reduce cellular swelling are indicated in water intoxication and severe sodium depletion. Rapid infusion of hyperalimentation solution, however, will cause cellular dehydration. Answer 3 is incorrect because it is not a hyperosmolar fluid. Look for the clue in the stem—"hyper"; from two choices with the prefix "hyper," choose one that would improve poor intake. A newborn's Apgar score at 1 and 5 minutes is 4. The nurse assisting with the care of this newborn should realize the primary goal is to: Establish an airway. Maintain an adequate temperature. Reassure the parents. Monitor the infant's vital signs. Ensuring adequate oxygenation of the infant's system is the number one priority to sustain life. Answers 2,3, and 4 are all appropriate secondary goals. Choose the first action; think priority (airway). Review Apgar scoring and what scores would require immediate resuscitation of the newborn. The nurse concludes from a patient's assessment and history of muscle fatigue and ankle swelling that vein-stripping is indicated, because of: Advancing varicosities and cosmetic reasons. Stasis ulceration and thrombophlebitis. Lymphedema and Raynaud's disease. Advancing varicosities only. Vein-stripping is done not only for advancing varicosities but also for cosmetic reasons. Vein-stripping is not done for thrombophlebitis (Answer 2), though it is done for stasis ulcerations following successful healing of the ulcer. Answer 3 is incorrect because lymphedema is due to blockage of lymph channels and Raynaud's disease is a syndrome that affects the arterial vasculature. Answer 4 is incomplete. Look at every word in the options because some correct answers may be combined with incorrect; e.g., thrombophlebitis is not a reason for vein stripping, yet stasis ulceration could be. Many people do have vascular surgery for cosmetic reasons, which would make Answer 4 less complete than Answer 1. Look for options that include others (more than one reason). Besides omission of food and fluids by mouth, other nursing considerations in the preparation of a patient for IVP would include: Ingestion of contrast medium the morning of the procedure. Administration of cathartics or enemas to improve visualization of contrast medium in renal structures. A low-protein and low-salt diet the evening before to increase hyperosmolarity of ECF. Institution of an intravenous line to maintain fluid and electrolyte balance. The evening before an intravenous pyelogram (IVP), the patient is administered oral cathartics or enemas to clean the bowel of fecal material and flatus, thereby improving visualization of the kidneys and ureters. The radiopaque dye used in this procedure is injected by a physician in the radiology department, not by the nurse before the procedure (Answer 1). Answer 3 is not part of IVP preparation. If the patient is having difficulty maintaining fluid volume balance, an intravenous infusion may be initiated to prevent dehydration, but it is not standard (Answer 4). If the intestine was not empty, would visualization of the kidney be accurate? The nurse gives postoperative explanation to a patient with diabetes that regular or crystalline insulin is used as an adjunct to NPH therapy because: There is increased tissue metabolism with surgery. Insulin production is decreased even further with the stress of surgery. Physiological and psychological stress increases serum-glucose levels via sympathetic nervous system stimulation. An increased insulin load is necessary to prevent hyperkalemia. Glycogcnolysis and therefore serum-glucose levels are increased due to the stresses of surgery. To blood-glucose levels and prevent ketoacidosis, secondary to increased tissue metabolism (Answer 1), and regular insulin is given in doses adjusted according to the insulin of urine tests (rainbow or sliding scale). Regular insulin may be given alone until results of urine tests for glucosuria and ketonuria stabilize or as a supplement along with intermediate-acting insulin such as NPH. Answer 2, decreased insulin production, results from the extent of the patient's dysfunction, not the stress of surgery. Insulin does facilitate the movement of potassium across the cellular membrane, thus preventing hyperkalemia (Answer 4) but this is not the best answer. Think of the stress reaction and its effects on the body. Increased stress leads to increased glucose level. Three days after successful resuscitation from cardiac arrest after myocardial infarction, the patient states to the nurse, "I'm all washed up. I don't think I'll ever be the same man again." The nurse's best response to this statement would be: Most patients who have been as ill as you feel that way. How do you feel you have changed from before your illness? Getting depressed won't help you get better. Tell me more. Life-threatening illnesses, especially those with complications resulting in prolonged recuperative periods, provoke alterations in body image. To assist a patient experiencing altered body image, the nurse needs to ascertain how the patient viewed his or her body previously and how he or she views it now. Doing this may unleash a torrent of feeling from the patient, which may help the nurse discover ways to help the patient cope. Answers 1 and 3, while acknowledging this patient's mood, tend to cut off further response from the patient. Answer 4 is too open-ended. Hear the words in the options as if they were spoken, and many times the correct option will jump out at you. The nurse recognizes dyspnea as: Increased awareness of respiratory effort. Decreased alveolar ventilation. Increased rate and depth of respiration. Decreased oxygen saturation of venous blood. Dyspnea is a term that describes the patient's subjective awareness of increased respiratory effort. The increased work of breathing may indeed be related to alveolar hypoventilation (Answer 2), which results in an increased rate and depth of respiration (Answer 3). Oxygen saturation (Answer 4) shows whether the circulation is normal or tissue demands have changed. Look for the option that is broad: Dyp-snea is subjective data. The other options have components of objective data. A teenage patient in a substance abuse facility feels very isolated from his peer group because he has been placed in an adult unit. In planning care for this patient, which would be most effective: Assisting the patient to develop a working relationship with a 51-year-old patient. Encouraging friends to visit frequently. Asking the adolescent what he enjoys doing. Establishing a one-to-one relationship with the patient. This allows the patient some over his care and makes the patient feel that the staff is interested in meeting his needs. Answer 1 is inappropriate unless they have a common interest. Frequent visits should initially be discouraged (Answer 2) to avoid the possibility of receiving drugs from the outside. Answer 4 may be appropriate; however, it is not as important as allowing the patient some over his own care. Giving a choice is an effective intervention in a milieu setting for patients who are substance abusers. A patient asks what type of anesthesia is usually used during vein-stripping. The nurse tells the patient to expect: Local. Topical. Regional. General. Vein-stripping is a painful and tiresome procedure and, for the patient's comfort, is almost always done under general anesthesia. Answer 1 is incorrect because local anesthesia is limited to small areas such as with laceration repair. Topical anesthesia (Answer 2) only decreases pain sensation in mucous membranes and, because the incisions for vein-stripping are made in the groin as well as the ankle, regional anesthesia (Answer 3) would be impractical. Vein-stripping could also be done using spinal anesthesia. The best option is the one that would provide most comfort for length of the surgical procedure. A patient with a history of many years of smoking and a smoker's cough is scheduled for bilateral herniorrhaphy. Which type of surgical anesthesia may be most appropriate for this situation General. Intravenous. Spinal. Local infiltration. Because the patient has a history of chronic cough, and because hernias can be repaired with spinal anesthesia, this approach may have the least amount of risk for postoperative complications. General anesthesia (Answer 1) has the greatest risk for respiratory complications after surgery. Intravenous (Answer 2) and local infiltration (Answer 4) would not supply the depth of anesthesia needed to complete the repair. Look for the anesthesia that will be safest for a high-risk patient. Pulmonary function testing on a patient with a long history of smoking revealed a vital capacity within normal limits but a reduced forced expiratory volume (FEV1). The nurse explains to the family that this means that the patient: Has difficulty moving air in and out of the lungs. May have some airway obstruction. Has weakened expiratory muscles of respirations. May have some areas of atelectasis in the lungs. Timed forced expiratory volume measures the functional ability of an individual to remove air from his or her lungs. Reduction in FEV1 is usually due to airway obstruction from excess mucus. Vital capacity measures the individual's ability to move a volume of air in and out of the lungs (Answer 1).Though inadequate innervation of the intercostals (Answer 3) would also reduce the FEV1, there is nothing in this case to indicate that this patient has neuromuscular problems.Atelectasis (Answer 4) is determined by x-ray, clinical symptomatology, and blood gases. Distinguish between the normal and the abnormal findings. Normal vital capacity means no difficulty in moving air in and out of the lungs. Reduced forced expiratory volume means something is interfering with expiratory phase of respiration; air is trapped (COPD?). A patient has a long leg cast due to a fractured right tibia and fibula. Which is an appropriate exercise for this patient to prevent complications of immobility? Quadriceps setting. Extension of the right knee. Passive range of motion of the hip. Flexion of the right knee. Quadriceps-setting exercise is an appropriate activity to prevent complications of immobility. Range-of-motion exercises for joints not enclosed in the cast are encouraged. The primary purpose of the cast is to immobilize those joints above and below the fracture site; therefore extension (Answer 2) and flexion (Answer 4) of the knees are inappropriate. Answer 3 is not correct because passive range of motion is not as effective as active range of motion in the prevention of complications of immobility. Visualize the cast; joints above and below the fracture site will be enclosed in the cast. That eliminates any activity for the ankle and knee. Prevention of complications from immobility is best accomplished with active range of motion rather than passive. The best answer would be quadriceps setting. Prevent atrophy while in the cast. The nurse concludes that an intradermal TB test result is positive if the following is present: An induration of 10 mm or more. An induration of 10 cm or more. An induration of 5-9 mm. A hivelike vesicle. An induration of 10 mm or more (not cm, as in Answer 2) is considered a positive reaction. The skin is generally reddened. Indurations of 5-9 mm (Answer 3) are considered doubtful reactions. Individuals with doubtful reactions should be retested, unless they have had a known contact with persons with tuberculosis. Indurations of less than 5 mm are considered negative reactions. The reaction is not hive-like (Answer 4). Visualize the size of each of the options given. Watch the unit of measure (mm versus cm). In providing emotional support for a couple whose infant is unhealthy or has an abnormality, the nurse should realize that at first they will probably: Wish to talk with other couples who have experienced the same circumstances. Wish to be left alone, unless they seek out someone to talk to. Need reassurance and emotional support. Avoid discussing the situation at this time. Initially this couple will be unable to make appropriate decisions regarding their own needs. They first need tender support, empathy, and reassurance to assist them in coping with this stress. Answer 1 may be appropriate at a later time. Answer 2 is incorrect because this couple is probably incapable of seeking out someone to talk or to listen to. They need guidance. If left alone, they may isolate themselves, withdraw, and become depressed. Avoidance (Answer 4) is non-therapeutic; the problems must be faced eventually. Support and reassurance are priority interventions. In assessing the acid-base status of a patient diagnosed with glomerulonephritis, the nurse would be alert to the following signs of metabolic acidosis: Hyperreflexia, paresthesias, and tetany. Giddiness, irregular respiratory pattern, and moist, cool skin. Muscle weakness, and numbness and tingling in the extremities. Lethargy, disorientation, and increased rate and depth of respirations. Lethargy, disorientation, and increased rate and depth of respirations are clinical manifestations of metabolic acidosis. As hydrogen ion concentration rises, the central nervous system is depressed, causing the patient to become increasingly lethargic and slower in his or her responses. Likewise, the lungs try to compensate for a metabolic acidosis by increasing both the rate and depth of respirations. Serum bicarbonates provide an estimate of metabolic components of acid-base balance. The level of these ions isled by the kidney's ability to secrete hydrogen ions and actively reabsorb bicarbonate ions. Decreased levels of bicarbonate indicate metabolic acidosis, and increased levels of serum bicarbonate indicate metabolic alkalosis. Answers 1,2, and 3 are symptoms of alkalosis. The diagnosis of glomerulonephritis tells you that the kidneys are not functioning as they should; waste products are not being excreted adequately. Look for a respiratory response to the metabolic acidosis. On the second day after a lobectomy, the fluid in the water-seal chamber ceases to fluctuate. The nurse knows that this most likely indicates: The chest tube is plugged by fibrin or a clot. There is an air leak in the system. Pulmonary edema has occurred due to increased blood volume in remaining lung tissue. The patient's position needs to change to facilitate drainage. Fluid in the water-sealed compartment will cease to fluctuate when the tubing is plugged by fibrin or a clot and/or when negative intra-pleural pressures have been reestablished and the lung has re-expanded. The likelihood of lung re-expansion on the second postoperative day is small. Therefore,it is necessary to check the tubing for fibrin, clots, or severe kinking. If the tubing is kinked, it needs to be repositioned. Milking of the tube may be ordered if fibrin or clots are suspected. Answer 2 is incorrect because an air leak is indicated by bubbling in the water-sealed compartment. Pulmonary edema (Answer 3) would be reflected in dyspnea, orthopnea, crackles, and pink, frothy sputum. Answer 4 is not entirely incorrect because the patient's position may be such that the chest tubes are unnecessarily looped or kinked and repositioning the patient may facilitate flow; however, it is not the best answer. The key concepts in this question are timing and what fluctuation means. What side effects would a patient demonstrate if he or she received hyperalimentation solution at too rapid an infusion rate: Cellular dehydration and potassium depletion. Circulatory overload and hypoglycemia. Hypoglycemia and hypovolemia. Potassium excess and congestive heart failure. The primary effect of rapid infusion of hyperalimentation solutions is cellular dehydration due to osmosis of water from the cell in response to vascular hyperosmolarity. Occasionally circulatory overload (Answer 2) does occur, but with hyperglycemia. When infusion rates are rapid, supplementary insulin should be administered to prevent the effects of hyperglycemia. Hypoglycemia (Answer 3) may occur if the infusion rate is suddenly decreased because the body generally adapts to hyperosmolar solutions by increasing insulin release from the pancreas. However, hypervolemia, not hypovolemia, generally occurs. Potassium depletion, not excess (Answer 4), also results. Know the concepts of osmosis and diffusion as they relate to a hypertonic solution, high in glucose. Which nursing action is least likely to assist parents to adjust to the psychological trauma of the birth of a deformed child: Encouraging verbalization of anxiety, fears, and concerns. Explaining all treatments and prognosis. Interacting normally with the infant. Expressing sympathy. Expressing sympathy is least likely to assist the family to adjust, whereas empathy and understanding are effective in providing emotional support to families in crisis. Answer 1 is wrong because the family may need to openly communicate their anxiety, fears, and concerns about the baby in order to begin positive coping. Answer 2 is wrong because understanding the treatment being given and the potential for a successful surgical repair may aid them in coping with their fears. Answer 3 is wrong because staff attitudes in working with compromised infants do affect parental perceptions of the infant. Note the key word in the stein—least. Nursing measures that should decrease the incidence of hemorrhage after thyroidectomy are: Frequent checking of dressing, semi Fowler's position, and ice packs to neck. Frequent checking of dressing, supine position, and ice packs to neck. Frequent checking of dressing, coughing every 2 hours, and moist packs to neck. Frequent checking of dressings and maintenance of neck flexion. Nursing measures designed to reduce the occurrence of post-thyroidectomy hemorrhage include frequent checks of the dressings and bedclothes under the patient, semi-Fowler's position to prevent hyperextension of the neck, and ice packs to reduce hematoma formation and edema. Answer 2 is partially correct; however, the supine position would increase edema because it prevents gravity drainage of the wound site. Answer 3 is incorrect because coughing will increase stress on the sutures unless the head and neck are well supported, and moist packs tend to increase local blood flow, which in turn tends to increase edema formation in this patient. Answer 4 is incorrect because flexion-like hyperextension puts increased stress on the suture line. Visualize the incision. For the patient with a thyroidectomy, breathing is sometimes difficult because of the location of the suture line and the dressings. Think patient comfort, safety, and prevention of complications (e.g., edema, hemorrhage). The nurse must assess past medical history and use of medications for any surgical candidate. Which drugs can negatively interfere with anesthesia or contribute to postoperative complications? Anticoagulants and antihypertensives. Anticoagulants and insulin. Digoxin and thiazide diuretics. Vitamins and mineral replacements. Anticoagulants increase bleeding time and tendency to hemorrhage. Antihypertensives such as reserpine, hydralazine, and methyldopa potentiate the hypotensive effects of anesthetic agents, thereby creating problems with maintenance of blood pressure. Thiazide diuretics may induce potassium depletion and lead to respiratory depression during anesthesia. Answers 2, 3, and 4 are incorrect because neither insulin, digoxin, nor vitamins and minerals potentiate the central nervous system depression due to anesthesia. Review the options as to risk in the postoperative phase. If a part of the option is wrong, the option is wrong even if it contains some part that is correct. Once you have eliminated those components that have something wrong in them, there is usually only one correct answer left. Use the process of elimination. Anticipatory guidance planned for a woman with diabetes who has just given birth includes health teaching regarding self-care health maintenance actions in the postpartum period. She wants to breastfeed her baby. Which should be emphasized as part of her postpartum instructions? Breastfeeding is contraindicated because it stimulates gluconeogenesis. Her caloric needs will decrease during the postpartum period, so she must be alert for signs of hyperglycemia. She should breastfeed the baby before feeding herself so that she can relax; stress inhibits the flow of breast milk. She must prevent hypoglycemia because it can inhibit the let-down reflex and decrease her milk supply. Hypoglycemia does inhibit the let-down reflex and interfere with successful breastfeeding. Further, maintaining a stable serum-glucose concentration is important to maternal health. Answer 1 is incorrect because breastfeeding exerts a positive effect on diabetes, reducing blood-sugar levels by transferring glucose from serum to the breast for conversion to lactose; energy is expended in milk production. Answer 2 is wrong because her caloric needs will increase with lactation; insulin dosage must be adjusted to maintain optimum serum-glucose levels. Answer 3 is wrong because hypoglycemia jeopardizes both successful breastfeeding and maternal status. There are two parts to the best answer. First, determine if it is OK or not OK to breastfeed. Then, focus on the need to maintain stable serum glucose. Choose a preventive option (4). Review the physiological mechanisms involved in lactation, and determine how diabetes mellitus might effect a woman's ability to nurse. To assess accurately a patient's functional and vocational rehabilitation potential with myasthenia gravis, the nurse must first ascertain: The degree of physical and emotional stress in the patient's present occupation. The activities of daily living that cause the greatest degree of muscle weakness and fatigue. The patient's understanding of and attitude toward myasthenia gravis, as well as the ability to cope with activity restrictions. Whether or not the patient's current occupation allows opportunities to sit down and rest when necessary. Before assessing and planning any rehabilitation program, the nurse must first assess the patient's and the family's understanding of and attitudes toward myasthenia, as well as their emotional response and coping abilities. Before ascertaining any further information about job stresses (Answers 1 and 4) or lifestyle (Answer 2), any unusual fears, misconceptions, or problems relating to the patient's condition need to be identified and dealt with. It may be necessary to utilize the skills of a psychiatric nurse specialist, health psychologist, or psychiatrist to evaluate the situation and assist in planning interventions. The question is asking for ordering (i.e.,first). The nurse tells a patient that NPH insulin reaches its peak action: 4 hours after injection. 6-12 hours after injection. 12-14 hours after injection. 15-18 hours after injection. NP1I is an intermediate-acting insulin with an onset time of 2 hours, peak action in 6-12 hours, and a duration of action of 24 hours. Answer 1 is the peak action time for regular insulin. Answers 3 and 4 are within the range for long-acting insulins. Know onset, peak and duration of each of the insulin preparations. NPH is intermediate, meaning it cannot be used for emergency situations (regular is used for that) and it does not have effects for the whole day. Look for a "middle" time. A patient has multiple fractures of both legs; treatment includes bed rest with skeletal traction. The nursing intervention that would be most effective in prevention of footdrop would be use of: A bed cradle. A footboard. Passive range of motion every shift. A trochanter roll. Keeping the foot in the correct anatomical position is the best method of preventing footdrop, and a footboard is best when the patient is in traction. A bed cradle (Answer 1) is effective in keeping pressure off the legs and feet. Passive range of motion (Answer 3) is most effective in preventing contractures. A trochanter roll (Answer 4) is most effective in preventing external rotation of the hip. Visualize the traction; it has ropes and pulleys and weights. This eliminates the bed cradle. A trochanter roll is used to prevent external rotation, not foot-drop. The key phrase is "most effective." Something that is continuous rather than three times a day would be best. Look for clues in the stem—footdrop ... foot board. While providing care for a newborn with a cleft lip and palate, the nurse must also be aware of the parents' feelings. Both appear stunned. However, they are still in touch with reality and are asking appropriate questions focused on the newborn's condition. At what level of anxiety is the couple functioning at this time? Mild. Moderate. Severe. Panic. The couple is able to perceive events and communicate their concerns, although there is overt tension present. Answer 1 is usually indicated by restlessness and increased alertness. Answer 3 is indicated by an increase in physical symptoms (headaches, nausea, dizziness, etc.) and perceiving only details. Answer 4 is indicated by an inability to communicate or function. Review theory on levels of anxiety to eliminate severe (3) and panic (4) levels of anxiety, because the parents are able to focus and ask appropriate questions. Which nursing action is inappropriate in the preparation of a patient for oral cholecystography? Administering a fat-free diet the evening before the test. Administering Telepaque (iopanoic acid) tablets in 3-minute intervals 1 hour after supper. Administering at least 6 oz of water with each Telepaque (iopanoic acid) tablet. Allowing the patient, after ingesting the tablets, to drink water until midnight, then NPO. Iopanoic acid (Telepaque) tablets are administered1 hour after eating a fat-free meal (Answer 1), one at a time and in 5-minute intervals (Answer 2), with a minimal amount of water (usually 8 oz) to swallow all the tablets. Water is allowed until bedtime (Answer 4), but food is withheld to allow as much dye as possible to concentrate in the gallbladder. The next morning an initial x-ray is taken, after which the patient is given a fatty meal, and several more pictures are taken to observe the functioning of the gallbladder. The key word is "inappropriate" or what would you not do for this patient. Look for the wrong answer, not the correct one, when it asks for what is "inappropriate." A preoperative nursing priority for a patient having a tracheostomy is: Establishing postoperative communication. Drawing blood for serum-electrolyte and blood gas determinations. Inserting a Foley catheter and attaching it to dependent drainage. Doing a surgical prep of the neck and upper chest wall. Since tracheostomy inhibits the patient from talking, it is essential to establish a mode of postoperative communication so that the patient can express needs. The mode chosen should be communicated to the rest of the staff so that the approach to the patient is consistent. Blood work (Answer 2) may or may not be ordered before tracheostomy, though blood gas analysis is frequently ordered to establish baseline data in order to evaluate the effectiveness of the intervention. Inserting a Foley catheter (Answer 3) is not a priority unless urinary output has decreased. A standard surgical prep (Answer 4), cleansing and shaving the operative area, is not done before tracheostomy. However, the physician does cleanse the area with an antiseptic before performing the tracheostomy. Do something for the patient directly, then take care of procedures. The nurse explains to a patient that the purpose of intermittent positive-pressure breathing (IPPB) with normal saline is to maintain patent airways and to mobilize secretions. To accomplish this, IPPB exerts: Positive pressures on inspiration. Negative pressures on inspiration. Positive pressures on expiration. Negative pressures on expiration. IPPB facilitates the flow of air deep into the lungs by exerting pressures greater than atmospheric pressure (positive pressure) on inspiration. The patient needs to learn to take slow, controlled inspirations to prevent hyperventilation. Answers 2,3, and 4 are incorrect because negative inspiratory pressures are consistent with CPAP or PEEP ventilatory systems, and pressures normally become more negative as the patient exhales. Key term in this question is "positive pressure." This eliminates two options immediately. To improve respiratory hygiene, you attempt to get more air in on inspiration. A 3-month-old infant brought unconscious to the emergency department (ED) by the parents was pronounced dead. The mother becomes hysterical, crying uncontrollably. The father asks the nurse to "do something." The most appropriate nursing action would be: Providing the parents with privacy. Obtaining an order for a tranquilizer. Sitting quietly with the couple. Asking the mother to calm down. It is essential that the nurse be readily available to provide physiological, sociological, and psychological support when needed. The father has requested assistance; therefore, although privacy (Answer 1) is important, remaining with the couple to provide support and guidance is paramount. Answer 2 may be appropriate if sitting with the couple does not decrease the mother's anxiety. Answer 4 will probably be ineffective. Furthermore, she may need to feel that it is OK to express her feelings, and the nurse should encourage her to be as open as possible. In crisis intervention, support (sitting quietly) is a first priority. A pregnant woman tells the nurse that she has a family history of cystic fibrosis and wonders if her unborn child is at risk for this disorder. The nurse's response is based on knowledge that most inborn errors of metabolism are: Autosomal-dominant inherited disorders. Autosomal-recessive inherited disorders. X-linked recessive inheritance disorders. Multifactorial inheritance disorders. Usually inborn errors of metabolism are autosomal-recessive inherited disorders; that is, if a woman with the disorder has a child with a man who carries the recessive gene, there is a chance for her child to exhibit the disorder. Answers 1,3, and 4 are incorrect, because this disorder is autosomal-recessive (individuals carrying the gene are not aware of it until two people with the gene have a child who exhibits the disorder), not a sex-linked disorder, and not a multifactorial inheritance disorder. Focus on the two "recessive" options and eliminate the sex-linked (X) recessive. The drainage period during peritoneal dialysis generally takes 20 minutes, though this may vary from patient to patient. If fluid is not draining properly, the nurse can facilitate return by: Turning the patient to a prone position. Manipulating the indwelling catheter. Elevating the head of the bed, thereby increasing intraabdominal pressures. Elevating the foot of the bed, thereby increasing abdominal pressures and gravity flow. The cumulative inflow and outflow records should show an outflow equal to or in excess of the amount instilled. The amount of excess outflow allowed is also determined by the physician; this rarely exceeds 200 ml per cycle. Occasionally, drainage is less then expected. Nursing measures to enhance outflow include turning the patient from side to side, elevating the head of the bed (increases intra-abdominal pressures),and/or gently massaging the abdomen. If the problem continues, notify the physician before initiating another cycle; she or he may attempt to clear the catheter by rotation or by probing it for fibrin clots (Answer 2). Answers 1 and 4 will not improve flow. Visualize where the catheter is placed and what would facilitate the return of fluid. By elevating the head of the bed, intra-abdominal pressure is increased; this in turn helps to force the fluid out through the catheter. The nurse needs to know that the essential purpose of the water-sealed drainage system for a patient following a lower left lobectomy is to: Prevent early precipitous reinflation of the lung. Drain off excess fluid and air, thereby promoting reestablishment of negative intrapleural pressures. Drain off excess fluid and air, thereby promoting reestablishment of positive intrapleural pressures. Decrease atelectasis in unaffected lung tissue and to monitor blood loss. The primary purpose of the water-sealed drainage system is to remove excess fluid and air from the pleural space, thereby speeding re-inflation of the lung, reestablishing normal negative intra-pleural pressure, and preventing the development of pneumothorax in the unaffected lung. Secondarily. Water-sealed drainage enables the nurse to monitor blood loss. Answers 1 and 3 are incorrect because both effects are the opposite of those intended. Answer 4 is incorrect because atelectasis is caused by insufficient removal of secretions from the bronchial tree. Chest tubes are inserted to assist in re-expansion of the lung from the surgical intervention. Remember that it is negative pressure in the pleural space. This is the reason that the end of the tube is inserted in water, so air can escape but no air can get back into the tube or pleural cavity. Know normal physiology; only one option explains the purpose. In providing post-operative nursing care for the infant after a cleft lip repair, the nurse should: Place the infant in a prone position to facilitate drainage. Avoid moving the infant too much in order to keep from dislodging the Logan bar. Cleanse the suture area frequently to prevent scarring. Encourage the infant to cry to promote adequate lung aeration. The prevention of scarring is essential. All crusts should be cleaned away as gently as possible, and the area should be cleansed frequently to prevent infection. The infant should be placed on the back or side and minimally restrained to prevent him or her from turning onto the face. The side position is preferred in order to prevent the aspiration of mucus or the regurgitation of milk (Answer 1). The infant needs to be repositioned frequently to lessen the danger of hypostatic pneumonia (Answer 2). Crying should be minimized as much as possible to avoid unnecessary strain on the suture line (Answer 4). Visualize the surgical site anatomically and eliminate Answer 1 (needs to be face up) and Answer 4 (what happens to suture line when crying?). Choose the option that prevents (3). Muscular twitching and hyperirritability of the nervous system indicate tetany (hypocalcemia). The nurse can assess for this complication by: Checking the urine calcium. Palpating the calf muscle, with the ankle hyperflexed. Tapping the facial nerve just proximal to the ear. Checking for ankle clonus. Tetany caused by hypocalcemia can be assessed for by briskly tapping the facial nerve, which is located near the middle of the masseter muscle just proximal to the ear lobe (Chvostek's sign). A positive reaction occurs when there is facial-muscle contraction, which includes a twitch of the upper lip on that side. Checking urine-calcium levels (Answer 1) is not helpful in assessing for early signs of hypocalcemia because urine-calcium levels are dependent not only on parathormone excretion but also on oral intake. Answer 2 describes Homans'sign, which is used to determine the presence of deep-vein thrombosis. Answer 4 is a late sign of hypocalcemia. Look for an early sign of tetany. Know the tests for tetany (e.g., Chvostek). Which problem should the nurse expect following uterine isotope insertion? Bladder atony. Constipation. Foul-smelling vaginal discharge. Loss of sexual libido. During treatment (total insertion time varies from 48—144 hours), vaginal discharge may become foul-smelling due to tissue destruction; however, perineal care is generally not allowed due to the danger of dislodging the needles. Frequently, patients find this quite distressing. A douche given under low pressure following removal of the applicator helps to reduce this side effect of therapy. Bladder atony (Answer 1) is a rare complication; diarrhea, rather than constipation (Answer 2), is more likely to occur. Sexual libido (Answer 4) following this therapy seems dependent on the relationship of the partners before therapy than on the therapy itself. Look for consistency between stem and option; only one option addresses a problem with the immediate area (vagina, uterus). Preoperative nursing measures for a patient having a cholecystectomy due to cholelithiasis and cholecystitis include: Observing for bruising or easy bleeding due to potential prothrombin deficiency. Informing the patient of the purpose of the postoperative Jackson-Pratt drain. Providing relief for abdominal discomfort by placing a heating pad on the upper abdomen. Providing a low-carbohydrate diet to stimulate release of glycogen stores in the liver. Fat-soluble vitamins, particularly vitamin K, are poorly absorbed in the absence of bile. This leads to decreased levels of circulating prothrombin, thus reducing normal clotting and increasing the tendency to bleed. Patients will have a T-tube postoperatively, not a Jackson-Pratt drain (Answer 2). Heating pads (Answer 3) are not used to relieve the abdominal discomfort of cholelithiasis and cholecystitis since they have little effect on reducing spasms of deeper organs. Instead, antispasmodics are used. A highcarbohydrate diet, rather than a low-carbohydrate one (Answer 4), would be given to build up glycogen stores in the liver. Eliminate the wrong answers: Jackson Pratt is not used (T-tube is used), heat is not used (medications are used) to decrease spasms, and low carbohydrate is incorrect, (need high carbohydrate to build glycogen stores). Which of the following is the best single nursing measure of fluid volume status in a patient with chronic renal dysfunction? Skin turgor. Vital signs. Daily weights. Intake and output. The single best measure for assessing fluid volume status is daily weights. Significant water loss must occur before there are changes in skin turgor (Answer 1). Similarly, blood pressure (Answer 2) may not reflect changes in fluid volume status if the fluid is sequestered in the interstitial spaces (edema formation). Finally, intake and output measures are important (Answer 4) but generally do not reflect insensible water losses (water lost per respiration and diaphoresis) and are not always as sensitive to decreases in urine output in chronic renal dysfunction as they are in more acute illnesses. Key word is "best." Other factors influence status of skin, vital signs, and intake and output besides fluid. The nurse discusses available methods for family planning with the patient. Which method acts by preventing implantation of the zygote if fertilization occurs: Tubal ligation. Intrauterine device. Oral contraceptives. Diaphragm and spermicidal jelly. Intrauterine devices (IUDs) are believed to prevent conception. The copper-bearing IUD damages sperm in transit to fallopian tubes. The progesterone-bearing IUD causes progestin-related effects on cervical mucus and endometrial maturation. Answer 1 is incorrect because tubal ligation prevents union of sperm and egg by closing the passage. Answer 3 is wrong because oral contraceptives prevent maturation of the graafian follicle and expulsion of the egg. Answer 4 is wrong because the diaphragm and spermicidal jelly serve as mechanical and chemical barriers to prevent viable sperm from gaining access to the egg. Key words are "prevent implantation." Only one method does that. The other methods prevent union of sperm/egg; prevent maturation of follicle; or provide a mechanical barrier to the egg. Which recreational activity for a hospitalized adolescent would be most appropriate for the nurse to support? A television to watch in the two-bed hospital room. Schoolwork that can be brought to the hospital. A board game such as checkers or Monopoly. Various novels the adolescent wants to read. Provide activities the patient enjoys. Answer 1 does not promote intellectual stimulation and may disturb the roommate. Furthermore, the nurse has not validated whether the patient enjoys watching television. Answer 2 is not a recreational activity. The nurse does not yet know whether the patient enjoys board games (Answer 3), and they also require a suitable partner. -Note the words most (age) appropriate and recreational activity. Eliminate the one choice that is not a recreational activity and two other options that assume the patient's likes. Women who tend to delay seeking medical advice after discovering a lump in the breast are displaying what common defense mechanism? Suppression. Denial. Repression. Intellectualization. Denial is a very strong defense mechanism used to allay the emotional effects of discovering a threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may result in greater pathology in a woman with breast carcinoma. Suppression (Answer 1) occurs when the individual recognizes the threat but consciously refuses to think about it. Repression (Answer 3) is an unconscious mechanism that keeps the knowledge of the threat from coming to one's conscious awareness. Intellectualization (Answer 4) occurs when the individual attempts to consciously allay anxiety by attributing symptoms to other possible causes, such as cystic breast disease. However, the patient who intellectualizes does not attempt to deny the possibility that a more serious pathology may be present. Application of definitions of coping mechanism will help select the only correct answer. Denial is also the most common. When can the nurse expect a patient who is receiving NPH insulin to most likely have a hypoglycemic reaction? Before lunch (10-11 A.M.). Early afternoon (1-3 P.M.). Late afternoon (4-7 P.M.). After supper (8-10 P.M.). The patient receiving NPH insulin is most likely to experience a hypoglycemic reaction in the late afternoon. Several factors may be involved, such as increased physical activity or inadequate dietary intake. Patients should be instructed to carry gumdrops or hard candies as a source of quickly absorbed carbohydrates should symptoms occur. Answers 1, 2, and 4 are not as likely. Know that intermediate-acting insulin lasts 8-12 hours. The physician has left orders to deflate a patient's Sengstaken-Blakemore tube, used to stop esophageal bleeding, for 5 minutes every 12 hours to prevent esophageal erosion. Two hours following the second reinflation, the patient suddenly becomes severely dyspneic and dusky. The nurse should: Call a code blue (cardiac arrest). Deflate the balloons. Decrease the traction on the tube where it enters the nose. Irrigate the tube with ice-cold saline to facilitate movement of the balloons into the stomach. Symptoms of severe respiratory distress indicate that the tube has dislodged and is obstructing the airway. Re-establishing an airway is the first priority: Deflate the balloons using a syringe. Following deflation, the doctor should be notified to assess the patient's condition and determine ongoing medical therapy. A code blue (Answer 1) would be called only after establishing the airway. Traction on the Sengstaken-Blakemore tube should be increased or decreased (Answer 3) only by the attending physician. Iced saline (Answer 4) is no longer used for irrigation during active bleeding, and this problem is respiratory, not hemorrhagic. Think of the common, yet most serious, thing that could happen to this special tube. When it was deflated, the position changed. Dyspnea and skin color change represent airway obstruction. Deflate the balloon and assess again. The nurse explains that the surgical preparation for a patient scheduled for bilateral herniorrhaphy would include cleansing and shaving: The entire abdomen from just below the nipple line to the midthigh. The entire abdomen from the axilla to the pubis. From the waistline of the abdomen to below both knees. Lower abdomen, the pubic area, perineum, and inner sides of thighs and buttocks. The skin preparation area for hernia repair includes the entire abdomen from just below the nipple line to the mid-thigh. It includes all pubic hair visible when the legs are together, and should extend to the bed line on each side. Answer 2 is an example of an abdominal prep when the incision is above the umbilicus. Answer 3 is lower-extremities prep for surgeries such as a femoral arterial graft. Answer 4 is a perineal prep used for vaginal or rectal surgeries. Visualize where the incision will be and extend the field in all directions. Postoperative coughing and deep breathing may become a nursing problem following cholecystectomy because: Patients having abdominal surgery are prone to pulmonary complications. Patients with biliary surgery tend to breathe shallowly to prevent pain and discomfort. Many people tend to be thoracic breathers rather than diaphragmatic breathers. Patients with upper-abdominal surgery usually have a nasogastric tube in place, which inhibits deep breathing. Patients having upper-abdominal surgery tend to breathe shallowly after surgery in order to splint incisional discomfort. Consequently, these patients need both assistance and encouragement to breathe deeply and cough. Splinting of the incisional area by the nurse helps, as well as planning deep breathing and particularly coughing times to follow the administration of a pain reliever. Answers 1 and 3 are correct statements but not the best answers. Patients having abdominal surgery tend to guard against coughing because it increases intra-abdominal pressures and incisional discomfort. Many people do tend to be thoracic breathers and need to be taught abdominal or diaphragmatic breathing in the preoperative period. Answer 4 is incorrect, because NG tubes do not inhibit deep breathing; rather, they tend to increase oral respirations, which causes drying of the oral mucous membranes. Think of where the incision is and consider what organs/function will be most affected due to pain and splinting. Upper abdominal incisions have a significant impact on respiratory function. Look for an answer that explains why deep breathing is a problem. A newborn is admitted to the high-risk neonatal nursery. The father requests permission to see the mother and baby immediately. The most appropriate nursing response would be to: Take him to see the mother. Inform him that they both need their rest. Refer him to the mother's physician. Allow him to go see the infant. It is important for the couple to be able to rely on each other at this time. They need time to communicate and to begin to cope with their feelings. As long as the mother's vital signs are stable, it may be most therapeutic to allow the father into the recovery room. Answer 2 isolates the father from all significant others. Answer 3 evades the problem and does not alleviate any anxiety. Answer 4 is a physician's decision, and the infant is probably still being worked up and treated at his time. Priority response by the nurse is to reinforce couple interaction. Which statement is correct regarding nursing care of a patient receiving hyperalimentation? The patient's urine should be tested for glucose acetone every 8-12 hours. The hyperalimentation subclavian line may be utilized for CVP readings and/or blood withdrawal. Occlusive dressings at the catheter insertion site are changed every 48 hours using the clean technique. Records of intake and output and daily weights should be kept. Intake and output records, as well as daily weights, provide important measures of the effectiveness of the treatment and are good monitors of fluid balance. Urine testing (Answer 1) is done to detect glycosuria every 4-6 hours. In the event glycosuria occurs, the physician should be notified. The physician may order insulin coverage or a decrease in the flow rate. Blood withdrawal and CVP readings (Answer 2) are contraindicated because infusion rates must be kept constant to avoid the formation of clots in the catheter. If the catheter insertion site remains dry, dressings are changed every 48 hours utilizing strict aseptic technique, not just clean technique (Answer 3). Cloves and masks are used during the dressing change and while the IV tubing and filter are changed. Hyperalimentation is administered through a central line, which is kept open exclusively for this purpose (no CVP readings as in 2). Because the solution is nutrient rich and contains a high content of glucose and other nutrients and additives, frequent monitoring is necessary, not 8—12 hours (1). Sterile technique, not clean technique, is used (3). The stem asks for "correct" action. Only one will be right. During the procedure to remove the opacified lens, an iridectomy will also be performed. The nurse tells the patient that this procedure is done: To prevent secondary glaucoma from developing in the postoperative period. To increase pupillary dilatation postoperatively. To facilitate circulation and postoperative healing. To prevent corneal scarring during the procedure. An iridectomy, or removal of a wedge from the iris, is performed with cataract removal to prevent the forward push of the aqueous humor from blocking the canal of Schlemm, which would produce a secondary glaucoma. Iridectomy does not affect pupillary dilation (Answer 2), facilitate retinal circulation (Answer 3), or prevent corneal scarring (Answer 4). Think about the normal eye structure. What would removing a wedge of iris do? In a closed chest drainage system (Pleur-evac), the nurse knows that: The first chamber establishes the suction pressure and the second chamber collects the drainage. The first chamber establishes the suction pressure and the second is attached to motor suction. The first chamber collects the drainage and the third chamber provides easy access for removing drainage specimens. The first chamber collects the drainage and the second contains the water seal. In a closed chest drainage system (Pleur Evac), the first chamber collects the drainage from the patient's chest, the second chamber provides the water seal to reestablish negative pressure, and the third chamber is attached to the suction. Answer 1 is incorrect because the third chamber establishes the suction and the first chamber collects the drainage. Answer 2 is incorrect because it is the third chamber that is associated with the suction, not the first and second. Answer 3 is incorrect because the self-sealing diaphragm for drainage sampling is in the first chamber. Picture the device: drainage is collected in the first chamber, which is closest to the patient. The second chamber is the water-seal chamber and the third is the suction. Patient drainage "first"; suction last. Women selecting oral contraceptives as their chosen method of family planning should be instructed to notify the clinic if they develop symptoms of potential problems. Which symptom requires prompt evaluation? Mild to moderate nausea during the first few days on the medication. Chloasma. Leg cramps or headaches. Breast tenderness and weight gain. Women should be instructed to contact the clinic doctor or nurse if they have leg cramps or headaches (signs of possible thrombophlebitis caused by the hypercoagulability that occurs under estrogen/progesterone stimulation). Answer 1 is incorrect because mild to moderate non-pathological nausea may occur during the first few days on oral contraceptives as the body adjusts to the elevated hormone levels. Answer 2 is wrong because chloasma, the "mask of pregnancy," is merely hyperpigmentation related to the high hormone levels. Answer 4 is wrong because breast tenderness and weight gain are nonpathologic and are associated with an increased tendency to retain fluid in the interstitial spaces. Prioritize which signs/symptoms might be life threatening and must be evaluated immediately. Think vascular, think neuro. Eliminate three options that are signs and symptoms associated with physiological adaptation in pregnancy. In anticipation of emergency complications after thyroidectomy, which nursing measure is essential in the postoperative period? Having calcium gluconate available for possible tetany. Having a thoracentesis tray available to reduce edema. Having a tracheostomy tray available for possible airway obstruction. Having pressure dressings available for possible hemorrhage. Maintenance of an adequate airway is always the primary goal of nursing care. Respiratory obstruction is a very serious complication; therefore it is wise to have both an emergency tracheostomy set and suctioning apparatus available at the bedside of the patient who has had a thyroidectomy. Answer 1 is also correct, but it is not the best answer because the onset of this complication is more gradual. With adequate nursing observation, it can be handled before it becomes life threatening. Answer 2 is incorrect because thoracentesis is utilized to remove excess fluid from the pleural space. The correct nursing strategy for postoperative bleeding (Answer 4) is to notify the physician immediately. Visualize the area of the incision. The greatest threat to patient safety is respiratory obstruction. This could be due to damage to the parathyroid gland during surgery. Select the greatest risk to the patient. A patient's skin test and sputum smear and culture are positive. The chest x-ray demonstrated four small lesions and one of moderate density. Diagnosis: tuberculosis. Respiratory isolation is initiated by the nurse. This means: Both patient and attending nurse must wear masks at all times. Full isolation; that is, caps and gowns are required during the period of contagion. Nurse and visitors must wear masks until chemotherapy is begun. Patient is instructed in cough and tissue techniques. Gloves are worn when handling the patient's tissues, excretions, and linen. Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Patients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the patient non-infectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require the patient to wear a mask when visitors are in the room or when the nurse is in attendance. Patients should be in a well-ventilated room, without air recirculation, to prevent air contamination. Answer 1, 2, and 4 are unnecessary precautions. Think of the mode of transmission of this disease (droplets). Selection of the correct answer will need to focus on whatever protects the nurse and others to avoid direct contamination. Select the best choice to prevent spread. The physician recommends an inpatient, short-term drug treatment program for an 11-year-old with a substance abuse problem. The adolescent's father becomes very hostile and states, "My child is no addict and isn't going to be put away in any crazy house." To assess the father's reaction to the physician's recommendation, the nurse should realize that the father is: Expressing anger about the accurate diagnosis. Denying that his child is a drug abuser. Projecting the blame elsewhere. Looking for another, better solution. He is attempting to cope with his anxiety by denying reality. He may also be angry (Answer 1), but his behavior and verbalization indicate denial. It is through the use of denial that he is displacing the blame (Answer 3), so denial is the more appropriate answer. He is unable to think clearly enough to seek any type of intervention (Answer 4); he is reacting rather than problem solving. Denial is the most common coping mechanism. One manifestation of denial can be anger, but denial is the more inclusive answer. Eliminate Answers 3 and 4 because they are not related to the stem. The preoperative laboratory data of a patient recorded an Hgb of 8.3. What is the nurse's first responsibility? To attach the lab report to the chart. To hang a unit of blood. To notify the physician immediately. To chart the report in the nurses' notes. The initial response would be to notify the physician of the critical hemoglobin (oxygen-carrying protein) level. A hemoglobin of 10 is desirable for the patient, decreasing the deleterious risks of general anesthetic and hypovolemic shock. The lab slip is then attached to the chart (Answer 1). Most likely a blood transfusion will be ordered before surgery (Answer 2), but there is no order yet. The nurse's actions will be charted on the nurse's notes (Answer 4), but charting is not the first priority. Know normal values. If no answer involves patient comfort or safety, call MD. The nurse explains to a patient that methyldopa acts to decrease hypertension by: Dilating peripheral blood vessels and increasing renal flow. Depleting norepinephrine at postganglionic synapses. Inhibiting formation of dopamine, a precursor of norepinephrine. Depressing reticular activating system activity. Methyldopa acts to decrease blood pressure by inhibiting the formation of dopamine, thus decreasing the amount of norepinephrine that is secreted in adrenergic synapses. Decreased adrenergic stimulation results in decreased vasoconstriction, which causes peripheral vascular resistance. Answer 1 is an example of the effects of hydralazine; Answer 2, of guanethidine SO,; and Answer 4, of diazepam. Read each choice—look for clues, such as "dopamine" for dopa. The mother of a newborn on an apnea monitor tells the nurse that her baby looks so frail and sick. The best response for the nurse to make is: Your baby docs have a life-threatening illness. Have you seen many newborns? Try not to think of your baby like that. Think positive! I know how you must feel. It can be very scary to see your baby looking like this. New parents, especially parents of infants with health problems, may need help focusing on what is normal and healthy in their infant. Discussing how their baby compares with other infants and focusing on the baby's strengths will help parents to focus on these important aspects of development. To tell this mother that her baby has a "life-threatening illness" (Answer 1) could be very frightening and not at all helpful to her at this time. False reassurance (Answer 3) and stating you "know how she feels" (Answer 4) are also not therapeutic responses. Eliminate two responses that are trite cliches (Answers 3 and 4). Choose Answer 2 because it is at least an attempt to assess for mother's knowledge deficit regarding what is normal. A patient refuses to cough after surgery "because it hurts." The nurse's action would be to: Administer an analgesic and wait a few minutes. Assist the patient to sit up on the side of the bed and splint the incision with a pillow during coughing. Allow the patient to rest this time, but inform the patient that coughing will be expected the next time. Increase fluid intake so as to loosen secretions and ease expectoration. Sitting the patient up allows for deeper ventilation, and splinting of the incisional area reduces incisional discomfort. Answer 1 is also correct but not specific enough. Generally 20-30 minutes should elapse before instituting coughing techniques following administration of an analgesic, to allow for the full effects of the drug. Answer 3 is incorrect unless the patient is in a good deal of pain; if so, the patient should be medicated, then coughed. Answer 4 is incorrect because oral intake is withheld until bowel activity is re-established. Secretions can be kept mobilized by frequent turning and deep breathing. Look for the option that has the nurse performing an independent nursing action. The postoperative nursing care plan following vein-stripping would include which of the following? Administration of anticoagulants to prevent clotting. Elastic stockings/bandages from toe to groin. Sitting in a chair. Bed rest for 48 hours after surgery. The legs of the patient undergoing vein-stripping are wrapped from foot to groin with elastic bandages. Anticoagulants (Answer 1) are not routinely ordered following surgery, although analgesics will be ordered for pain. Sitting in a chair (Answer 3) is contraindicated because the pressure this position exerts behind the knees and at the hips impedes venous return and increases dependent venous pressures. Answer 4 is incorrect because the patient is usually ambulated the day of vein-stripping surgery to enhance venous return by way of muscle contraction. Picture the extent of the surgical wounds and the best action to prevent complications. On her third postpartum day, a woman with diabetes prepares to return home with her new infant. Which of the following is the priority information to be discussed with this woman before she leaves the hospital? The statistical probability of her infant developing diabetes. The type of medical and obstetric problems that may occur in subsequent pregnancies. Coping strategies with her new baby and diabetes in the immediate postpartum period. Follow-up medical visits for both the infant and herself in the next 6 weeks. The primary goal is to prepare the new mother with diabetes to care for her infant while effectively managing her disease. Answer 1 is incorrect because it will not ensure adequate home health maintenance of mother and infant. Answer 2 is incorrect because problems will vary, depending on many factors such as maternal age, and it does not address the primary health maintenance goal. Answer 4 is incorrect because, although follow-up care is an important aspects of discharge teaching, it is subsumed under the broader goal of discussing coping strategies for managing diabetes. Prioritize the most important goals for both mother and infant during the immediate postpartum period for a woman with diabetes. The question asks for early considerations; Answers 1, 2, and 4 are later considerations. The patient returns to the surgical unit following a bilateral hernia repair. The nurse observes that his scrotum is quite swollen. The first nursing action is to: Notify the surgeon stat. Elevate the scrotum on a rolled towel and apply ice bags. Administer prn pain medication. Encourage vigorous deep breathing and coughing. Postoperative inflammation and edema underlie the frequent occurrence of scrotal swelling after indirect hernia repair. This complication is very painful, and any movement by the patient results in discomfort. Elevating the scrotum on rolled towels or providing support with a suspensory helps to reduce edema. Ice bags facilitate pain relief. Answer 1 is inappropriate because this is not an emergency side effect of surgery. Pain medication (Answer 3) may also be administered, but vigorous coughing (Answer 4) is contraindicated following herniorrhaphy. Look for what the nurse can do to assist with the identified problem. Think of the basic intervention: ice and elevation. A patient with chest tubes returns to the unit. The first nursing measure concerning the closed chest drainage system is: Milking the tubing to prevent accumulation of fibrin and clots. Raising the bottle to bed height to accurately assess the meniscus level. Attaching the chest tubes to the bed linen to ensure that airflow and drainage are unhindered by kinks. Marking the time and the amount of drainage in the collection bottle. The first nursing measure should be to mark the time and the amount of drainage in the collection bottle to ensure a baseline measurement for further observations. The milking of chest tubes (Answer 1) is a matter of debate at this time. Although the process of stripping or milking does assist in the removal of fibrin and clots from the chest tubes, compression of the tubes also increases intrapleural pressures by preventing the movement of air and fluid. Whether the chest tubes are milked or not will depend on institutional or individual physician's policies. Answer 2 is incorrect because the drainage system is always kept in a dependent position to maintain gravity flow of air and fluids. The nurse's next measure is to secure the tubes to the bed linen (Answer 3) to prevent kinking or unnecessary looping of the drainage tubes, which would hinder the flow of air and fluid. Think baseline data. Complete assessment first. For which complication of thyroidectomy would the nurse monitor? Hypercalcemia. Respiratory obstruction. Elevated serum T4. Paralytic ileus. Respiratory obstruction, hemorrhage, tetany, and laryngeal nerve injury are the major complications following thyroid surgery. Hypocalcemia, not hypercalcemia (Answer 1), is a complication resulting from damage to the parathyroidglands during surgery. Serum T4 will be decreased or absent, not elevated (Answer 3), and the patient will need replacement therapy because no thyroid hormone is secreted once the total thyroid gland is removed. Answer 4 is not a good answer. Because the integrity of the gastrointestinal tract is not interrupted during thyroid surgery, paralytic ileus is a rare complication. Think of where this incision is and the first priority—airway. Which precaution would the nurse implement when caring for a neonate born to a woman who is HIV positive? The nurse should wear gloves until all blood and amniotic fluid have been removed. The woman should be encouraged to breastfeed. The HIV-positive father should have limited contact with the child. The parents should be encouraged to place the infant for adoption since the outlook for the mother is poor. Standard precautions specify that all health care providers should wear gloves until all blood and amniotic fluid have been removed. Because transmission of the virus may occur via breast milk, breastfeeding is discouraged (Answer 2). Answers 3 and 4 are incorrect because the parents are encouraged to bond with the child and the nurse needs to support all positive parental feelings. The priority is infection, that is, standard precautions (gloves when in contact with body fluids). See the word "precaution" in the stem and an example of standard precautions in Answer 1. After the birth of an abnormal or unhealthy infant, the nurse should expect the parents' initial reactions to include: Depression. Apathy. Withdrawal. Anger. This couple is experiencing an actual loss and will probably exhibit many of the same symptoms as a person who has lost someone to death. Answers 1, 2, and 3 will most likely occur at some later time. Note the key word "initial." During a postoperative period following a cholecystectomy, the patient has a T-tube connected to gravity drainage. The nurse knows that the purpose of the T-tube is to: Maintain patency of the common bile duct. Reduce the occurrence of postoperative hemorrhage. Prevent infection. Reduce bile flow into the duodenum. The purpose of the T-tube is to maintain the patency of the bile duct after surgery. Localized edema in the surgery area tends to obstruct the outflow of bile, which is continuously being synthesized by the liver. The T-tube does not directly prevent postoperative hemorrhage (Answer 2) or post operative wound infection (Answer 3). A secondary effect of this procedure is that bile flow is directed away from the duodenum (Answer 4). Visualize the T-tube. The horizontal part of the T is inserted into the common bile duct to maintain patency. Drainage comes into the tube from both sides of the horizontal portion of the tube into the vertical part of the T, which is connected to a collection apparatus. The T-tube remains in the duct until the edema subsides, because exploration causes swelling. A patient being admitted for modified radical mastectomy was restless and had the following vital signs: BP, 186/110 mm Hg; pulse, 90 bpm; respirations, 22; and temperature, 98.4░F. A half-hour later the nurse retakes the patient's vital signs: BP, 132/86 mm Hg; pulse, 80 bpm; and respirations, 16. The patient's initial elevated BP indicated: She may be an individual who is highly sensitive to sympathetic nervous system stimulation. She is emotionally labile and will need to be assessed closely in the postoperative period. She is psychologically unprepared for surgery and a psych consult is in order. She is denying the possible loss of her breast. Anxiety, like pain, glucose imbalance, or changes in blood pressure, stimulates discharge of the sympathetic nervous system. In some patients this increased adrenergic discharge results in moderate to severe increases in systolic and diastolic pressures that decrease to normal levels when emotional equilibrium is restored. The patient may be emotionally labile (Answer 2), but at this time there are insufficient data to make this judgment. She is fearful, but that does not mean she is unprepared for this surgery (Answer 3). Should her anxiety remain high, however, the attending physician should be notified. Though the patient may be attempting to employ denial (Answer 4), her emotional response (restlessness and increased blood pressure) indicates this defense mechanism is ineffective in allaying her present anxieties (Answer 4). When in doubt as to the answer, look for a pattern in the options-—three are psychological explanations; choose the one that is different. A patient diagnosed with cirrhosis has been placed on a moderate-protein, high-carbohydrate, high-calorie, low-salt diet. Which statement would the nurse select as the best rationale for this diet: Because the liver may not be able to detoxify proteins, carbohydrates are substituted to meet metabolic and nutritional needs. Proteins are given in sufficient amount to facilitate tissue repair. High-carbohydrate diet prevents further weight loss and spares proteins from energy metabolism. Sodium restriction facilitates management of fluid imbalances. High-protein foods are harder to digest and also have a high sodium content. Carbohydrates are more palatable and will more quickly correct the patient's weight loss. High-carbohydrate diets, particularly if they contain adequate fiber, are more likely to decrease dyspepsia and diarrhea. Sodium is always restricted when the patient is edematous. The diet of a patient with cirrhosis should provide ample protein for tissue repair, at least 0.5 g/lb. Some modification occurs if serum-ammonia levels are elevated (Answer 1). Sufficient carbohydrate intake is needed to sustain weight and prevent proteins from being utilized for energy, not for the reason stated in Answer 3. Answer 4 is partially correct. Salt is restricted to assist in decreasing edema formation. However, the reason for high-carbohydrate foods is as discussed above.Fluids may also be restricted to 1000-1500 mL/day. Vitamin supplements, particularly fat-soluble vitamins (A, D, and K), are usually prescribed because of decreased bile production for their absorption and because of the inability of the liver to store them successfully. Initially, if the patient has a very poor appetite, liquid protein supplements such as Sustagen may be given. Frequent, small feedings may also increase intake. How would each dietary restriction or specific allowance relate to the pathophysiology of the disease identified? Patients with cirrhosis often need adequate protein intake. Fluid accumulation is another significant problem to be considered. Neomycin is administered by the nurse before ileostomy surgery: To decrease the incidence of postoperative atelectasis due to decreased depth of respirations. To increase the effectiveness of the body's immunologic response following surgical trauma. To reduce the incidence of wound infections by decreasing the number of intestinal organisms. To prevent postoperative bladder atony due to catheterization. Neomycin is administered preoperatively because it is a poorly absorbed antibiotic and therefore is effective in reducing the number of intestinal organisms that may cause infection of the suture line. Neomycin is not effective in reducing postoperative atelectasis (Answer 1). Prevention of atelectasis is dependent on adequate pulmonary hygiene (deep breathing and coughing up of secretions) in the postoperative period. Answer 2 is correct, but it is not the best answer, because the ability of the body to ward off infection is a result of the decrease in intestinal organisms. Answer 4 is incorrect because bladder atony is generally due to decreased parasympathetic outflow and bladder tone secondary to anesthesia. Look for an option relating to the drug action (i.e., decreased intestinal organisms). A patient has been diagnosed with cirrhosis and placed on a special diet. One nursing measure that might increase the patient's acceptance of the diet is to: Sit with the patient until he or she has eaten everything. Give a family member the responsibility of seeing that the patient eats. Feed the patient yourself. Offer frequent, small feedings instead of three large ones. Frequent, small meals do not visually overwhelm the patient and they require less energy for ingestion. Because patients with cirrhosis frequently have veiy pooi appetites, the nurse may have to be very creative in approaches to ensure adequate nutritional intake. Answers 1,2, and 3 take the responsibility away from the patient and increase his or her dependency. Look for a pattern—three options take away patient or independence. Choose the one that does not. The most important postoperative thoracic surgical activity a patient performs is: Arm exercises to prevent shoulder ankylosis. Deep breathing and coughing up of sputum to prevent airway obstruction. Leg exercises to prevent thrombophlebitis due to prolonged bed rest. Deep breathing only to prevent undue suture stress while maintaining ventilation. Postoperatively, deep breathing and particularly coughing up of sputum are the most important activities engaged in by the patient after chest surgery. These activities reduce bronchotracheal secretions, prevent atelectasis, and promote adequate ventilation. Although Answers 1 and 3 are also important in preventing postoperative complication, airway integrity is always the first priority. Answer 4 is employed for patients having herniorrhaphies. The question is asking for "most important postoperative activity." Priority should focus on prevention of airway complication if appropriate for the location. A patient becomes extremely lethargic following administration of meperidine HC1 100 mg IM for pain. What is the most appropriate nursing action? Give only 50 mg of meperidine next time if pain medication is required. Administer an oral preparation of meperidine instead of the intramuscular preparation. Consult with physician about decreasing the amount of pain medication ordered. Try to prolong the time between medication dosages by employing alternative pain relief strategies. Although most patients are able to rest more comfortably and even sleep after administration of a narcotic, extreme or prolonged lethargy indicates that the medication dose may be too large. The physician should be consulted for both a change of dose and route of administration (Answers 1 and 2). Alternative modes of pain relief can and should be instituted if the patients' discomfort is not severe, but not as a delaying tactic (Answer 4) when the issue is the appropriateness of a specific medication dose. Three options are not nursing decisions, once an adverse effect is noted. Postoperatively, a patient with a cataract should be positioned: In a semi-Fowler's position. In a prone position only. On the back or on the unoperated side. On the operative side. Postoperatively the patient with a cataract may be placed in a flat or low Fowler's position on the back or turned to the unoperated side. Turning the patient to the operated side (Answer 4) or raising the head of the bed (Answer 1) increases the stress on the sutures and may lead to hemorrhage. The patient may assume a prone position with the head turned to the unoperated side (Answer 2), though most patients find a side-lying position more comfortable. Visualize which position will lower pressure in the head. To evaluate a woman's understanding of the use of a diaphragm for family planning, the nurse asks her to explain, in her own words, how she will use the appliance. Which response indicates a need for further health teaching? I really need to use the diaphragm and jelly most during the middle of my menstrual cycle. The diaphragm must be left in place for at least 6 hours after intercourse. I may need a different size diaphragm if I gain or lose more than 20 pounds. I should check the diaphragm carefully for holes every time I use it. The woman must understand that, although the "fertile" period is approximately midcycle, hormonal variations do occur and can result in early or late ovulations. To be effective, the diaphragm should be inserted before every intercourse. Answer 2 is incorrect because the diaphragm must be left in place for a minimum of 6 hours after intercourse. Premature removal may permit passage of viable sperm. Answer 3 is incorrect because marked variations in weight may result in the need for a larger or smaller appliance. Answer 4 is wrong because pin holes in the diaphragm may permit viable sperm to pass the barrier. The question asks for an answer that would require further teaching. Reword the question when it asks for this. The best answer will have an incorrect statement. In observing the drainage from the T-tube during a patient's early postoperative cholecystectomy period, the nurse would notify the physician if: The drainage contained blood during the first 2-4 hours after surgery. The drainage was less than 500 mL on the first postoperative day. The drainage turned greenish brown in color. The drainage was more than 500 mL on the fourth postoperative day. Normally drainage from the T-tube averages 300-500mL during the first few days after surgery and then gradually decreases; the tube is generally removed in 7-10 days. By the fourth postoperative day, flow has usually begun to decrease. Excessive drainage at this time should be reported as it indicates possible reobstruction of the duct. Answers 1, 2, and 3 are normal postoperative findings. Think of timing. Know normal postop course. Would you expect more than 500 mL of drainage on day 4? Usually the patient is ambulatory, discharged home, and healing well. 500 mL is a great deal of T-tube drainage. Nurse should notify the MD for an abnormal finding, not expected findings such as in Answers 1, 2, and 3. When a toddler's mother comes to visit, the toddler clings to the aide, who is washing her, and refuses to look at her mother. How should the nurse explain this behavior to the mother: The toddler is upset because her mother left her at the hospital. The toddler is spoiled and needs firm, consistent limits set for her. The toddler has adjusted well to the hospital and is doing fine. The toddler may be trying to make her mother jealous of the aide. After a settling-in period, the toddler experiencing separation anxiety may enter the phase of "denial," covering up painful feelings toward parents and seeming to turn instead to others, such as the aide. Although it may seem like the toddler is doing fine (Answer 3), she is actually denying feelings that are too painful to deal with just now. At her age, she is not trying to make her mother jealous (Answer 4); neither does she need discipline (Answer 2). Know age-appropriate manifestations of separation anxiety. A couple asks to see their baby, who is in a high-risk new born nursery. The most appropriate nursing action would encompass: Assessing and analyzing the couple's level of readiness. Arranging for the couple to see and hold their baby immediately. Teaching the couple what to expect. Preparing the couple for what to expect while making the arrangements for visitation. It is essential that the couple be prepared for what they will see. However, it is equally as important for them to be able to see, touch, and hold their infant as soon as possible, to begin the attachment process. Answer 1 merely delays the couple in seeing their infant. The nurse continually assesses the parents' readiness while caring for the infant. Parents do need some preparation before seeing their infant (Answer 2). Teaching without immediate parent-child contact can increase the parents' anxiety (Answer 3). The underlying concept for the best answer is facilitating early bonding and attachment, when complications with the newborn might affect the bonding. Paracentesis is a minor surgical procedure done at the bedside; its purpose is to remove ascitic fluid. After explaining the procedure to the patient, the next nursing action would be to: Position the patient in a chair or in high Fowler's position. Instruct the patient to void. Take vital signs. Drape the abdomen with sterile towels. After explaining the procedure to the patient, the nurse should first instruct the patient to void. This prevents accidental nicking or perforation of the bladder during the procedure. The patient is positioned in a chair or in high Fowler's position in bed (Answer 1), after the vital signs have been taken to establish baseline information (Answer 3) and the abdomen is prepared (Answer 4). This question is establishing a priority order. Assume all actions are correct. Instructing the patient to void would be the second thing the nurse would do. Following ileostomy, the nurse would expect the drainage appliance to be applied to the stoma: 24 hours later, when edema has subsided. In the operating room. After the ileostomy begins to function. When the patient is able to begin self-care procedures. The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated. Answers 1, 3, and 4 are incorrect because they would result in skin irritation. Think of the consistency (liquid green, not formed) of the contents and irritability in that portion of the intestine. The best explanation the nurse could give for the signs and symptoms (edema, joint pain, oliguria, muscle cramps, and lethargy) a patient with a history of renal disease has on admission would be: Renal ischemia due to increase in circulating toxins and chronic hypertension. A decrease in the number of functioning nephrons, which further decreases glomerular filtration. Increased water and salt loss due to flushing effect in the diseased kidney tubules. Water and salt retention due to insufficient renal blood flow. Chronic renal failure symptomatology is due to a decrease in the number of functioning nephrons, with resultant decrease in glomerular filtration due to the extension of the disease process. Answer 1 is incorrect because the cause of the renal failure was likely related to intrarenal damage from acute glomerulonephritis. Answers 3 and 4 are incorrect because the patient has moved from the second stage of chronic kidney disease (renal insufficiency, characterized by water diuresis and mild azotemia) to renal failure, which is characterized by acidosis, marked electrolyte imbalances, fluid retention, anemia, and increases in serum urea, uric acid, and creatinine. The problem is within the kidney (the nephrons), not to or from the kidney. One potential complication of an abdominal hysterectomy is abdominal distention. Postoperative nursing measures designed to avoid abdominal distention are: Auscultation of the abdomen for bowel sounds. Abdominal massage and bed rest. Insertion of nasogastric and rectal tubes and ambulation, as ordered. Progression of postoperative diet. Manipulation of abdominal contents during surgery produces inhibition of peristalsis for 24-48 hours. Measures to avoid distention could include insertion of a nasogastric tube before surgery and continuous postsurgical suction until peristalsis returns; rectal tubes can be inserted to remove excess air in the lower colon; and early ambulation promotes return of gastrointestinal functioning. Auscultation of the abdomen for return of bowel sounds (Answer 1) will be necessary in assessing the return and degree of peristalsis. Abdominal massage is not recommended (Answer 2). When bowel sounds return, oral intake (Answer 4) may be started. The key word is "avoid." The most appropriate plan for immediate follow-up care for a family whose baby has died would include: Referring the family to a psychotherapist. Arranging for the social worker to visit the family. Asking the family to identify their needs. Assessing the family's need for follow-up care. Immediately following a death, the nurse must assess and validate the family's needs for follow-up care. It is important to look at their past ability to cope with stress, how effective these coping mechanisms were, and so forth. However, initially the family will be unable to communicate their feelings and perceptions due to their high level of anxiety. Answer 1 may be necessary if the family is unable to cope effectively with their anxiety. Answer 2 would depend on the individual family's needs. Answer 3 may be appropriate once the family is able to communicate their feelings and needs. Recall that the first step in nursing process is "to assess." Look for the word "assessing" in the options. Ten hours after bilateral hernia surgery, a male patient has not been able to void, despite repeated efforts, including standing to void. He states that he feels like he could void but just can't seem to get his stream started. The nurse should: Try getting him up in a standing position once again. Insert a Foley catheter stat. Run water while he attempts to use the urinal. Consult with his physician to obtain either a medication or catheterization order. If all the secondary measures have been tried and the patient's bladder is distended, the physician should be notified if he or she has not left a catheterization order. Occasionally, drugs such as neostigmine bromide (Prostigmin) are ordered to stimulate bladder contractions before resorting to catheterization. Answer 1 will only tire the patient more. Catheters should not be inserted without an order (Answer 2), nor should the patient be unduly fatigued by continuing to try other measures (Answer 3) that most likely were unsuccessful prior to this point in time. The bladder should not be allowed to become over-distended. All usual activities have been tried. It is time to call the physician. Because ascitic fluids are rich in serum proteins, for which complication following a paracentesis would the nurse observe the patient? Disequilibrium. Hypotension. Hypoalbuminuria. Paralytic ileus. Hypotension and shock can occur during or after paracentesis. Fluid from the vascular compartment shifts into the abdomen to replace fluids that are withdrawn. This complication can be minimized if withdrawal of ascitic fluid is limited to 1000 ml or if lost fluid is replaced by administration of salt-poor albumin. To assess for this complication, vital signs are taken every 15 minutes during the procedure and afterward until stable, then every hour for 4 hours. Disequilibrium (Answer 1) occurs with rapid removal of wastes during renal dialysis. Hypoalbuminuria (no protein inurine) is a normal physical finding; therefore Answer 3 is incorrect. Paralytic ileus (Answer 4) is rarely a complication of this procedure. Look for a pattern—only one option would be an immediate response. A patient receiving internal radiation therapy for treatment of adenocarcinoma complains of nausea and a general feeling of weakness. The patient's stools are loose. The nurse might suspect: Extension of the cancer to the abdominal contents. Radiation syndrome. Electrolyte imbalances. Depression. Local radiation is generally used under four conditions: the tumor is relatively well defined, a larger dose of radiation can be delivered than by an external source, there is a critical need to reduce involvement of other tissue, and the site is accessible for introduction of seeds or implants. As a result of cobalt implantation, diarrhea may occur due to radiation-induced toxicosis of the mucous membranes of the large bowel. Diarrhea may be painful as well as profuse and bloody. Answer 1 is incorrect because the rationale for doing an implant is that the tumor is generally well defined. The effects of severe diarrhea may indeed be electrolyte imbalance (Answer 3), but this is not the cause in this situation. Answer 4 may indeed be occurring, but is not the basis for the patient's present symptoms. The problem is caused by the treatment, not additional disease. Think of the proximity of the radiation to nearby structures. Signs and symptoms of post-thyroidectomy respiratory obstruction vary with the degree of severity. Early warnings observed by the nurse might include: Hoarseness and weakness of the voice. Stridor and cyanosis. Vague feeling of choking, difficulty swallowing, and fullness of the throat. Pale nailbeds, disorientation, and combative behavior. In early respiratory obstruction, the patient generally complains of a feeling of fullness or a choking sensation. Swallowing difficulties are fairly common due to tracheal irritation; however, difficulty in swallowing in conjunction with a choking sensation is indicative of airway obstruction. Answer 1, hoarseness and weakness of the voice, is common and is secondary to edema of the larynx. Answer 2, stridor and cyanosis, is a late sign of airway obstruction. Answer 4, disorientation and combative behaviors, is indicative of severe anoxia. Rule out what is expected in the postoperative period from what is an early sign and what is a late sign. Objective data seen with hypoglycemic reactions include: Irritability, confusion, and lethargy. Increased temperature and flushing of skin. Muscle tremors and hyperreflexia. Decreased blood pressure and fatigue. Hypoglycemic or insulin reactions are the result of decreased circulatory serum glucose to the brain. This stimulates epinephrine release. Early symptoms include cold, clammy skin, nervousness, tremors, numbness of the hands or around the lips, and cardiac palpitations. Later symptoms may mimic alcoholic intoxication, such as staggering gait, slurring of words, combative behavior, or uncontrolled weeping. As hypoglycemia deepens, the patient may develop convulsions and coma. Answers 1,2, and 4 are symptoms of ketoacidosis, which acts to depress the central nervous system. The key word is "objective" data; decide between hypoglycemia and ketoacidosis. Which of the following activities of daily living must a patient be given instructions to avoid to prevent complications upon returning home following cataract removal: Self-feeding. Self-dressing. Adjusting shoelaces. Ambulating. Bending to adjust shoelaces would increase intraocular pressures and should therefore be avoided during the early postoperative period; the patient who is ambulatory should wear slip-on shoes or slippers to avoid bending or stooping.Other activities to avoid include coughing, brushing the teeth, shaving, and vomiting. Self-feeding (Answer 1) is encouraged, to help reduce the patient's perception of helplessness, though food may need to be cut up for the patient to reduce exertion. Self-dressing (Answer 2) and ambulation (Answer 4) are permitted. Look for an option that increases pressure on the operative site as the activity to avoid. A woman who had rheumatic fever at age 8 is admitted in labor 4 days before her EDB. If implemented during labor and birth, which of the following would increase the stress on her heart: Maintaining a semirecumbent position. Monitoring her pulse more frequently than her other vital signs. Preparing her for regional anesthesia (epidural). After complete dilation, coaching her to bear down only once per contraction. Bearing down is too strenuous for the pregnant cardiac patient. Answer 1 is incorrect because relaxation in a semi- recumbent position reduces the workload on the heart. Answer 2 is wrong because frequent monitoring may help identify increased pulse rate as an early sign of cardiac decompensation. Answer 3 is wrong because regional anesthesia reduces pain and the physiological response to pain,which may cause cardiac decompensation. It also pools blood in the lower extremities, thereby preventing the rapid increase in cardiac output that immediately follows birth Identify the action that would increase the stress on the heart and therefore is to be avoided. Which instruction would be inappropriate preoperative instruction for a patient regarding thoracic surgery and postoperative care: Explain that he or she will be surrounded, for example, by chest tubes, oxygen equipment, and IV infusions, and that these are routine. Tell the patient that he or she will have periods of rest but will be awakened approximately every 2 hours for turning, coughing, and deep breathing. Assure the patient that he or she will receive medication that will assist in relieving the discomfort. Assure the patient that anesthesia will not have any untoward effects on respiratory status. The rationale for turning, coughing, and deep breathing every 1-2 hours is to rid the lungs of the side effects of anesthesia. Inhalant anesthetics, like cigarette smoke, irritate the mucous membranes lining the bronchi, increasing mucous production. It is exceedingly important that the patient understand that these activities are important in mobilizing and removing these excess secretions. Failure to remove them may lead to atelectasis or hypostatic pneumonias. Answers 1, 2, and 3 are all appropriate interventions. The key word is "inappropriate." Look for a wrong answer, something the nurse should not do. Nursing measures to eliminate the cause of joint pain from chronic renal failure would include: Using Amphogel (aluminum hydroxide) to lower the elevated blood phosphate that occurs with renal failure. Preparing for dialysis to decrease serum-creatinine levels. Increasing the patient's activity level. Implementing a low-purine diet to decrease uric-acid level. Increased circulating levels of uric acid, an end product of purine metabolism, are responsible for the patient's gout like joint discomfort. Thus the diet will exclude foods high in purines (e.g., high-protein foods, organ meats). Hyperphosphatemia does occur in the third stage of chronic kidney disease. Normally this would stimulate the parathyroid gland to increase parathormone, thus raising calcium levels and lowering phosphate. However, in chronic renal failure the kidney fails to produce a metabolite of vitamin D, which effectively reduces parathormone activity, lowering serum-calcium levels. Amphogel (an aluminum hydroxide preparation) is given to bind the phosphate excreted in the bowel (Answer 1). Dialysis is used to decrease the serum-creatinine level, which causes central nervous system depresson (Answer 2), not joint pain. Joint pain is usually related to inflammation or trauma rather than decreased activity level. Increasing activity (Answer 3) might aggravate the pain. Look for a known cause of joint pain in answers—increased uric acid, as with gout. The physician orders a magnesium sulfate infusion for a woman with preeclampsia. Which assessment is most important when administering this drug? Monitoring the serum-magnesium level every 8 hours. Evaluating the apical heart rate every 4 hours. Counting the respiratory rate every hour. Auscultating bowel sounds before meals. Respiratory depression is a cardinal sign of magnesium toxicity. Answer 1 is incorrect because individual variations in respiratory depression are observed at the same serum-magnesium level. Answer 2 is incorrect because respiratory compromise normally precedes depressed cardiac function and is a late sign of magnesium toxicity. Answer 4 is incorrect be cause, although decreased peristalsis can occur with a magnesium infusion, it is not the most important assessment to make. Assess respirations first, before cardiac status, because respirations are earlier signs of toxicity. A patient is treated with isoniazid (INH) 300 mg PO, and rifampin (RMP). Which vitamin would the nurse expect this patient to receive to prevent the peripheral neuritis that may occur with INH therapy? Ascorbic acid (vitamin C). Pyridoxine (vitamin B6). Vitamin E. Vitamin Bl2. Pyridoxine (vitamin B6) 25-50 mg a day is ordered prophylactically to prevent symptoms of peripheral neuritis. Serious side effects of INH therapy are rare. Answers 1, 3, and 4 have no effect on peripheral neuritis. Know the effects of vitamin supplements on the body (C is used to increase healing, prevent infections, and help other substances achieve their goals; E protects red blood cells from hemolysis; B12 is essential for red blood cell formation; and B6 is used to prevent peripheral neuritis). The nurse explains to a patient that urinary retention maybe a problem after spinal anesthesia because: Conduction of autonomic nervous system impulses as well as central nervous system impulses is inhibited. Sensation and motor responses are decreased. Patients tend to secrete less ADH with spinal anesthesia than they do with general anesthesia. Vasomotor depression, which occurs with spinal anesthesia, reduces the glomerular filtration rate. Urinary retention following spinal anesthesia is due to blockage of autonomic nervous system fibers, which innervate the bladder and sensory perception. Answer 2, though correct, is not as complete as Answer 1. All patients secrete ADH postoperatively because of the surgical insult. However, ADH reduces the volume of urine (Answer 3), as does lowered blood pressure (Answer 4), but neither causes urinary retention. Think of the action of spinal anesthesia. The medication used during this type of anesthesia inhibits the conduction of autonomic nervous system impulses and central nervous system impulses. When trying to figure out what happens, try to think of why it should happen. During discharge teaching with a patient following abdominal hysterectomy, the nurse should include the following instruction: Avoid sitting for long period of time. Evacuate bowels daily. Restrict sexual activity for 6 months after hysterectomy. Avoid all household chores for 7 months Sitting for long periods of time and wearing constrictive clothing tend to increase pelvic congestion. Daily bowel movements (Answer 2) are not necessary as long as a normal pattern is achieved. It is important to reinforce the physician's instructions that sexual activity may he resumed within a specific period of time, usually 6—8 weeks. Six months (Answer 3) is too long. Paced and gradual ambulation aids in increasing venous return and general strength. Complete avoidance of chores for 2 months (Answer 4) is not necessary. Lifting of heavy objects, however, may injure the incision site and promote bleeding. Look for options that will prevent stasis and pooling of blood to prevent complications. Select the option that is not as restrictive as the other three (i.e., "daily" is not necessary; 6 months is too long; "all household chores" is too inclusive). Select the more general answer ("long periods"). The labor room nurse decides to intervene when the fetal heart rate (FHR) pattern indicates: A baseline range of 110-160 bpm. Absence of variability. Early decelerations. Mild variable decelerations. Absence of variability (a smooth baseline) is an ominous sign of fetal distress. It can result from fetal hypoxia and acidosis and certain drugs that depress the central nervous system. A baseline range of 110-160 bpm is within normal limits (Answer 1). Early decelerations (from head compression) are of no clinical significance (Answer 3). Mild variable decelerations are usually remedied by changing the woman's position (Answer 4). Look at the key words: "baseline," "absence," "early," "mild." An intervention goes with "absence." Understand basic electronic fetal monitoring (EFM) patterns. Compare early, late, and variable decelerations. The nurse would explain to a patient that elevation of the foot of the bed after vein-stripping surgery is done to: Decrease pain. Aid venous return. Increase blood supply to feet. Make the patient more comfortable. Elevation of the foot of the bed enhances venous return and reduces edema by utilizing the force of gravity. Pain is decreased (Answer 1) as the edema is reduced. Answer 3 is incorrect because raising the foot of the bed should not greatly affect arterial blood flow. Reducing edema is what makes the patient more comfortable (Answer 4). Visualize the body positions. Would venous stasis be prevented? Which goals would be described as the highest nursing priority to a patient recovering from ileostomy surgery: Relief of pain to promote rest and relaxation. Assisting the patient with self-care activities. Maintenance of fluid, electrolyte, and nutritional balances. Skin care and control of odors. Postoperatively the potential for severe fluid and electrolyte imbalances exists for several reasons: (a) the ileostomy drainage contains large amounts of sodium and water, (b) postsurgical diuresis increases both water and potassium excretion, and (c) nasogastric suction further decreases fluid and electrolytes by preventing their normal re-absorption. Answers 1, 2, and 4 are also important measures in this patient's postoperative care; however, maintenance of fluid and electrolyte balance is most critical. Look for the most life-threatening option (a priority question). A woman's initial reaction to seeing her infant in the high-risk neonatal nursery is to cry and tremble slightly. The most appropriate nursing intervention would be to: Remove her from the area immediately. Monitor her for vital signs. Allow her to cry. Ask her what she is feeling. Crying is an appropriate, expected, and natural response. Answers 1, 2, and 4 all invade the woman's need for privacy at this time. Choose "allow" rather than "remove" or "ask." Omit the physical aspects of care (vital signs) when a psychosocial response is the priority here because it is a psychological shock. On the fourth postoperative day after a cholecystectomy, the surgeon orders a patient's T-tube clamped for 1 hour before the first solid meal. The nurse explains to this patient that the purpose of clamping the T-tube is to: Inhibit excessive bile drainage during meals. Allow bile to flow into the duodenum and aid digestion. Relieve abdominal distention and promote normal peristalsis. Assess the patency of the common bile duct. The T-tube is clamped before eating to increase bile flow into the duodenum and assist in the digestion of fats. Answer 1 is incorrect because the act of eating normally stimulates bile secretion, and clamping of the T-tube will not inhibit its flow except to the dependent drainage bag. Answer 3 is incorrect because bile does not affect peristalsis, although inadequate bile flow can result in abdominal distention. Answer 4 is also correct, though it is not the best answer. If the patient is able to tolerate clamping of the T-tube, bile is flowing normally into the duodenum and the duct is patent. It is a test to see if the body is ready for the tube to be removed. Look for a choice that allows bile to do its job. When ECG changes would the nurse anticipate a patient who is in chronic renal failure to demonstrate on assessment, given a potassium level of 6.5 mEq/L? Peaked T waves. Flattened T waves. ST-segment depression. ST-segment elevation. Increased serum potassium (hyperkalemia) causes the T waves to lose their normal, rounded configuration and become more pointy or peaked (the difference in shape between a mountain and a mound); therefore Answer 2 is incorrect. ST segments are not significantly affected by this electrolyte imbalance (Answers 3 and 4). Think "mountains" for high K+ and "mounds" for low K+—T-wave changes. In reviewing an infant's admission history, the nurse should know that intussusception most typically presents with which two signs or symptoms? Currant-jelly stools and paroxysmal abdominal pain. Olive-shaped mass in the right upper quadrant and projectile vomiting. Obstinate constipation and increasing abdominal girth. Excessive amounts of mucus and abdominal distention. Severe, crampy, intermittent pain accompanies the progressive telescoping of the bowel wall found in intussusception; as this progresses, the stools become bloody and full of mucus ("currant jelly"). An olive-shaped mass in the right upper quadrant and projectile vomiting (Answer 2) are found in pyloric stenosis. Obstinate constipation and increasing abdominal girth (Answer 3) are found in Hirschsprung’s disease. Excess mucus and abdominal distention (Answer 4) are found in tracheoesophageal fistula. Know distinguishing classic symptoms between TEF, Hirschsprung's disease, pyloric stenosis, and intussusception. The nurse can anticipate that the amount of ascitic fluid removed during a paracentesis will generally be: 500 mL. 1000 mL. 2000 mL. 3000 mL. Hypotension and shock can occur during or after paracentesis. Fluid from the vascular compartment shifts into the abdomen to replace fluids that are withdrawn. This complication can be minimized if withdrawal of ascitic fluid is limited to 1000 mL or if lost fluid is replaced by administration of salt-poor albumin. To assess for this complication, vital signs are taken every 15 minutes during the procedure and afterward until stable, then every hour for 4 hours. Answers 1, 3, and 4 are incorrect amounts. The general rule of thumb is to not remove more than 1000 mL of fluid from anywhere at one time without observation of the patient's vital signs. The husband of a woman having a modified radical mastectomy has arrived early to be with his wife before surgery. After his wife leaves for the operating room, the nurse would initially: Tell him to go on to work and come back in the early evening, when his wife is likely to be more responsive. Explain that, following surgery, his wife will be taken to the recovery room, but the surgeon will contact him when the procedure is over. Get him a cup of coffee and tell him to make himself comfortable, because it will be some time before his wife returns to her room. Encourage him to express his feelings and concerns so as to plan for postoperative family teaching. After the patient has left for surgery, family members should be told the approximate time the patient will be in surgery and that from there the patient will go to the recovery room until awake and all vital signs are stable. Clarify that delays may occur and that the induction of, as well as the emergence from, anesthesia takes time. Answers 1 and 3 are incorrect because family members should be allowed to decide whether they will stay or go and come back later. If family members decide to wait, direct them to a waiting area where they can be comfortable. Assure them that you will direct the surgeon to them after the surgery is finished. Answer 4 is not an initial action. The nurse does answer any questions and concerns the family members may have, being as supportive as possible. Look at the action words carefully: "tell him," "explain that," "get him," or "encourage him." Best answer is to encourage him. One week after surgery, a patient was fitted with cataract glasses. Which nursing statement would best prepare this patient for adjusting to these glasses? The cataract lenses magnify objects so that they will seem closer to you than they really are. While your central vision may be somewhat distorted, you will be able to see well peripherally. These lenses will enable you to see as well as you did before the cataract formed. The lenses on these glasses are quite narrow, and therefore you may have some double vision. Patients should be informed that the cataract glasses will magnify objects; this not only causes distortions in the shape of an object but also may result in color distortions. The spatial changes that result from these lenses may cause the patient to under reach for an object or have difficulty walking and climbing stairs. Peripheral vision is decreased (Answer 2), so the patient needs to be taught to turn the head and utilize the central vision provided by the lenses. Answers 3 and 4 are incorrect because the magnification created by these lenses (up to 35%) is not similar to the size perception before the cataract formed, nor do they cause double vision. Think of the purpose of the glasses-magnification. Upon returning from the recovery room after a thyroidectomy, the patient begins to complain of a choking sensation. The immediate nursing action should be to: Elevate the head to high Fowler's. Suggest the patient suck on some ice chips. Assess the wound and dressing for increased swelling, and loosen dressing if necessary. Call the physician. An immediate response to the choking sensation is assessment of the surgical site by examining under the dressing. If the area appears edematous, loosen the dressing and have someone remain with the patient. Elevating the head to a high Fowler's position (Answer 1), though the preferred position for improving ventilation of the lung, will not reduce upper-airway obstruction. Answer 2 is inappropriate for this situation and may actually increase the patient's distress. Notify the physician (Answer 4), who might order the sutures or clips to be removed, after assessing the surgical site. Choose the first step of the nursing process—assess, before implementation. The blood gases of a patient with chronic renal failure reveal the following: pH, 7.36; P02, 90; Pco2, 34; serum bicarbonate, 20 mEq/L. The nurse's interpretation would be: Metabolic acidosis. Compensated metabolic acidosis. Respiratory alkalosis with metabolic compensation. Metabolic acidosis with minimal respiratory compensation. This patient's blood gases indicate mild acidosis. pH is still within normal limits. Answer 1 is incorrect because the remaining functional nephrons and the lungs have been able to compensate for the increase in circulating hydrogen ions. If respiratory alkalosis (Answer 3) were the underlying pathology, the pH would demonstrate alkalosis (pH above 7.40). Answer 4 is incorrect because the patient does have respiratory alkalosis, but it represents respiratory compensation rather than the primary pathologic mechanism. Know the normal values. The pH is normal—only one option says "compensated." Four days after admission for cirrhosis of the liver, a patient began to bleed from an esophageal varix. The earliest indications of bleeding noted by the nurse would include: Tachycardia, restlessness, and pallor. Tachycardia, lethargy, and flushing. Sudden drop in blood pressure of 10 mm Hg or more. Increasing combativeness and widening pulse pressure. The earliest clinical signs of bleeding include restlessness, pallor, tachycardia, and cooling of the skin. These symptoms occur as the result of vasoconstriction (increased sympathetic stimulation) in order to maintain venous return and cardiac output. Answer 2 represents symptoms of ketoacidosis. When the vasoconstrictive mechanisms discussed above are no longer effective, the blood pressure begins to fall (Answer 3). It is essential to identify bleeding early because liver cells are very susceptible to ischemia. Answer 4 may occur with increases in intracranial pressure. The key word is "earliest." Look for restlessness. Initially, a new mother is reluctant to touch or hold her son, who is in a high-risk newborn nursery. She says, "I don't know what to do. He's so small, so helpless. He looks so awful." Crying, she turns into her husband's arms. Which nursing diagnosis is the least accurate interpretation of her behavior: Altered parenting. Ineffective family coping: compromised. Impaired verbal communication. High risk for altered family processes. The mother is communicating her feelings of distress at seeing her physiologically compromised son. Answer 1 is wrong because interference with the bonding process may affect later parenting. Answer 2 is wrong because the mother is demonstrating her inability to cope with the situation at present. Answer 4 is wrong because the family system is unable to meet the neonate's emotional needs at present due to being overwhelmed by their own reactions to the baby. Note key phrase in the stem: "least accurate." Objective assessment data indicating circulatory overload in a patient who has chronic renal failure would include: Neck vein distention, apprehension, soft eyeballs. Periorbital edema, distended neck veins, moist crackles. Increased blood pressure, flattened neck veins, shock. Decreased pulse pressure, cool, dry skin, decreased skin turgor. Symptoms of circulatory overload result from varying degrees of cardiac decompensation, with blood backing up into the pulmonary (moist crackles) and systemic circuits (neck vein distention, dependent edema, periorbital edema, and hepatomegaly). Symptoms of circulatory failure or hypovolemia include apprehension, soft eyeballs, flattened neck veins, shock, decreased pulse pressure, and poor skin turgor (Answers 1,3, and 4). Because the question is asking for objective data, eliminate subjective information (apprehension). What would you see with fluid volume deficit and fluid volume overload? Renal failure means fluids are held in, unable to be excreted. On the fifth postoperative day, a patient who has had abdominal surgery complains of a "giving" sensation around the wound when walking about. After assisting the patient back in bed, the nurse notes that the dressing covering the incision is saturated with clear, pink drainage. The nurse should suspect: Late hemorrhage. Dehiscence. Infection. Evisceration. Given the patient's complaint and evidence of pink drainage, the nurse should suspect dehiscence. Dehiscence is characterized by a gush of pink serous drainage and a parting of the wound edges. Dehiscence generally occurs in the fifth to seventh day following surgery, due to increased intra-abdominal pressures from flatus, coughing, retching, or inadequate tissue support. Late hemorrhage (Answer 1) would be accompanied by signs of shock such as decreased blood pressure, rapid pulse, and diaphoresis. Wound infection (Answer 3) would be characterized by pain, redness, and fever. Evisceration (Answer 4) occurs after dehiscence when loops of intestine escape through the opened incision. Sound out and visualize what the patient said about a "giving" sensation, similar to a "splitting" or "moving away" feeling. Considering that the patient has an abdominal incision, the nurse should be alerted that the problem could be dehiscence (separation of the wound). Evisceration is when the internal contents protrude through the opened wound. Know the risks of abdominal surgery. Dehiscence comes before evisceration, just as a "d" comes before "e" in the alphabet. The nurse working with a family who experienced S1DS (sudden infant death syndrome) should: Be knowledgeable about various theories of psychotherapy. Have extensive experience working with dying patients. Be able to identify personal feelings about death. Be able to suppress personal feelings about death. It is important for all health team members to be in touch with their feelings about death and dying in order to help the family work through their feelings. Answers 1 and 2 may help the nurse teach the family to express their feelings, but Answer 3 is still primary. Answer 4 is inappropriate be cause suppression may lead to avoidance and to the ineffective resolution of feelings. Ask yourself, Is it knowledge and experience that is primary? Or is it "feelings"? "Feelings" are primary. Then ask, Is it suppression or identification of feelings? Being in touch with your own feelings is a primary nursing concept. The nurse knows that a Sengstaken-Blakemore tube is primarily used to: Prevent bleeding by applying pressure to the esophageal varices. Prevent accumulation of blood in the GI tract, which could precipitate hepatic coma. Stop bleeding by applying pressure to the cardiac portion of the stomach and against the esophageal varices. Reduce transfusion requirements. The Sengstaken-Blakemore tube is a triple-lumen tube composed of a catheter that goes to the stomach for suctioning, a lumen that ends in a gastric balloon, and a lumen that ends in an esophageal balloon. The primary purpose of this tube is to stop bleeding by applying pressure to the cardiac portion of the stomach and against the esophageal varices. Thus, Answer 1 is only partially correct. The secondary purposes of the tube are (a) to prevent accumulation of blood in the gastrointestinal tract (Answer 2), which could precipitate hepatic coma, and (b) to reduce blood transfusion requirements (Answer 4). With two good choices, pick the most comprehensive answer that covers them both. (Answer 1 is correct but not as complete as Answer 3.) Which postoperative instruction for a patient who had an abdominal hysterectomy includes inaccurate information? Monitor vaginal drainage and report any color changes. Expect that vaginal discharge will diminish and cease gradually. Plan on contraception, considering that her ovaries are still intact. Expect that menses will no longer occur. Once the uterus is removed, the woman is infertile and contraception is not necessary. Answers 1, 2, and 4 should be included in the teaching plan. Following a hysterectomy, the vaginal flow is usually brownish in nature and will gradually diminish and cease. If the flow continues and is obviously red in nature, the physician must be notified- These signs could indicate a bleeding vessel. Menses will be absent following removal of the uterus. When a question asks for inaccurate information, choose the one that is wrong. While the T-tube is clamped, the nurse should observe a patient after a cholecystectomy for signs of: Abdominal discomfort or pain. Eructation. Jaundice. Increased respiratory rate. Following clamping of the T-tube, observe the patient for signs of abdominal distress, pain, nausea, chills, or fever. These symptoms may be due to a localized reaction to the bile, edema, or obstructed flow. Severe abdominal pain may indicate leakage of bile into the peritoneal cavity. Eructation (Answer 2) or burping may occur after eating if bile flow was insufficient. Jaundice (Answer 3) is a late symptom of biliary obstruction. An increased respiratory rate (Answer 4) may occur if the patient has abdominal discomfort, pain, or nausea. Know the purpose of the T tube allow for bile to flow into the intestine. Bile in the abdominal cavity causes pain and discomfort. Although chemotherapy for TB renders a patient noninfectious within days to a few weeks, barring side effects, the patient is instructed by the nurse to continue INH therapy for: 6 months. 1 year. 2 years. The rest of the patient's life. Because tubercle bacilli multiply very slowly, and because antitubercular drugs are bacteriostatic, not bactericidal, the patient must continue therapy for at least 2 years to allow time for the body's defenses to contain the organisms. Six months (Answer 1) would be insufficient treatment. Individuals who have been inspected for tuberculosis but who do not have evidence of active disease are treated prophylactically with INH for a 1-year period (Answer 2). Answer 4 is an excessive length of time. The difference between noninfectious and effectively treated is significant. Before lobectomy surgery for squamous cell carcinoma of the left lower lobe, pulmonary function tests are done and blood is drawn for blood gas analysis to establish baseline data on a patient admitted with fever, tachypnea, productive cough, wheezes, and a smoking history that covered 30 years. Given the respiratory symptomatology, which out come would the nurse expect to find: Increased vital capacity and respiratory acidosis. Decreased vital capacity and respiratory alkalosis. Increased total lung capacity and metabolic acidosis. Decreased FEV, and respiratory acidosis. Space-occupying lesions and pneumonia tend to decrease vital capacity by reducing inspiratory capacity. In order to maintain arterial oxygen levels, the respiratory rate is increased, which results in excess C02 excretion by the lungs (respiratory alkalosis). It is important to remember that patients can be hypoxic (4- PO>) but not hypercapnic (T COj—respiratory acidosis) because of the facility with which carbon dioxide passes through the respiratory membrane. Answer 1 is incorrect because the patient's pathology tends to decrease, not increase, vital capacity. The total lung capacity (Answer 3) is usually increased with the hyperinflation of obstructive airway disease. Even though the patient has an extensive smoking history, neither the health history nor the physical assessment findings indicate hyperinflation (chronic cough, barrel chest). Answer 4 is partially correct and partially incorrect. With extensive wheezes, the nurse would expect a slight to moderate decrease in the forced expiratory volume in 1 second (FEV), however, the respiratory rate and lack of other symptoms (lethargy, easy fatigue) tend to contradict the occurrence of respiratory acidosis. Something is filling the normal capacity (tumor). What effect will signs and symptoms have on acid-base balance? Remember that the patient is getting rid of C02 (alkalosis) rather than retaining it (acidosis). When teaching the parents about the care of their baby with a cleft lip and palate, the nurse should inform them that: It is important to use a nipple with large holes to make sucking easier. The infant will have difficulty feeding because the baby cannot create a vacuum in the mouth. The infant should be given small amounts of formula while being maintained in a supine position to facilitate feeding. It is important to isolate the infant from others to prevent possible infection. The nurse must meet the parents at their level of readiness while at the same time providing them with enough information to allow them to care adequately for the infant. Sucking needs to be avoided in an infant with a cleft palate because of the possibility of aspiration and because the infant will not be allowed to suck postoperatively (Answer 1). A special nipple or feeder is helpful, such as Lamb's nipple or Brecht feeder. The infant should be fed in an upright position to decrease the likelihood of aspiration (Answer 3). The infant needs to be isolated only from those individuals with infectious diseases such as colds or chickenpox (Answer 4). The infant should be treated as normally as possible to stimulate 3. Eliminate three of the options (too specific and incorrect); instead, select the most general response ("difficulty feeding"). After presenting a brief class on various methods of family planning to students in a health course, the nurse administers a post test. If teaching has been effective, which statement should the students select as true? To be effective, rhythm requires avoiding intercourse during the last week of the menstrual cycle. Couples using coitus interruptus may become pregnant accidentally due to escape of pre-ejaculatory fluid containing spermatozoa. Spermicidal jellies are highly effective whether used alone or with a diaphragm. The intrauterine device is the most effective method of contraception. Withdrawal of the penis before orgasm is not reliable as a method of birth because fluid containing semen, stored in the prostate or Cowper's glands, may release viable sperm around or into the vaginal canal before ejaculation. Answer 1 is incorrect because the rhythm method of birth requires avoiding intercourse around the time of ovulation (approximately 14 days before next menses). Answer 3 is incorrect because spermicidal jellies are most effective when used in conjunction with the barrier diaphragm. Answer 4 is wrong because long-acting Progestin implants provide the most effective modern method of contraception when used appropriately. Three of the answers indicate that the students need further teaching. Choose the one that would indicate that the students understand. The nurse would recognize signs of hypovolemia, which include: Dry mucous membranes and soft eyeballs. Decreased hematocrit and hemoglobin. Decreased pulse rate and widened pulse pressure. Dyspnea and crackles. Decreases in body fluids lead to dryness of mucous membranes and softness of eyeballs. Weight loss and decreased urinary output would also be present. Answer 2 is incorrect because hemoglobin and hematocrit are elevated due to hemoconcentration. Answer 3 is incorrect because the pulse elevates to increase blood flow to vital organs; and crackles and dyspnea (Answer 4) would be present influid overload. Look for data that indicate not enough fluid. Newborn assessment revealed a scaphoid-shaped abdomen. The nurse knows that this finding suggests a: Diaphragmatic hernia. Normal newborn abdomen. Imperforate anus. Gastroschisis or omphalocele. A scaphoid-shaped abdomen suggests a diaphragmatic hernia. The newborn abdomen should have a symmetric, slightly rounded contour. Diaphragmatic hernia is the most urgent of the neonatal emergencies. The abdominal viscera are in the thoracic cavity. If extensive, the viscera in the thoracic cavity during embryonic life prevent the normal development of pulmonary tissue. Answer 2 is incorrect because a normal newborn abdomen should have a symmetric, slightly rounded contour. Imperforate anus does not manifest with a scaphoid-shaped abdomen (Answer 3). Answer 4 is incorrect because gastroschisis is an abdominal wall defect at the base of the umbilical stalk, and omphalocele is a congenital defect resulting from failure of the abdominal wall or muscles to close and leads to herniation of abdominal contents through the navel. First decision is whether this is normal or not. Then recall the assessment findings for diaphragmatic hernia versus imperforate anus versus omphalocele. During a predischarge teaching session, the nurse tells a patient who has had vein ligation surgery that elastic stockings are best applied: Before rising in the morning, to prevent pooling of blood in the lower extremities. After showering and application of skin care to the legs, to prevent undue dermal irritation. After 15 minutes of vigorous leg exercises designed to increase blood flow. Only when the patient plans to be standing for an extended period of time because undue constriction of the veins can cause a recurrence of varicosities. Elastic stockings are applied before standing up in order to prevent stagnation of blood in the lower extremities. If the patient has been standing or exercising (Answer 3), he or she should sit in a chair, with legs elevated, for at least 15 minutes before applying the stockings. Elastic stockings should be removed regularly, both to inspect the skin and to provide skin care (Answer 2). The patient should be cautioned not to sit or stand in any one position for a prolonged period of time (Answer 4). Stockings should fit properly and be kept wrinkle free because when improperly used they can cause venous stasis, the condition they are designed to prevent. Look for a pattern—in three options the patient is standing. Choose the one that is different. Which assessment finding provides data to validate an 8-week gestation? Fundal height. Auscultation of fetal heart tones. Positive radioimmunoassay (RIA) test. Leopold maneuvers. Serum radioimmunoassay (RIA) is accurate within 7 days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH levels. Answer 1 is incorrect because the pregnant uterus is not palpable at or above the public symphysis before 12-week gestation. Answer 2 is incorrect because fetal heart tones are not audible by present methods before 9—12 weeks (Doppler) or 20 weeks (fetoscope). Answer 4 is wrong be cause Leopold maneuvers are neither possible nor applicable until much later in pregnancy. Note the time clement in the stem: 8-week gestation. Three of the options are possible later than 8 weeks. Choose the option that is different (does not involve hands-on assessment)—a blood test. On the third postoperative day after a mastectomy, the patient voiced concern about her husband's reaction to her surgery. Which approach by the nurse is most likely to help minimize this patient's concern? Emphasizing the lifesaving aspects of her surgery. Explaining that depression and anxiety are common behaviors following radical surgery. Interviewing the husband to learn about his real reaction to his wife's surgery. Encouraging her to identify the strengths in her relationship with her husband. Initial intervention when patients are reacting to the loss of a significant body part is to encourage verbalization of their fears and to assist them in identifying how they see the change in their body image as well as how it may affect their relationships. One of the most important factors in the patient's response to mastectomy surgery is the reaction of her husband or the person with whom she is intimately involved. Answers 1 and 2 tend to cut off communication in this instance. Many partners are very supportive; others are not. It is therefore also important to assist the partners to talk with each other, not just to the nurse, to acknowledge feelings and concerns (Answer 3). The patient needs the reassurance of the partner's love and support to work through her own emotional reaction and begin the work of recovery. Focus on the patient, not the husband (3); focus on feelings, not cognitive explanations (1 and 2). The nurse must be alert to the development of spontaneous bleeding (ecchymoses) in cirrhosis due to: Rupture of esophageal varices. Decreased synthesis of blood-clotting factors by the liver. Failure of the gut to absorb water-soluble vitamins needed to promote coagulation. Decreased venous pressures and slow blood flow. Ecchymoses occur in cirrhosis due to decreased synthesis of clotting factors as well as decreased vitamin K storage. Dilation and slow blood flow in veins cause the formation of spider angiomas (particularly on the upper chest), palmar redness, and varicosities (esophageal and rectal are common). Esophageal hemorrhage (Answer 1) results in the vomiting of bright red blood. Vitamin K is fat soluble, not water soluble (Answer 3). Venous pressures will increase, not decrease (Answer 4), due to mechanical obstruction in the liver, which results in increased capillary fragility. Recall the normal physiology of the organ and trace what functions will be interfered with during the disease. Vitamin K and synthesis of clotting factor take place in the normal liver; and in disease, these functions are decreased or absent. Visualize where "ecchymoses" would be seen—on the skin (spider angiomas) due to slow blood flow (4- vitamin K).