Nursing preparations for a gastroscopy procedure include: Holding the patient NPO for 24 hours before the procedure. Having an operative or procedure permit signed. Reassuring the patient that gastroscopy is not an uncomfortable procedure, though he or she will need to lie quietly. Removing dentures and administering pain medication before the procedure. All permits must be signed before the procedure. Patients are NPO 6-8 hours, not 24 hours (Answer1). Gastroscopy is an uncomfortable procedure; to mislead the patient by saying it is not uncomfortable (Answer can only increase anxiety and discomfort during the procedure. This procedure involves the passage of a long tube into the stomach, with a lighted, mirrored lens that permits direct visualization of the stomach mucosa. The patient must lie quietly during insertion of the tube to prevent perforation of the esophagus. Usually sedatives, not pain medications (Answer 4), are given before the procedure. One answer is different from the others. Three of the choices deal with physical preparation. Which nursing action is the first priority during a generalized tonic-clonic seizure episode? Observe and record all events that occur before, during, and after the seizure. Maintain a patent airway by turning the head to the side. Protect the patient from injury. Monitor vital signs, with special attention directed to respiratory status. The first priority is to protect the patient from injury. Do not restrain the patient's arms or legs, but make sure he or she does not hit anything. Protect the head with the nurse's hand, a towel, or a jacket. During the initial tonic phase, the patient usually stops breathing for up to a minute. There is no cause for alarm, as spontaneous breathing will, in most patients, return with no harm. In the absence of breathing, airway patency by this position change (Answer is not the first priority. Muscle contraction will prevent "positioning" of the head. A padded tongue blade, once indicated during a seizure, is also no longer used. Answers 1 and 4 are appropriate nursing actions after the seizure has ended. The correct choice is broadest, encompassing the other choices. Key word: first priority. Which nursing intervention would be the most beneficial in preparing the patient psychologically for ileostomy surgery? Include the patient's family in preoperative teaching sessions. Encourage the patient to express his or her concerns and to ask questions regarding the management of the ileostomy. Thorough, brief explanation of all preoperative and postoperative procedures. Have a member of an "ostomy club" visit the patient. Although all of these interventions are appropriate in the preoperative period, research indicates that the best postoperative outcomes are related to the patient's reduced preoperative anxiety levels. Patients who deny apprehension and refuse information, as well as those who are highly anxious and who are unable to ask questions or assimilate information, have the most difficult postsurgical course. Patients who are able to express their concerns and who are given emotional support as well as accurate, brief explanations tend to have less pain and fewer postoperative complications. Answers 1, 3, and 4 do not address the patient's need to verbalize concerns. The correct answer is the only one that asks the patient what he or she would like to know. Which of the following indicates circulatory constriction in the patient with a newly applied long leg cast? Tingling and numbness of toes. Inability to move toes. Blanching or cyanosis of toes. Complaints of pressure or tightness of the cast. Signs of circulatory constriction include blanching (delayed capillary refill) and cyanosis, swelling of the toes, pain that is out of proportion for the type of fracture, and temperature changes. Tingling and numbness (Answer 1), loss of movement (Answer 2), and constant pain (Answer are symptoms associated with constriction or pressure on a peripheral nerve. Requires knowledge of difference between motor, sensory, and circulatory signs/symptoms. Paralytic ileus is described by the nurse as: Edema of the intestinal mucosa. Acute dilation of the colon. Absent, diminished, or uncoordinated autonomic stimulation of peristalsis. High, tinkling bowel sounds over the area of obstruction. Paralytic ileus is characterized by diminished, absent, or uncoordinated bowel sounds due to inappropriate or absent autonomic nervous system (vagal) stimulation of the intestinal tract. Paralytic ileus may occur due to anesthetic interruption of autonomic outflow or hypokalemia. Edema of the intestinal mucosa (Answer 1) is usually found with inflammation or ulcerative colitis. Acute dilation of the colon (Answer 2) and high, tinkling bowel sounds (Answer 4) are associated with large bowel obstruction. Look for words in the answer that define "paralysis." The doctor has ordered ambulation on crutches, with no weight bearing on the affected limb. An appropriate crutch gait for the nurse to teach the patient would be: Two-point gait. Three-point gait. Four-point gait. Tripod gait. The three-point gait is appropriate when weight bearing is not allowed on the affected limb. The swing-to and swing through crutch gaits may also be used when only one leg can be used for weight bearing. Answers 1 and 3 are utilized when weight bearing is allowed on both feet. Answer 4, the tripod gait, is utilized when the patient has little or no sensation or movement (paralysis) in the lower limbs. Need to know which limbs are used with each gait. Key words: "no weight bearing." Nursing preparation for an upper GI series includes: NPO for 24 hours before the procedure. Administering an enema or cathartic to enhance visualization. Discouraging the patient from smoking the morning of the procedure because smoking can stimulate gastric motility. Instructing the patient that the test involves insertion of a rubber gastroscopy tube. Patients are NPO and encouraged not to smoke or take medications the morning of an upper GI series. Patients are NPO for 6-8 hours, not 24 hours (Answer 1). Enemas and cathartics (Answer 2) are not administered before an upper GI series; however, they are given after the series, to aid in the elimination of the barium. The test involves an x-ray, using a barium swallow as contrast medium. Gastroscopy (Answer 4) is the direct visualization of the stomach. Note the time element: before; this eliminates #2. Eliminate #1 because being NPO for 24 hours is excessive. #4 is the description for a different test, not for UGI series. Burns are classified according to the depth of tissue destruction. The nurse would recognize a deep partial-thickness burn because the burn: Involves the epidermis only. Extends to the dermis and is very painful. Extends to subcutaneous tissues and is rarely painful. Extends to muscle and bone and is very painful. Deep partial-thickness burns involve both the epidermis and some of the dermis. They have a pink-red appearance and are characterized by moisture or blisters. Deep partial-thickness burns are very painful, because nerve endings remain and maybe exposed to the air. A superficial partial-thickness burn involves only the epidermis (Answer 1). An example is sunburn: the skin is usually red and dry. In full- thickness burns, subcutaneous tissue, muscle, and even bone are also involved (Answers 3 and 4). Typically, a full-thickness burn is white, gray, or charred in color and is dry and leathery in appearance. Nerve endings have been destroyed, so the area is painless. The key word is "deep." Three of the choices are not deep. The nurse's best explanation of the basic emotional issue underlying or contributing to the development of ulcers would be: Anxiety neurosis. Dependence-independence conflict. Repressed anger and hostility. Compulsive time orientation. Some authorities believe that the psychosomatic issue contributing to ulcers is an unresolved dependence-independence conflict. This conflict frequently prevents the patient from accepting a dependent role, even on a temporary basis. However, the unresolved dependency wish that many of these people have frequently results in irritable, angry behavior when treatments are not exactly on time. Other psychosomatic research has linked anxiety and neurotic behavior (Answer 1) with the occurrence of angina pectoris; repressed anger and hostility (Answer 3) with the development of rheumatoid arthritis; and compulsive time orientation (Answer 4) (type A personality) with onset of myocardial infarction. Ask which emotional response would most likely stimulate a parasympathetic (stress) response. Which patient problem relating to altered nutrition is a consequence of impaired physical mobility? Increased appetite. Decreased protein catabolism. Increased carbohydrate needs. Increased secretion of digestive enzymes. Increased carbohydrates are needed for healing and tissue repair. Anorexia, not increased appetite (Answer 1) , is a problem. Increased, not decreased protein catabolism is present (Answer 2). Digestive enzyme secretion is decreased, not increased (Answer 4). Need to know the effects of immobility on metabolism. Selecting Answer 2 would be too obvious! The signs and symptoms of open-angle glaucoma are related to: An imbalance between the rate of secretion of intraocular fluids and the rate of absorption of aqueous humor. A degenerative disease characterized by narrowing of the arterioles of the retina and areas of ischemia. An infectious process that causes clouding and scarring of the cornea. A dysfunction of aging in which the retina of the eye buckles from inadequate fluid pressures. Glaucoma is an imbalance between the rate of secretion of intraocular fluids and the rate of their absorption. Glaucoma may be acute/closed-angle (obstruction of the angle between the cornea and iris) or chronic/open-angle (obstruction occurs proximal or distal to the angle). It is characterized by increased intraocular pressures. Narrowing of the arterioles and retinal ischemia (Answer 2) are the result of prolonged hypertension. Clouding of the cornea (Answer 3) is not seen in glaucoma. Buckling of the retina (Answer 4) is associated with retinal detachment. Only one choice describes a problem of imbalance, the major problem in glaucoma that leads to increased intraocular pressure related to the imbalance. Patients suffering from dumping syndrome should be advised by the nurse to: Drink liquids between meals. Drink liquids only with meals. Drink liquids any time they want. Restrict fluid intake to 1200 mL/day. Patients experiencing dumping syndrome should be advised to ingest liquids between meals rather than with meals (Answer 2) or at any time they desire (Answer 3). Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. Six small meals rather than three large meals, as well as resting after eating, are also measures used to prevent the occurrence of symptoms, which usually disappear over time. There is no need to restrict the quantity of fluids (Answer 4), just the timing. Key point is a time factor (when). Decreasing volume at meal time, not in general, is the key. Fluid spreads the process. Urinary output is closely assessed after nephrectomy. Which assessment finding is an early indicator of fluid retention in the postoperative period? Increased specific gravity of urine. Daily weight gain of 2 lb or more. A urinary output of 50 mL/hr. Periorbital edema. Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are indicative of fluid retention and should be reported to the physician. Intake and output records may also reflect this imbalance. Increased specific gravity of urine (Answer 1) indicates that the patient is underhydrated rather than overhydrated. A urinary output of 50 mL/hr (Answer 3) is the desired minimum following renal surgery. Periorbital edema (Answer 4) is a later sign of excess fluid retention. Key word: "early" indicator. Daily weight is the best indicator. Which statement by the nurse accurately describes the Miller-Abbott tube? A double-lumen tube, with one lumen leading to the inflatable balloon and the other lumen used for aspiration. A plastic or rubber tube with holes near its tip facilitating withdrawal of fluids from the stomach. A single-lumen, saline-, air-, or water-weighted tube approximately 6 feet long. A 10-foot-long rubber tube with a saline, air, or water bag at its end. The Miller-Abbott tube is a double-lumen tube, with one lumen leading to the inflatable balloon and the other lumen used for aspiration of intestinal contents. Answer 2 is an example of a Levin tube, used for gastric suction. Answer 3 is an example of a Harris tube, and Answer 4, a Cantor tube, both used for intestinal decompression, like the Miller-Abbott. Need to know which tubes are single vs. double lumen. If treatment with thyroid hormone is effective, the nurse should expect: Diuresis, a decrease in pulse rate, and an increase in blood pressure. Diuresis, a widening pulse pressure, and an increase in both temperature and respiratory rate. Increased pulse rate, decreased respiratory rate, and decreased puffiness. Weight loss, increased diastolic blood pressure, and decreased pulse rate. If treatment with thyroid hormone is effective, there should be an overall increase in metabolic rate and a decrease in fluid retention; that is, increased blood pressure, pulse rate, pulse pressure, temperature, and rate and depth of respirations. As a result of improved renal blood flow, glomerular filtration and urine output should also increase, thus reducing the weight gain due to fluid retention. Answers 1, 3, and 4 are incorrect because each contains at least one outcome that is not consistent with improved status. Know the physiological effect of the thyroid on the body. Thyroid function = BP.P.T.R. pulse pressure = fluid retention. A patient was admitted to the hospital with deep partial-thickness burns of the left leg and thigh. The nurse would expect this patient's serum-sodium level to be within normal limits at the time of admission because: The pituitary has increased ADH release. Vascular fluid losses due to exudate and edema formation have resulted in hemoconcentration. Sodium has diffused from disrupted cells into the vascular compartment. Increased serum potassium has depressed aldosterone secretion by the adrenal cortex. Aldosterone secretion by the adrenal cortex is stimulated by decreases in cardiac output. Aldosterone acts to conserve sodium in the kidney tubules, passively increasing water reabsorption and improving fluid volume balance. Normally, if the patient had only a water loss, he or she would also be hypernatremic because of this mechanism. However, in burns the patient's hypovolemia (hemoconcentration) is due to both fluid and electrolyte loss in edema fluids, as well as through the denuded areas of skin. Answer 1 is not the best answer because, although ADH is being released, its action has not at this time prevented hemoconcentration. Answer 3 is incorrect because very little sodium is released due to cellular disruption. Sodium is the main cation of the extracellular fluid. Answer 4 is incorrect because increased serum-potassium levels stimulate the release of aldosterone. Think fluid shift and hemoconcentration early in burns. Nursing actions for patients with Addison's disease include: Providing a low-sodium diet. Restricting fluids to 1500 mL/day. Administering insulin-replacement therapy. Reducing physical and emotional stress. Because the patient's ability to react to stress is decreased, maintaining a quiet environment becomes a nursing priority. Dehydration is a common problem in Addison's disease, so close observation of the patient's hydration level is crucial. To promote optimal hydration and sodium intake, fluid intake is increased, particularly fluids containing electrolytes, such as broths, carbonated beverages, and juices. Answer 1 is incorrect because it limits sodium. Answer 2 is incorrect because it limits fluids. Daily weights and intake and output records are essential for monitoring fluid balance. Drug therapy in Addison's disease is directed toward oral replacement of adrenocorticosteroids such as cortisone, prednisone, and fludrohydrocortisone (Florinef). Insulin (Answer is not required. Addison's is the reverse of Cushing's syndrome. Note the pattern in the options: three relate to physical aspects of care; one deals with stress. In this case, choose the one that is different. The nurse explains to a patient that a vagotomy is done in conjunction with a subtotal gastrectomy because the vagus nerve: Stimulates increased gastric motility. Decreases gastric motility, thereby preventing the movement of HC1 out of the stomach. Stimulates both increased gastric secretion and gastric motility. Stimulates decreased gastric secretion, thereby increasing nausea and vomiting. The vagus nerve stimulates an increase in both hydrochloric acid secretion and gastric motility. Vagotomy not only decreases hydrochloric acid secretion but also alters the motility of the stomach and intestines; this may result in a sensation of fullness after meals, eructation, and abdominal distention. Answer 1 is incomplete. Answers 2 and 4 are the reverse of effects of vagal action. Look for a choice that would be similar to the problem that led to the gastrectomy. Note that both #1 and #3 are correct, but #3 incorporates #1. In planning care for a patient with hyperkalemia, the nurse knows that the treatment of choice to reduce hyperkalemia is: Morphine sulfate. Sodium polystyrene sulfonate (Kayexalate). Insulin and 50% glucose solution. Synthetic aldosterone. Potassium is transported back into the cells along with glucose; therefore the administration of insulin and glucose will facilitate the movement of potassium back into the cell. Sodium polystyrene sulfonate (Kayexalate) (Answer 2) is a resin that attacks and binds potassium. It may be given either orally or as an enema; however, its use would not be indicated in this case unless more conservative means were unsuccessful. Morphine sulfate (Answer 1) and synthetic aldosterone (Answer 4) are not indicated for the management of hyperkalemia. The "choice" would always be to move K+ back into the cell, not get rid of it through diarrhea. Understanding that prolonged immobilization could lead to decubitus ulcers, the nurse plans interventions to prevent alterations in skin integrity. Which would be the least appropriate intervention? Use of a bed cradle. Giving backrubs with alcohol. Encouraging a high-protein diet. Frequent assessment of the skin. Alcohol is extremely drying and contributes to skin breakdown. An emollient lotion should be used. Bed cradles (Answer 1) keep the pressure of bed clothing off pressure points. High-protein diet (Answer 3) aids in the healing process. Assessment of skin (Answer 4) is vital, to recognize any red areas. Think of the effect of each choice on the skin, using a true-or-false approach regarding prevention of decubitus. Note that the question asks for least appropriate. The nurse knows that the physiological response to the stress of extensive burns may result in the following complication in the postburn period: Curling's ulcer due to elevated serum Cortisol. Positive nitrogen balance due to mobilization of body proteins. Decreased hematocrit due to red-blood-cell agglutination by epinephrine. Hypothermia and hyperthermia due to failure of hypothalamic temperature regulators. The hypovolemia and shock that accompany burns greatly increase the body's stress response. Increased serum levels of norepinephrine, epinephrine, and aldosterone facilitate venous return and thus assist in maintaining cardiac output and blood pressure. The pituitary is also stimulated in the stress response to increase circulating levels of ADH (decreases water output) and Cortisol. Increased levels of the latter hormone are implicated in the development of Curling's ulcer (stress ulcer), which may develop in patients of all ages and with both minor and major burns. Generally, H2 antagonists and antacids are used to reduce its occurrence. Answer 2 is incorrect because negative nitrogen balance occurs due to protein mobilization for healing. Patients with burns are given high-protein, high-calorie meals and supple mental vitamins to promote wound healing. Answer 3 is incorrect because hemolysis of red blood cells and decreased hematocrit are primarily due to the injury itself rather than to epinephrine agglutination. In thermal burns, up to 40% of the red blood cell mass may be hemolyzed. Hypothermia is a problem in the postburn period but is the result of the loss of skin areas; hence Answer 4 is incorrect. The patient treated by the open or exposed method of burn therapy is particularly susceptible to chilling. Increased thermostat set tings and radiant heat lamps may be employed to aid in maintaining normal body temperature. Burns are a major stress; ulcers are caused by stress (Curling's ulcer is also known as stress ulcer). Several hours after a long leg cast has been applied, the nurse notices that the patient's toes have become edematous. The physician decides to bivalve the cast. The nurse explains to the patient that this procedure: Requires recasting after 24 hours. Includes splitting and spreading the cast down the middle to relieve constriction. Includes splitting and spreading the cast on each side and cutting the underlying padding. Should be followed by placing the patient's leg in a dependent position. Bivalving the cast involves full-length splitting of the cast on each side. The underlying padding is also cut, because blood-soaked padding shrinks and can also cause circulatory constriction. After the cast is cut, it is spread sufficiently to relieve constriction. This procedure does not disturb reduction of the bone. The cast is then reapplied (Answer 1) after the swelling has gone down. Answer 2 is the technique used when the cast is removed. The patient's limb should always be elevated (Answer 4) after bivalving, because the underlying condition (edema, i.e., swelling) is best relieved by elevation of the limb, ice packs, and isometric exercises. Look for the best method for relieving pressure. Look at two similar options (#2 and #3) and how they differ ("split and spread down the middle" vs. "on each side"). Note that the word "bivalve" in the question is similar to "split/spread cast in each side" ("bi" = 2; each side = 2 sides). Which statement would the nurse include in teaching regarding nasogastric tubes? Nasogastric tubes should be irrigated with sterile water. Patient should be in a sitting position with head slightly flexed for tube insertion. When resistance is met while irrigating a nasogastric tube, pressure should be increased to complete that irrigation, and the physician should be notified at the completion. Ice chips can be taken as often as desired to promote comfort in the throat. The tube will be inserted with greater ease if the patient is sitting up with head slightly flexed. The tube should be lubricated and will be passed into the stomach with greater accuracy if the patient is given water to drink through a straw; at the same time that the patient is swallowing, the tube is advanced. Answer 1 is not correct because the tube should be irrigated with saline, not water, to prevent electrolyte imbalances. Answer 3 is not correct because pressure must not be used during irrigation. If resistance is met, the physician should be notified immediately. Ice chips (Answer 4) should be used sparingly, not as often as desired, to prevent electrolyte imbalances from excessive hypotonic water ingestion. One choice involves tube insertion; the others involve tube management (although not correct). To correctly instill pilocarpine in a patient's eyes, the nurse should gently pull down the lower lid of the eye and instill the drops: Directly on the central surface of the cornea. On the inner canthus of the eye. Into the conjunctival sac. Directly on the dilated pupil. Eyedrops should be instilled into the conjunctival sac to prevent medication from hitting the sensitive cornea. The patient should then be instructed to close the eye, but not squeeze shut, so that the medication can be distributed evenly over the eye. Answers 1 and 4 are incorrect because instillation on these structures would increase corneal irritation. Answer 2 is incorrect because drops instilled into the inner canthus are likely to run down the outer aspects of the nose or be absorbed systemically through the tear duct. The correct choice is more indirect placement of drops; the other choices are all direct locations. The nurse anticipates that the backbone of treatment for patients with myasthenia gravis will be: Adrenergic drugs. Anticholinergic drugs. Anticholinesterase drugs. Cholinergic drugs. The main treatment for patients with myasthenia gravis is anticholinesterase drugs. These drugs increase the response of muscles to nerve impulses and improve muscle strength by inhibiting the rapid removal of acetylcholine from the myoneural junction. Answer 1 is partially correct, in that adrenergic drugs such as ephedrine sulfate are administered to improve muscle tone but these drugs do not inhibit cholinesterase at the myoneural junction. Likewise, anticholinergic drugs (Answer 2) such as atropine are also used in the treatment of myasthenia, primarily to reduce the incidence of side effects of the anticholinesterase drugs and to reverse their effect if "cholinergic crisis" occurs. Cholinergic drugs (Answer 4) are not indicated in the treatment of myasthenia gravis. Need to know effects of broad drug classes. Clue: two drugs look similar (#2 and #3); #2 is used if there are side effects from #3—the drugs of choice. A patient's burns were treated by the closed method. The burned left leg was cleaned and the left ankle debrided. Mafenide 1% (Sulfamylon) was applied, and the leg was wrapped in fine mesh gauze. Nursing measures when this approach is used include: Cleansing of the wound daily and maintenance of strict isolation to prevent air contamination. Cleansing of the wound daily, or more often if needed, and application of new dressings using clean technique. Cleansing the wound one or more times each day and application of new dressing using sterile technique. Cleansing of the wound daily and utilization of heat lamps to help maintain normal body temperature. Patients with burns limited to an extremity are generally treated by a closed method; that is, wounds are covered with a layer of sterile, fine mesh gauze impregnated with an antibacterial agent such as mafenide 1%. Wounds are cleansed one or more times per day, and dressing are reap plied using strict sterile technique. Patients treated by the closed or semi-open method do not have to be isolated (Answer 1). Patients treated by the open method (wounds completely exposed to the air) require strict isolation to prevent infection. The open method is usually used for minor burns, areas difficult to dress (burns of trunk, perineum), or new skin grafts. Answer 2 is incorrect because sterile technique must be used. Heat lamp (Answer 4) is incorrect because the wound is covered in the closed method. Two choices are "closed" to the air, and only one uses aseptic technique. The nurse tells a postoperative gastrectomy patient that dumping syndrome is a significant problem for: 70-80% of patients having gastrectomies. 50% of patients having gastrectomies. 25% of patients having gastrectomies. 5-10% of patients having gastrectomies. Although 70-80% of patients having subtotal gastrectomies may experience some symptoms of dumping syndrome, it is a significant problem for only a small percentage (5-10%). The term dumping is used because the symptoms are believed to be due to the rapid emptying of the gastric contents into the small intestine. This produces gastric distention, and some authorities believe that large amounts of extracellular fluid then enter the intestines to dilute the hypertonic stomach contents. The subsequent lowering of the blood volume produces shocklike symptoms, such as weakness, diaphoresis, faintness, and palpitations. Answers 1, 2, and 3 are incorrect percentages. Select the smaller percentage; you would remember if most patients develop a "significant" problem. The nurse knows that, in contrast to patients with hypothyroidism, women with hyperthyroidism have: Increased serum cholesterol. Increased basal metabolic rate and serum T3 and T4 Increased serum thyroid-stimulating hormone (TSH). Increased menstrual volume. Patients with hyperthyroidism have an increased basal metabolic rate (BMR) and increased T3 and T4. Increased serum cholesterol (Answer 1), increased TSH (Answer 3), and increased menstrual volume (Answer 4) are findings consistent with hypothyroidism. Menstruation in hyperthyroidism characteristically is decreased in volume. Cycle lengths may be shortened or prolonged, but eventually amenorrhea develops. Look for an answer with a change in metabolism. Pilocarpine is the drug of choice in the treatment of open-angle glaucoma. The expected outcome following administration would be: Blocked action of cholinesterase at the cholinergic nerve endings, and therefore increased pupil size. Constricted pupil and therefore widened outflow channels and increased flow of aqueous fluid. Impaired vision from decreased aqueous humor production. Constriction of aqueous veins and therefore decreased venous pooling in the eye. Pilocarpine constricts the pupil by causing contraction of the ciliary muscles, thus widening the outflow channels and increasing aqueous flow. Answer 1 is incorrect because pilocarpine is a parasympathomimetic; that is, it mimics the action of acetylcholine at cholinergic nerve endings, thus decreasing pupil size. Answer 3 is incorrect, in that diuretics such as acetazolamide (Diamox), a carbonic anhydrase inhibitor, are used to decrease aqueous production, not pilocarpine. Answer 4 does not describe the actions of any medication used in glaucoma therapy. Look for a choice that would let the pressure "out." Hyponatremia may develop in patients with burns due to: Displacement of sodium in edema fluids and loss through denuded areas of skin. Increased aldosterone secretion. Inadequate fluid replacement. Metabolic acidosis. Hyponatremia, or decreased serum sodium, may develop in patients with burns because sodium tends to move with water into edema fluids and into denuded areas of skin. Answers 2 and 4 are incorrect because both these mechanisms tend to increase sodium reabsorption by the kidney tubules. Inadequate fluid replacement (Answer 3) would tend to mask hyponatremia because of hemoconcentration. Look for the only answer that relates to destruction of skin (longest answer might be a hint). Also, hyponatremia is similar to the word "loss" in the correct option. A patient has had a partial gastrectomy, vagotomy, and gastrojejunostomy. Which complication would the nurse primarily anticipate in this patient's postoperative period? Thrombophlebitis from decreased mobility. Abdominal distention due to air swallowing. Atelectasis due to shallow breathing. Urinary retention due to prolonged use of anticholinergic medications. Patients with high abdominal incisions are prone to atelectasis following surgery because they tend to breathe shallowly to prevent incisional pain. However, the nurse must also institute measures to prevent thrombophlebitis (Answer 1), wound infection, and dehiscence. Abdominal distention due to air swallowing (Answer 2) is unlikely because the patient has a nasogastric tube in place. Urinary retention after surgery (Answer 4) is generally due to the effects of anesthesia on the autonomic nervous system rather than to the residual effects of anticholinergic medications. Think postoperative pain. Which answer would pain cause? The nurse tells a postoperative gastrectomy patient that the nasogastric tube will be removed: Standard only on the fourth postoperative day. When bowel sounds are established and the patient has passed flatus or stool. Thirty-six hours after the cessation of bloody drainage. After 2 days of alternate clamping and unclamping of the tube. The nasogastric tube is removed after bowel sounds have been reestablished (generally around the third day) and after the patient has passed flatus or stool. Answers 1 and 3 are incorrect because they do not include the return of bowel sounds. Before removal, the tube is frequently clamped for 2-4 hours—not 2 days (Answer 4)—to test the patient's tolerance. Gastric residue is measured after this period. If it is more than 100 mL, the nasogastric tube is left in place. Likewise, if the patient experiences any pain, nausea, vomiting, or distention during this period, the tube is left in. If no symptoms occur and there is a minimal amount of gastric residue, the tube is removed. The "time" depends on the patient's bowel sounds. Follow the logic: GI surgery, NG tube —> "bowel sounds" (#2). Correct choice is the only one without a specific time. A patient with burns is to receive fluid replacement therapy. Besides assessing size and depth of the burn, which physical parameters are also important baseline data for fluid replacement therapy? Age, sex, and vital signs. Age, weight, vital signs, and skin turgor. Vital signs, level of mentation, and urine output. Vital signs and quantity and specific gravity of urine. Age is important baseline information because IV infusion rates to maintain appropriate quantity and specific gravity of urinary output differ; for example, 10—20 mL/hr for infants versus 50-70 mL/hr for adults. Weight is significant if the Evans or Brooke formula is used for fluid replacement therapy. Both of these formulas use both the size of the burn and the weight of the patient to calculate the amount of fluid to be replaced. Vital signs and skin turgor are both important measures of the degree or extent of hypovolemia. As dehydration develops, skin turgor becomes poor, mucous membranes dry, and the eyeballs feel soft. Likewise, the pulse may become thready and the blood pressure may decrease. Size (weight), as discussed, not sex would determine therapy (Answer 1). Level of mentation (Answer 3) is less helpful in this particular situation because of the fear, pain, and acute anxiety experienced by some patients. Quantity and specific gravity of urine output (Answer 4) are important in assessing the adequacy of fluid replacement rather than as part of the initial assessment. Look for an answer with "body weight." The nurse is to administer the drug of choice for long-term control of generalized tonic-clonic seizures. This drug is: Phenobarbital. Diazepam (Valium). Diphenylhydantoin (Dilantin) sodium. Trimethadione (Tridione). Dilantin (phenytoin, diphenylhydantoin) is consistently found to be effective against most types of seizures except absence seizures. Its precise action is unknown, but it appears to stabilize cell membranes by altering intracellular sodium concentrations. Plasma levels of the drug are checked frequently lo avoid toxicity and to determine effective dosage. Side effects include gastritis and nervousness, and at toxic levels the drug may cause ataxia. Phenobarbital (Answer 1) is also used in conjunction with diphenylhydantoin. Diazepam (Answer 2) may be used as adjunct therapy in seizure disorders. Trimethadione (Answer 4) is used in the control of absence seizures. "Drug of choice" means first line of drugs used to decrease seizures (Dilantin decreases seizures). An angiogram was performed using a catheter inserted into the left femoral artery. Which nursing action is the first priority following this procedure? Monitoring vital signs until stable. Frequently checking the puncture site for fresh bleeding, swelling, or increasing tenderness. Measuring the quantity and specific gravity of urinary output. Checking the peripheral pulses distal to the femoral puncture site. After arterial punctures, the first nursing priority is to observe for bleeding or hematoma formation, particularly in the first 4 hours after the procedure. Vital signs (Answer 1) are monitored. The specific gravity and urinary output (Answer 3) are monitored, but this is not as significant as observing the puncture site. The peripheral pulse distal to the puncture site (Answer 4) is also monitored. Because of the size of the vessel, bleeding can quickly cause volume depletion and shock. This is a priority question—look for the choice with the most immediate risk to the patient (bleeding). Which replacement fluid will the nurse least often be expected to administer to a patient with burns within the first 24 hours postburn? Ringer's lactate. Whole blood. Dextran. Dextrose and water. With the exception of the Evans formula, whole blood is administered to patients with burns only when the hematocrit begins to manifest red blood cell loss. Several fluid formulas have been developed to serve as a guideline for fluid replacement in the patient with burns. The Evans formula is the oldest and is based on both the size of the wound and the patient's weight. Colloids (blood, dextran, plasma) and crystalloids (electrolyte solutions) are administered during the first 48 hours. The Brooke formula is similar, except that blood is not given until the hematocrit level has fallen and the need is demonstrated. The Parkland formula is based on the premise that volume expansion is dependent on the rate of infusion rather than the type of replacement. During the first 24 hours, fluid volume is replaced with electrolyte solutions (Ringer's lactate) only (Answer 1). Colloids are used only if urine output is not maintained (Answer 3). During the first or second 24 hours, dextrose and water (Answer 4) are used to maintain fluid volume. Keep in mind the time period: within first 24 hours. Question also asks for least likely choice. With burns, think volume (water) loss is what needs to be replaced, not blood. The nurse must observe for which imbalance to occur with prolonged nasogastric suctioning? Hypernatremia. Hyperkalemia. Metabolic alkalosis. Hypoproteinemia. Removal of gastric secretions incurs the loss of sodium, potassium, and hydrochloric acid ions. The loss of these ions may lead not only to metabolic alkalosis (H+) but also to hypokalemia. Answers 1 and 2 are incorrect because hypernatremia and hyperkalemia indicate an excess in sodium and potassium ions. Hypoproteinemia (Answer 4) occurs with liver dysfunctions and is not a side effect of nasogastric suctioning. The key word is prolonged. Acid will be lost; therefore, think alkalosis. After left nephrectomy, a patient has a large flank incision. In order to facilitate deep breathing and coughing, the nurse should: Have the patient lie on the unaffected side. Coordinate breathing and coughing exercises with administration of analgesics. Maintain the patient in high Fowler's position. Push fluid administration to loosen respiratory secretions. Because the flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesic administration every 3-4 hours for 24-48 hours after surgery. Therefore turning, coughing, and deep-breathing exercises should be planned to maximize the analgesic effects. The patient may be on either side, as long as drainage tubes are not kinked and gravity flow is uninhibited (Answer 1). A low Fowler's or semi-Fowler's position is generally more comfortable for the patient and of sufficient height to encourage gravity flow from drainage tubes (Answer 3). Fluid administration is directed toward maintaining blood volume and urinary output (Answer 4). Think patient comfort (analgesics) to reduce patient complications. Note that the words "deep breathing and coughing" in the stem also are in the correct option (#2). The postoperative nephrectomy patient should be closely observed by the nurse for: Hemorrhage. Hyperkalemia. Respiratory alkalosis and tetany. Polyuria. Hemorrhage may follow nephrectomy because of the difficulty in securing ligatures in the short renal-artery stump. It may occur on the day of surgery or 8-12 days postoperatively, when normal tissue sloughing occurs with healing. Dressing and urine are observed for bright-red bleeding, vital signs are monitored, and the patient is continually observed for any other indications of shock. Hyperkalemia (Answer 2), tetany (Answer 3), and polyuria (Answer 4) are not common complications after nephrectomy. After any surgery, bleeding is a potential problem. Two days postoperatively, a patient who has had an ileostomy begins to refuse care and repeatedly says to the staff, "Leave me alone, I just want to sleep." What would be the first nursing action? Provide accurate, brief, and reassuring explanations of all procedures. Encourage ambulation in the hall with other patients. Invite a member of an "ostomy club" to visit the patient. Encourage the patient to verbalize his or her feelings, fears, and questions. It is important to recognize that the loss of anatomical integrity initiates a grieving process. Allowing the patient to express feelings of depression, apathy, or disinterest indicates that such feelings are acceptable and not uncommon. Answer 1 is always appropriate and should be consistently carried out; however, in the situation depicted it would follow the verbalization of feelings. Answers 2 and 3 are also alternatives the nurse may wish to employ after assessing the patient's major concerns. First priority—what is concerning the patient? First, feelings. Before insertion of a Miller-Abbott tube, the balloon is tested for patency and capacity and then deflated. Which nursing measure will ease the insertion of the nasoenteric tube? Chilling the tube before insertion. Administering a sedative to reduce anxiety. Warming the tube before insertion. Positioning the patient in low Fowler's position. Chilling the tube before insertion assists in relieving some of the nasal discomfort. Water-soluble lubricants along with viscous lidocaine (Xylocaine) may also be used. It is usually only lightly lubricated before insertion. The patient may be administered a sedative (Answer 2) on physician's orders to reduce apprehension during insertion. Warming the tube (Answer 3) has no advantages. The patient is usually positioned (Answer 4) in high Fowler's position during insertion to aid in swallowing the tube. Note two contradictory options: "chill" vs. "warm" the tube. Think patient comfort: cold reduces pain. Small, frequent feedings of which type of diet would the nurse recommend for patients experiencing dumping syndrome? Low-protein, high-fat, low-carbohydrate diet. High-protein, high-fat, high-carbohydrate diet. High-protein, high-fat, low-carbohydrate diet. Low-protein, low-fat, high-carbohydrate diet. The symptoms of dumping syndrome are most likely to occur following the ingestion of large amounts of sugars or carbohydrates. Therefore a diet that is high in protein and fats and low in carbohydrates is recommended, to reduce symptomatology and to provide the patient with essential energy requirements. Answers 1 and 4 are incorrect because they do not supply sufficient protein for energy and tissue repair. High protein intake is essential after surgery and most prolonged illnesses for rebuilding tissue. Answers 2 and 4 are incorrect because they list high carbohydrates. Look for foods that slow the movement of food out of the stomach (e.g. CHO, fat). The nurse recognizes that myasthenia gravis is: An upper motor neuron lesion. A lower motor neuron lesion. A combined upper and lower motor neuron lesion. A genetic dysfunction. Because the dysfunction in myasthenia gravis occurs at the myoneural junction, it is considered a lower motor neuron lesion. Upper motor neuron lesions (Answer 1) involve cranial neurons and their axons in the spinal cord. Combined lesions (Answer 3) generally occur with spinal injury when axons of cranial neurons are destroyed, resulting in hyperreflexia and increased muscle tone below the level of the lesion, and destruction of motor neurons at the level of the injury, which in turn leads to hyporeflexia, decrease muscle tone, and muscle atrophy in those muscles normally innervated by these neurons. Myasthenia gravis is not an inherited disorder (Answer 4). Recent evidence suggests an autoimmune basis. Think of the symptoms—which answer best explains myasthenia gravis. Eliminate #3 and #4. Is it upper or lower motor? The mouth care measure that should be used with caution by the nurse when a patient has a nasogastric tube is: Regularly brushing teeth and tongue with soft brush. Sucking on ice chips to relieve dryness. Occasionally rinsing mouth with a nonastringent substance and massaging gums. Application of lemon juice and glycerine swabs to the lips The patient should be cautioned to limit the number of ice cubes he or she sucks on because the nasogastric suction will remove not only the increased water ingested from the melted cubes but also essential electrolytes. Answers 1, 3, and 4 are appropriate mouth care measures for a patient who has a nasogastric tube. One answer is different from the others (teeth, tongue, mouth, gums, lips)—it involves swallowing melted ice. Note the key term with caution. The nurse can expect hyperkalemia to develop following burn damage because there is: Increased exudate formation at the burn site. Disruption of cell membrane integrity, allowing intracellular electrolytes to diffuse into the vascular compartment. Decreased aldosterone secretion, increasing sodium excretion, and retention of potassium. Hyperbilirubinemia secondary to red blood cell destruction. Hyperkalemia (excesses in serum potassium) occurs in burns due to three separate mechanism: (1) cellular injury resulting in the movement of potassium from the intracellular spare into the extracellular space; (2) decreased glomerular filtration and urine output preventing excretion of increased serum potassium; and (3) inadequate tissue metabolism resulting in increased hydrogen ion formation (metabolic acidosis). In the kidney tubules, hydrogen and potassium ions are exchanged for sodium ions. In metabolic acidosis, more hydrogen ions are excreted than potassium ions. Exudate formation itself does not significantly affect serum-potassium levels (Answer 1). During physical and emotional stress, aldosterone levels are increased, thereby lowering serum potassium (Answer 3). Hyperbilirubinemia itself does not affect potassium concentration (Answer 4), though red blood cell destruction probably increases the amount of circulating potassium, because potassium is the major intracellular cation. Look for an answer that describes destruction of tissue or cells ("disruption of cell membrane"). Two days before discharge following a left nephrectomy, a patient expressed renewed concern over the ability to continue many activities with only one kidney. The nurse responds. You seem depressed. Actually you are very lucky, since the pathology reports indicate your tumor was encapsulated. Lots of people do quite well with only one kidney. Would you like me to call the doctor so you two can discuss it? I can understand your concern, but your remaining kidney is sufficient to maintain normal renal functions. Recognizing the patient's concern is essential both in maintaining rapport and in keeping the lines of communication open. Having done this, the nurse can then assure the patient that one kidney is sufficient to handle renal functions. This statement can then be followed by other discharge instructions, such as the need for adequate fluid intake, avoiding infections, and untoward signs that the patient needs to observe for. Answers 1, 2, and 3 do not recognize the patient's concern or facilitate open communication. The best answer acknowledges the patient's concern. Eliminate "call the doctor" (#3) because a nurse can discuss the patient's concerns. Eliminate #1 and #2 because they are trite cliches that close off elaboration. A patient is admitted to the orthopedic unit with a long leg cast, used to immobilize a transverse fracture of the right tibia and fibula. The plaster of paris cast is damp, and the patient is complaining that it feels very hot. The nurse should: Explain to the patient that the cast will feel hot for several hours as the moisture evaporates and the cast hardens. Recognize that this is a sign of excessive pressure on the soft tissues and notify the physician. Tell the patient not to worry; this is a common complaint. Administer meperidine (Demerol), 50 mg IM, to relieve discomfort. A freshly applied cast generates heat as moisture evaporates and the cast hardens. To facilitate drying, keep it exposed to the air. Do not use plastic covers or Chux on pillows to elevate the limb, because these tend to slow drying. Answer 2 is incorrect; signs of increased pressure are numbness and tingling, pain, and loss of movement. Answer 3 is an inappropriate response to the question because it fails to recognize the patient's cognitive needs. Answer 4 does not take into account that discomfort and apprehension can be reduced if the patient understands what is to be expected. The question asks expected outcome with a new cast. Eliminate #3 because #1 gives the same information without offering a trite cliche. Diagnosis of myasthenia gravis is frequently based on the patient's response to an intravenous injection of edrophonium (Tensilon). If the patient responds positively to this drug, the nurse should expect: Exacerbation of symptomatology. Relief of ptosis but not of weakness in other facial muscles. A prompt and dramatic increase in muscle strength. A slight increase in muscle strength that is countered by an increase in muscle fatigability. Edrophonium (Tensilon) is a short-acting anticholinesterase compound. A positive Tensilon test result (a prompt and dramatic increase in muscle strength) is consistent with the diagnosis of myasthenia gravis. Answer 1 is incorrect because an exacerbation of symptoms would indicate another cause for the muscle dysfunction. Answer 2 is partially correct: ptosis is relieved, but so is sagging of the other facial muscles. Answer 4 is incorrect because the increase in muscle strength is accompanied by decreased fatigability as long as the drug continues to circulate. Look for improvement as a result. Eliminate "slight" (#4) and partial relief (#2) in favor of "prompt and dramatic." Assessment of the intraocular pressure as measured by tonometry would be normal if the value is in the range: 5-10 mm Hg. 12-22 mm Hg. 10-20 cm H20. 20-30 mm Hg. The normal range of intraocular pressures is 12-22 mm Hg. Answer 1 is below the range of normal pressures and may occur in hypovolemia (soft eyeballs) or dehydration. Answer 3 is incorrect because ocular pressures are measured in millimeters of mercury. Answer 4 is incorrect because pressures above 22 mm Hg are considered elevated. Watch for the correct unit of measure (mm, not cm). Eliminate too low (#1), too high (#4). On the morning of discharge, a patient who had an emergency abdominal hysterectomy is found sitting with her back to the door, staring out the window. She says that she no longer feels like a real woman. The nurse's response should be to: Ask her if she would like her diazepam (Valium). Notify the physician. Ask, "Can you tell me what makes you feel that way?" Reassure her that this is a common reaction. It is not uncommon for a patient to feel that she will no longer be able to fulfill her role and needs as a woman following a hysterectomy. Verbalization of feelings allows the nurse to assess the patient's coping mechanisms and encourages the patient to deal with her emotional response. Answer 3 is an open-ended question that allows the patient room to respond. Answers 1 and 2 avoid the problem initially. Answer 2 may be appropriate if, after talking to the patient, the nurse assesses that her responses represent a more significant or deep-seated problem. Answer 4 would be appropriate after the patient has aired her feelings. Use therapeutic communication—first, explore patient's comment. Eliminate MD and meds as initial responses. First, focus on feelings! Which behavior is least likely to be included in the nursing assessment of a patient with burns during the recovery period? Anxiety with mild confusion. Desperation and panic. Withdrawal and depression. Dependency and regression. Desperation and panic may strike while the injury is occurring but rarely occur during the recovery period. During the acute stage of burn recovery, anxiety is common due to the stress and pain of injury and dressing changes. Anxiety decreases the individual's ability to perceive situations realistically, which may result in an altered mental state (Answer 1). During the intermediate phase of burn recovery, patients may react to continued pain, changes in body image, and financial stress with various psychological responses, ranging from withdrawal and depression (Answer 3) to acting out anger by refusing to cooperate with the medical regimen and by dependency (Answer 4). Note "least likely" in the stem, meaning "which one is incorrect." Also note time period: during recovery. Forty-eight hours after a nephrectomy, a patient complains of increasing nausea and abdominal pressure. The nurse's first nursing action is to: Change the patient's position to relieve abdominal pressure. Auscultate bowel sounds. Insert a rectal tube to relieve flatus. Administer morphine S04, 6 mg, as ordered for the relief of discomfort. Though nausea may occur following the administration of narcotics, if it is accompanied by the absence of bowel sounds and upper abdominal distention, gastric or small-intestine dilation should be suspected and the nurse's findings reported to the physician. Changing the patient's position (Answer 1) and insertion of a rectal tube (Answer 3) are not helpful if peristalsis is not present (bowel sounds). Administering morphine (Answer 4) is not indicated until the source of the patient's discomfort is diagnosed. Note the time of the event following surgery. What functions should return within 48 hours? Only one option deals with assessment (auscultate); the other three are implementation responses (change, insert, administer). Which instruction would be inappropriate when teaching a patient to use crutches? Use axilla to help carry weight. Use short strides to maintain maximum mobility. Keep feet 6-8 inches apart to provide a wide base for support. If the patient should begin to fall, throw crutches to the side to prevent falling on them. In the use of crutches, all weight bearing should be on the hands. Constant pressure in the axilla from weight bearing can lead to damage of the brachial plexus nerves and produce crutch paralysis. Answers 2, 3, and 4 are appropriate instructions to give to the patient preparing for crutch walking. The best answer is the wrong thing to teach. The nurse explains that epileptic seizures or convulsions result from: Excessive exercise with lactic acid accumulation. Excessive, simultaneous, disordered neuronal discharge. Excessive cerebral metabolism, with local K+ increased. Excessive circulating cerebrospinal fluid increasing cerebral pressures. Epileptic seizures or convulsions are the result of excessive, simultaneous, disordered neuronal discharge in the brain. This dysrhythmic electrical discharge may be focal (jacksonian seizure) or widely dispersed (grand mal seizures). Answers 3 and 4 are incorrect because theories for the initiation of these convulsions vary from decreased (Answer 3) intracellular K+ to decreased (Answer 4) cerebrospinal fluid to alteration in neuronal defense due to trauma, toxins, or inflammation. Depending on existing potential in the individual, Answer 1 may be a precipitating factor. Look for the key word: "neuronal." What nursing action best facilitates the passage of the nasoenteric tube from the stomach through the pylorus and into the duodenum? Gently advancing the tube 1-4 inches at regular time intervals. Positioning the patient on the right side for 2 hours after insertion. Maintaining strict bed rest and avoiding all unnecessary movement. Positioning the patient in a flat supine position. After the tube has been inserted into the stomach, its movement into the duodenum is first facilitated by having the patient lie on the right side for 2 hours, then on the back with head elevated for 2 hours, and finally on the left side for 2 hours. After the tube has passed the pylorus (this is usually checked by x-ray), ambulating the patient will help move the tube to the point of obstruction. After positioning and ambulation, the physician or the nurse may advance the tube 1-4 inches at specified time intervals (Answer 1) to provide slack for peristaltic action. Remaining quiet or flat in bed (Answers 3 and 4) will not facilitate the advancement of the tube either through the pylorus or through the small intestine. Focus on the two positioning options: right vs. flat supine. Understand the concept of peristalsis and think of the sequence of positioning (right —> supine in semi-Fowler's —> left). During the initial stage of burns, a primary fluid imbalance occurs. The nurse knows that there has been a shift of fluids from: The cell to the interstitial space. The interstitial space into the cell. The interstitial space to the plasma. The plasma to the interstitial space. The hypovolemia that occurs in the initial stage of burns is the result of fluid lost from denuded areas of skin mid edema in and around the burned surface area. Edema formation is due to a shift of plasma fluids to the interstitial space. Answers 1, 2, and 3 are incorrect because when tissues are burned, a change in the permeability of both tissue and capillary membranes occurs. This change and increased vasodilation result in a shift of excessively large amounts of extracellular fluid (electrolytes and proteins) into the burned area. Most of this fluid loss occurs deep in the wound, where fluid moves into the deeper tissue. Burns of a highly vascular area (muscle, face) are believed to cause more severe fluid volume shifts than comparable burns to other areas of the body. Where was fluid before the burn? Where would it go after the burn? Note the time period: initial stage. Bed rest is ordered for a patient with chronic glaucoma during a period of acute distress, because activity tends to increase intraocular pressure. Which activity of daily living should this patient be instructed to avoid? Watching television. Brushing teeth and hair. Self-feeding. Passive range-of-motion exercises. Vigorous activities such as brushing the teeth and brushing the hair are generally discouraged during periods of acute distress. These activities tend to increase aqueous production and therefore pressures because they activate sympathetic nervous system stimulation of the vasculature. Quiet activities such as watching TV (Answer 1), moderate activities such as reading, self-feeding (Answer 3), and passive range-of motion exercises (Answer 4) are encouraged. Look for the activity most likely to increase pressure in the eyes or head. Look for what is not OK because the stem says "to avoid." Three activities are quiet, passive; one is active (brushing). Nursing implications with diphenylhydantoin given during treatment of status epilepticus include giving the intravenous injection slowly and in small increments to prevent: Respiratory depression and/or arrest. Vasodepression and circulatory shock. Irritation and/or necrosis of the vein and surrounding tissue. Vasomotor stimulation, with a sudden, malignant increase in blood pressure. Diphenylhydantoin (phenytoin, Dilantin) must be injected IV slowly and in small increments to prevent vasodepression and circulatory collapse. Respiratory depression (Answer 1) is generally associated with morphine sulfate. Adrenergic (alpha) drugs such as norepinephrine bitartrate (Levophed) may cause vein and tissue necrosis (Answer 3) and have only rarely caused sudden malignant increases in blood pressure (Answer 4). Know the expected effects of IV Dilantin. Think circulatory. The nurse would be alerted to a sudden increase in intraocular pressure if the patient with open-angle glaucoma complained of: Generalized decrease in peripheral vision over the past year. Difficulty with close vision. Increasing discomfort in the left eye with radiation to the forehead and left temple. Halos around lights. Generally the patient with chronic, or open angle glaucoma has few complaints of intense symptomatology. The usual onset of this condition is slow, silent, and painless. However, some patients experience prodromal symptoms, such as aching and discomfort around the eye, disturbed accommodation to darkness, and blurring of peripheral vision (Answer 1). Any complaint of pain or increasing discomfort with radiation to the forehead and temporal area is a grave sign of a sudden increase in pressure. Difficulty with close vision (Answer 2) is not characteristic of glaucoma. Halos around lights (Answer 4) occur less commonly. Key word is sudden—complaint of eye pain often indicates an acute (sudden) change in intraocular pressure. The nurse will usually ambulate a patient postgastrectomy beginning: The day after surgery. 3-4 days after surgery. After 4 days of bed rest. Immediately after awakening from anesthesia. Patients are ambulated as soon as possible to prevent the complications of bed rest; generally ambulation can begin as soon as 24 hours after surgery. In some instances, such as when the patient is severely debilitated or has complications due to ulcer perforation, bed rest may be prolonged, as in Answers 2 and 3. If this is die case, the nurse will need to observe closely for signs of complications (atelectasis, thrombophlebitis, etc.) and institute measures to prevent them. The patient is rarely if ever gotten up immediately after awakening, as in Answer 4. Look for the best general timing to prevent complications and ensure patient safety. Key term: "usually," meaning typically (not rarely, or under special circumstances). If "cholinergic crisis" is demonstrated in a patient who has myasthenia gravis, all anticholinesterase drugs are withdrawn. To reduce symptoms, which of the following drugs should the nurse be prepared to give? Atropine. Ephedrine sulfate. Potassium chloride. Neostigmine bromide. In cholinergic crisis, all anticholinesterase drugs are withdrawn and atropine (an anticholinergic drug) is given in 2 mg doses IV every hour until signs of atropine toxicity develop (dry mouth, blurred vision, tachycardia, rash or flushing of the skin, and elevated temperature). Answers 2, 3, and 4 are incorrect because they do not act to decrease cholinergic responses. Ephedrine (Answer 2) is used in myasthenia gravis to increase muscle tone; potassium chloride (Answer 3) is used to increase serum K+ because it is believed that adequate serum-potassium levels potentiate the effects of cholinergic drugs; and neostigmine bromide (Answer 4) is an anticholinesterase that acts to improve cholinergic transmission of impulses at the myoneural junction. Look for the antidote (an anticholinergic drug) to counteract untoward effects. Equally important as the depth of tissue destruction in determining severity of burns is the total body surface involved. The nurse would anticipate potential fluid and electrolyte problems when burns are: Superficial partial thickness and cover 20% of the body surface. Deep partial thickness and cover 15% of the body surface. Full thickness and cover 10% of the body surface. Fourth degree and cover 5% of the body surface. Critical burns are classified as deep partial-thickness over 30% of the body or full thickness over 10% of the body. Extensive burns involving the face, hands, and feet or those associated with respiratory injuries are also considered critical. The most frequently used method of calculating the extent of a burn is the "rule of nines." Although this method is fairly simple to apply, it is somewhat inaccurate. This is particularly true when it is applied to children because allowances are not made for the proportional differences in head size and extremity size between children and adults. Hence superficial partial-thickness burns (Answer 1) are not serious unless large areas are involved or the patient is very young or old. Deep partial-thickness burns (Answer 2) are classified as a major burn if over 25% of the body is involved. The fourth degree burn classification is not routinely used (Answer 4). First, eliminate what is least (superficial) and not used (#4).Then, think proportion—greater depth (full thickness) and less area. Patient teaching about glaucoma should include a comparison of the two types. Open-angle, or chronic glaucoma differs from closed-angle or acute glaucoma in that: Open-angle glaucoma occurs less frequently than closed-angle glaucoma. Open-angle glaucoma's symptomatology includes pain, severe headache, nausea, and vomiting; closed-angle glaucoma has a slow, silent, and generally painless onset. The obstruction to aqueous flow in open-angle glaucoma generally occurs somewhere in Schlemm's canal or aqueous veins. It does not narrow or close the angle of the anterior chamber, as in closed-angle glaucoma. Open-angle glaucoma rarely occurs in families; however, there is a hereditary predisposition for closed-angle glaucoma. In chronic, or open-angle glaucoma, the obstruction to aqueous outflow is due to degenerative changes in either the trabeculum, Schlemm's canal, or the aqueous veins. Closed angle glaucoma is characterized by obstruction of aqueous outflow due to narrowing of the angle between the anterior chamber and the root of the iris. The other answers are incorrect because chronic, or open-angle, glaucoma occurs more frequently than closed-angle (Answer 1), is characterized by slow, insidious, painless onset rather than the acute symptoms of closed-angle glaucoma (Answer 2), and is certainly familial, if not hereditary (Answer 4). Due to this latter characteristic, family members of patients with open-angle glaucoma should be encouraged to have their intraocular pressure assessed annually, particularly past age 40. Look for similarity between the condition ("open-angle") and clues in the choice that says "does not close," meaning it is open. The question asks how open angle is different. The adequacy of fluid volume replacement in the early postburn period is best reflected by: Blood pressure, pulse rates, and daily weights. Quantity of urinary output and vital signs. Hemoglobin and hematocrit levels. Serum-electrolyte levels and urinary output. Although each of the listed measures can be used to assess the adequacy of the fluid replacement, hourly urine outputs and vital signs provide significant information on fluid balance in the acute burn period. Decreased urine output, increased pulse rate, and restlessness are early signs of inadequate fluid replacement. Increase in blood pressure, pulse, respirations, and urine output are early signs of circulatory overload. Changes in daily weights provide accurate data over the long run and are extremely important in monitoring fluid volumes in patients on diuretic therapy, such as patients with congestive heart failure or cirrhosis. Answers 1, 3, and 4 are not the best indicators. Key words: best and early. Look for indication of adequate volume. Note the two options that include "urinary output," and choose the one that also has vital signs that are vital to assess 4-fluid volume and overload. Which aspect of open-angle glaucoma and its medical treatment is the most frequent cause of patient noncompliance? Loss of mobility due to severe driving restrictions. The painful and insidious progression of this type of glaucoma. Decreased light and near-vision accommodation due to miotic effects of pilocarpine. The frequent nausea and vomiting accompanying use of miotic drugs. The most frequent cause of noncompliance to the medical treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the patient's ability to read for extended periods, and making participation in games with fast-moving objects impossible. Answer 1 is incorrect because daytime driving is not restricted. Answer 2 is incorrect because this process is painless. The fact that the process is painless and insidious may in fact increase patients' non compliance because they do not usually experience any adverse reactions if they do not instill their eyedrops. Nausea and vomiting are rare toxic effects of pilocarpine and are usually very mild; hence Answer 4 is incorrect. Try KIS—Keep it simple: glaucoma is a problem with vision; hence, "decreased . . . vision" in #3 looks good. In addition, the stem mentions "medical treatment"; pilocarpine is a specific drug mentioned in #3. Recognize expected effects of miotics. Which would the nurse expect to see with the dumping syndrome? Feeling of hunger. Constipation. Increased strength. Diaphoresis. Profuse perspiration, diaphoresis, is one of a group of symptoms that happen 5-30 minutes after a high-carbohydrate meal or when liquid is taken with the meal. This is caused by entrance of food into the jejunum before it has had a chance to begin the digestive process. Other symptoms include a feeling of fullness, not hunger (Answer 1); diarrhea, not constipation (Answer 2); and weakness, not increased strength (Answer 3). Stem asks what would the nurse see (objective). Three choices are subjective. Choose the one that is different. The nurse observes a patient in the orthopedic clinic using a long pencil to scratch the skin under the cast. The nurse should: Ask the physician for an oral medication order to relieve itching. Explain to the patient that scratching under the cast should be avoided, because it may break the skin and cause an infection. Assist the patient by gently rolling the casted leg in the palmar surfaces of the nurse's hands. Take the pencil away from the patient. It is not safe to insert any foreign object under a cast, because the skin may break and become infected. Scratching also disturbs the padded surface under the cast, causing it to become wrinkled, which may lead to skin irritation and breakdown. Itching under the cast can be relieved by directing air (from a blower) under the cast. Oral medication is not generally effective in relieving this type of skin irritation (Answer 1). Rolling the cast (Answer 3) while the patient scratched would only increase the risk of skin damage. Taking the pencil from the patient (Answer 4) would deny his nr her ability both to understand the rationale and to take responsibility for actions. Patient safety is a priority (reduce risk of damage to skin). The best explanation for the nurse to offer to a patient and family would be that myasthenia gravis is a: Degenerative dysfunction of the basal ganglia. Transmission dysfunction at the myoneural junction. Hypertrophic reaction in the anterior motor neurons of the spinal cord. Hereditary condition of cranial nerves VII, IX, and X. The primary dysfunction in myasthenia gravis occurs at the myoneural junction (the synapse between the end of a myelinated nerve fiber and a skeletal muscle fiber). Normally, acetylcholine is secreted by the nerve ending, which counts on the muscle fiber membrane by increasing its permeability to sodium. If sufficient sodium enters the muscle fiber membrane, an action potential is promulgated and causes the muscle fiber to contract. To enable the muscle fiber to repolarize, the acetylcholine in the synaptic junction is destroyed by cholinesterase. In myasthenia gravis, these normal impulses are blocked at the myoneural junction. Answer 1 is incorrect because degeneration of the basal ganglia results in increased muscle tone, as occurs with Parkinson's disease. Answer 3 is incorrect because increased stimulation of muscle fibers by anterior motor neurons would also increase muscle contractions. Answer 4 is partially correct, in that there does seem to be a familial tendency toward the development of myasthenia; however, if myasthenia is generalized, it usually affects not only racial and mastication muscles but also ocular movement (diplopia and ptosis), as well as muscles of the neck, trunk (respirations), and limbs. Look for clues—myo (muscle); neural (nerve). Major problem is muscle weakness. Fifty-four hours after a patient sustained deep partial thickness burns of the left leg and thigh, the patient's urine output increased from 1000 to 2300 mL/24 hr. Laboratory values were as follows: serum sodium, 136 mEq/L; serum potassium, 4 mEq/L; and hematocrit, 34%. The nurse knows that the changes in the patient's urinary output and lab studies indicate: Beginning of the interstitial-to-plasma fluid shift phase of burns. Kidney failure. Circulatory overload due to rapid IV infusion rate. Hyponatremia. The diuretic stage of burns occurs 48-72 hours alter injury. The fluid shift is the opposite of that in the initial stage. Fluids, electrolytes, and proteins may move very rapidly from the interstitial space back into the vascular compartment. Unless renal damage has occurred and there is no indication (Answer 2), diuresis ensues, due to the increased blood volume and renal blood flow. Serum electrolytes and hematocrit are decreased due to hemodilution. If urine output is insufficient at this time, symptoms of circulatory overload and cardiac failure will occur. There are no data to support Answer 3. The sodium value is within normal limits (Answer 4). Clue: time frame—after the initial phase (54 hours). Think expected changes over time in fluid balance (major shifts). Recognize normal serum Na+ value and eliminate #4. With increased output, you can eliminate #2 and #3. A nursing care plan includes observing for the most common patient problems arising from the use of pyridostigmine (Mestinon) and neostigmine bromide (Prostigmin), which include: Gastric distress - nausea, anorexia, diarrhea. Elimination problems - urinary retention. Central nervous system excitation - flushing, irritability. Cardiac arrhythmias - palpitations, PVCs. The most common side effects of pyridostigmine (Mestinon) and neostigmine bromide (Prostigmin) include anorexia, nausea, diarrhea, and abdominal cramps. These symptoms are due to increased gastrointestinal secretions, smooth-muscle contractions (peristalsis), and irritation of the gastric mucosa. Answer 2 is incorrect because increased cholinergic discharge increases bladder tone and contraction, thus facilitating voiding. Answers 3 and 4 are incorrect because the symptoms listed are consistent with increased adrenergic, not cholinergic, discharge or stimulation. Need to know expected common outcomes. Think GI system: nausea is a common side effect with many drugs. Other options are more severe. Before discharge a postoperative gastrectomy patient asks the nurse pointedly, "How long will it be before I can eat three meals a day like the rest of my family?" The nurse responds: Eating six meals a day can be a bother, can't it? Some patients can tolerate three meals a day by the time they leave the hospital. Maybe it will be a little longer for you. You will probably have to eat six meals a day for the rest of your life. It varies from patient to patient, but generally in 6-12 months most patients can return to their previous meal patterns. In response to direct questioning by the patient, the nurse needs to provide brief, accurate information. Some patients who have had gastrectomies are able to tolerate three meals a day before discharge from the hospital. However, for the majority of patients, it takes 6-12 months before their surgically reduced stomach has stretched enough to accommodate a larger meal. Answer 1 is incorrect because it does not answer the question. Answer 2 is correct as far as it goes, but still does not answer the patient's question. If the nurse does not know the answer to a question, he or she should admit it but try to get the information. Answer 3 is incorrect because it gives inaccurate information. The correct choice answers what the patient asked; #2 and #4 are similar, but #4 gives more specific information (6-12 months as opposed to "a little longer"). The nurse would be correct in saying that two common causes of primary hypothyroidism are: Destruction of thyroid tissue by radioactive iodine during therapy for hyperthyroidism, and spontaneous atrophy due to autoimmune response. Spontaneous atrophy due to autoimmune response, and surgical removal of the thyroid gland. Surgical removal of the thyroid gland, and tumors of the pituitary gland that decrease the amount of circulating thyroxine. Tumors of the pituitary gland, and/or large doses of antithyroid drugs. The most common cause of hypothyroidism is excess thyroid tissue destruction due to radioactive iodine therapy for hyperthyroidism. Spontaneous hypothyroidism is believed to be due to an autoimmune response. Several studies have revealed a high incidence of antibodies for thyroid antigen in patients with spontaneous atrophy (Answer 2). Other, less common causes include surgical removal (Answer 3), Hashimoto's thyroiditis, overuse of antithyroid drugs (Answer 4), and pituitary tumors or insufficiency that decrease the circulating levels of thyroid-stimulating hormone. Use a process of elimination and keep two common causes in mind. In order to take full advantage of the effects of pyridostigmine bromide and neostigmine bromide in reducing dysphagia related to myasthenia gravis, the nurse should plan to give the medications before meals. How long before? 2 hours. 45-60 minutes. 20-30 minutes. 10-15 minutes. In order to take full advantage of the effects of anti cholinesterase drugs, they should generally be scheduled 20-30 minutes before eating. Answers 1 and 2 are not totally incorrect, in that these drugs generally act over a 3-hour period; however, peak action occurs quickly, and patients with dysphagia need time to eat, chew, and swallow during meals. Rushing at meals causes unnecessary fatigue. Answer 4 may not allow enough time for the drug to take effect. Clue: time frame. First, eliminate the extremes (#1, #4); look for a midpoint. Most drugs take effect within 30 min. What is the desired outcome? Improve swallowing of food. A patient recuperating from burns is withdrawn and depressed. The nurse can expect this patient to exhibit such psychological reactions during the recuperative stage because of: Pain and immobility. Changes in body image. Financial concerns. Anger. Body image changes are the most frequent basis for psychological responses during the recuperative phase. This is particularly true if the patient is young or has sustained facial or neck burns. Also, self-esteem is often lowered. The patient needs to be encouraged to talk about the perceived changes between what he or she was, and what he or she is now. Sessions with a psychiatric nurse specialist may be helpful. Occasionally individual or group therapy is indicated. Pain and immobility (Answer 1) create problems in the acute phase of burns. Financial concerns (Answer 3) may affect responses during the recuperative phase, but they are not a significant concern for all patients. Anger (Answer 4) may be a response during each phase as the patient reacts to various real and imagined losses. Clue: time frame ("recuperative stage"), not acute stage. The reality of disfigurement fits the time period. Because medications have been increased for a patient with myasthenia gravis, it is important that the nurse observe for signs of "cholinergic crisis." These include: Dilated pupils, profuse diaphoresis, and trembling. Constricted pupils, hypersalivation, and hypotension. Dilated pupils, nausea, and tachycardia. Constricted pupils, dry mucous membranes, and bradycardia. Signs of "cholinergic crisis" include pupils constricted to less than 2 mm, severe diarrhea, nausea, vomiting, hypersalivation, lacrimation, pallor, and hypotension. Bradycardia may occur but is uncommon. In severe cases, confusion progressing to coma may occur due to blockage of cerebral synapses. Answers 1 and 3 are symptoms related to increased adrenergic discharge. Answer 4 is only partially correct. The "eyes" have it! First decide that constricted pupils occur (this means that #1 and #5 are eliminated). The expected effects of too much medication in this condition would eliminate #4 (not dry mucous membranes, but hypersalivation). The nursing assessment of a patient recently diagnosed with hypothyroidism will likely reveal the most common clinical manifestations of hypothyroidism, which are: Increased body temperature, tachycardia, and fatigue. Decreased exercise tolerance and facial and pitting edema. Increased sluggishness, increased cold intolerance, and puffy eyelids, hands, and feet. Decreased facial expression, diarrhea, and weight gain. A deficiency of thyroid hormone causes widespread metabolic changes. Alterations in fluid and electrolyte balance due to increased capillary permeability lead to fluid retention that results in edema, particularly of the eyelids, hands, and feet. Answer 1 is ncorrect because the lowered metabolic rate decreases cellular oxygen consumption; as a result, the heart rate, pulse pressure, and blood pressure are educed. Answer 2 is incorrect because there is eyelid edema, not facial edema. The basal metabolic rate is educed, causing symptoms of anorexia, constipation, and intolerance to cold due to a lowered body temperature. Answer 4 is incorrect because it includes diarrhea. Reduced cerebral blood flow affects both perception and coordination and results in symptoms of lethargy, generalized weakness, and slowing of both intellectual and motor functions. Note hypo (), not hyper (). Associate metabolic changes with the thyroid. Increased () sluggishness (#3) really means slow down (). In contrast to hypothyroidism, hyperthyroidism is due to excessive levels of thyroxine in the plasma. Clinical data gathered by the nurse indicating this endocrine dysfunction would include: Systolic hypertension and heat intolerance. Diastolic hypertension and widened pulse pressure. Heat intolerance and weight gain. Emotional hyperexcitability and anorexia. The patient with hyperthyroidism has an increased metabolic rate due to excess serum thyroxine leading to symptoms of systolic hypertension, heat intolerance, widened pulse pressure, and emotional excitability. Answer 2 is incorrect because the diastolic blood pressure reduces due to decreased peripheral resistance. Weight loss (not gain, as in Answer 3) occurs because of increased catabolism despite an increase in appetite. Anorexia in Answer 4 is incorrect because the patient has increased appetite. Note hyper—metabolism speeds up. Three options have both a correct and an incorrect element. Look for the option in which both parts are correct (#1). Which statement by the nurse about myasthenia gravis is accurate? Thymectomies rarely produce remissions in myasthenia gravis. Myasthenia gravis is an acute illness that progresses rapidly. Myasthenia gravis has increased muscle strength as a major symptom. Myasthenia gravis may be an autoimmune disease. Myasthenia gravis is a rare disease of unknown cause but is suspected to have autoimmune characteristics. Answer 1 is not correct because thymectomy has often resulted in remission or improvement (in approximately 70% of patients), not rarely. Answer 2 is not correct because myasthenia gravis runs a chronic and progressive, not acute and rapid course. One of the major symptoms is muscle weakness, not increased strength (Answer 3). Use process of elimination, with a true-or-false approach as you look at key words in the options: rarely, acute, increased muscle strength. Which nursing intervention would be included in the preoperative period for a patient who will have a partial gastrectomy, vagotomy, and gastrojejunostomy? Insertion of a nasogastric tube before surgery. Administration of diazepam (Valium), 4 mg, with 4 oz water 1 hour before surgery. Detailed description of the possible complications that could happen postoperatively Instructions to avoid taking pain medication too frequently in the first 2 postoperative days to avoid drug dependency. A nasogastric tube will be inserted early on the surgical day to monitor GI contents. Answer 2 is not correct because the patient will not be allowed anything by mouth; all medications will be administered by injection in the immediate preoperative period. Answer 3 is not correct because, although it is important for the physician (not a nursing intervention) to explain possible complications when obtaining permission to perform the surgery, the timing is inappropriate for any lengthy descriptions of possible complications. Answer 4 is not a good choice because the patient should be encouraged, not discouraged, to take an appropriate amount of pain medications so he or she will be able to cough, turn, and deep breathe to avoid respiratory complications. Choose the best answer to present complication during or after surgery. Clue: because it is gastric surgery; look at the option that has "nasogastric tube." Both Cushing's syndrome and Addison's disease are due to dysfunction of the adrenal cortex. In order to plan for the care of a patient with Cushing's syndrome, the nurse should know that the primary pathology is: Increased Cortisol secretion. Increased epinephrine secretion. Decreased aldosterone secretion. Decreased ACTH secretion. The primary pathology in Cushing's syndrome is increased scrum Cortisol, which acts to accelerate the rate of gluconeogenesis in the body, thus mobilizing stored fats and proteins. Serum glucose is increased, stimulating insulin secretion by the pancreas and resulting in abnormalities in fat metabolism and deposition. Weight gain is common; the torso enlarges and fat pads develop on the back of the neck and in the cheeks, giving the patient the characteristic "buffalo hump" and "moon fades." Increased epinephrine secretion (Answer 2) is associated with pheochromocytoma. Increased aldosterone Answer 3 is associated with primary aldosteronism. Decreased ACTH secretion (Answer 4) is associated with dysfunctions of the pituitary gland. Cushing's and Cortisol both start with C. Because Cortisol is a glucocorticoid, the nurse caring for the patient with Cushing's syndrome should expect: Hypoglycemia due to increased insulin production. Skeletal-muscle wasting because glucocorticoids promote protein and fat mobilization. Dependent edema and severe hypokalemia due to abnormal aldosterone secretion. Discoloration or hyperpigmentation of the skin due to increased pituitary secretion of ACTH. Lassitude and muscle weakness are early clinical signs of Cushing's syndrome. Catabolism from gluconeogenesis occasionally results in a marked decrease in skeletal mass, and the patient's extremities may appear wasted. Answer 1 is incorrect because gluconeogenesis from excess Cortisol secretion results in hyperglycemia. Answer 3 is partially correct: hypersecretion of aldosterone in Cushing's disease is rare; however, large quantities of Cortisol tend to increase sodium and water retention and potassium excretion. Edema and hypokalemia occur only in severe cases. Discoloration and hyperpigmentation (Answer 4) occur with adrenal insufficiency. Visualize the patient with Cushing's— skinny legs (wasting) and buffalo hump (fat mobilization). In Addison's disease, glucocorticoids, mineralocorticoids, and androgenic hormones are all reduced. Therefore, in contrast to Cushing's syndrome, the nurse should expect to find: Hypotension, weight loss, and physical and mental exhaustion. Hypertension, moon facies, and masculinization in women. Hypotension, hyperglycemia, and weight gain. Hypertension, male impotency, and menstrual disturbances. Signs and symptoms of Addison's disease include hypotension, hypoglycemia, muscular weakness, fatigue, weight loss, hyperkalemia, and depression. These symptoms are primarily due to disturbances in sodium, water, and potassium imbalances that cause severe dehydration. Answer 2 includes symptoms of Cushing's syndrome. Answer 3 is incorrect because hyperglycemia and weight gain are consistent also with Cushing's Syndrome. Answer 4 also includes symptoms of Cushing's syndrome. Look for signs of a deficiency (hypo, weight loss, energy). If one part of an option is incorrect, the entire option is incorrect (e.g., weight gain in #3 makes the entire option incorrect, although hypotension is correct). Iron deficiency anemia is best described as: Hypochromic microcytic. Hyperchromic macrocytic. Hyperchromic microcytic. Hypochromic macrocytic. Iron deficiency anemia is characterized by a decrease in red blood cell color due to a decrease in iron (hypochromic) and an increase in immature red blood cells (microcytic) Answer 2 describes the red blood cells in pernicious anemia. Answers 3 and 4 describe no particular conditions. Look for similar meanings in stem and answer—deficiency in the stem, and hypo and micro in the correct option (#1). The nurse should expect that a patient's emotional responses to acute rheumatoid arthritis would primarily depend on the patient's: Self-concept, body image, and usual effective coping strategies. Relationship with the patient's mother. Usual effective or palliative coping strategies only. Economic status and work history. In assessing any patient's emotional responses, the nurse should first assess the patient's ego strength, body image, and coping abilities for life situations in general. The manner in which the patient views himself or herself will greatly affect attitudes toward disease and emotional response. If the patient normally denies or represses threatening information or situations, desirable outcomes may be difficult to achieve. Research indicates that social supports are extremely important in maintaining health. The relationship between the patient and the patient's mother (Answer 2) should be assessed. However, if the patient has a strong self-image, the issues between mother and adult child should be resolvable either alone or with objective outside help. Answer 3 is incomplete. Economic status and work history (Answer 4), depending on their value to the patient, may not be important determinants of emotional response. Select the broadest, most inclusive answer that covers them all. When in doubt about the best psychosocial option, choose the "self-image, self-concept" type of answer. Because aldosterone is the major mineralocorticoid secreted by the adrenal cortex, which fluid and electrolyte imbalance should the nurse anticipate with decreased secretion of this hormone? Hyperkalemia. Hypernatremia. Hypervolemia. Hypercalcemia. The primary fluid and electrolyte imbalances in Addison's disease are hyponatremia, hypovolemia, and hyperkalemia. These imbalances are caused by decreased aldosterone secretion. Answers 2 and 3 are incorrect because they occur with excessive secretion of this hormone. Calcium levels are not affected by this condition (Answer 4). Need to know relationship with sodium () and potassium (). Key word is decreased aldosterone secretion. The care plan for a patient who is burned includes observing for side effects of mafenide 1% (Sulfamylon), such as: Severe electrolyte disturbances. Metabolic acidosis. Metabolic alkalosis. Staining of linen. Mafenide 1% (Sulfamylon) is a white antibacterial ointment applied once or twice daily. Besides causing pain on application, this medication is a carbonic anhydrase inhibitor that interferes with the kidney's ability to excrete hydrogen ions and thus may cause metabolic acidosis, not metabolic alkosis (Answer 3). Patients who are treated with mafenide 1% need to have their acid base balance monitored by blood gas determinations. Clinical signs of metabolic acidosis are increased rate and depth of respirations. Silver nitrate causes black discoloration of linens, and its hypotonicity causes electrolyte imbalances (Answers 1 and 4). Patients treated with silver nitrate need supplemental sodium, potassium, and chloride. Recognize expected desired and untoward metabolic effects. This eliminates #1; #4 is a side effect of a different drug. A patient complains of not having had a bowel movement since being admitted 2 days ago for multiple fractures of both lower legs. The patient is on bed rest and skeletal traction. Which intervention would be the most appropriate nursing action? Administer an enema. Put the patient on the bedpan every 2 hours. Ensure maximum fluid intake (3000 mL/day). Perform range-of-motion exercises to all extremities. The best early intervention would be to increase fluid intake, because constipation is common when activity is decreased or usual routines have been interrupted. Answer 1 is incorrect because this may not be necessary and also requires a doctor's order. Answer 2 is incorrect because this is a great deal of exertion when the patient is not expressing an urge to defecate. Although activity usually helps bowel evacuation, it would be impossible to exercise extremities that have unhealed fractures (Answer 4). Priority nursing action is to prevent and correct constipation: fluids —> fecal movement. Which cardinal sign heralds the onset of thyroid storm? Fever. Tachycardia. Hypertension. Tremulousness. Thyroid storm may be precipitated by a number of stresses, such as infection, real or threatened loss of a loved one, or thyroid surgery undertaken before the patient was prepared adequately with antithyroid drugs. A change heralding thyroid storm is a fever: the patient's temperature may rise as high as 106 F (41 C). Answers 2, 3, and 4 are symptoms of hyperthyroidism and become exaggerated during thyroid storm. Without treatment, the patient progresses from delirium to coma; death ensues as the result of heart failure. Key word is cardinal—most important; what you will note first. The nurse would recognize drainage of blood from the nasogastric tube after gastrectomy surgery as abnormal if: It continued for 4-6 hours. It continued for a period longer than 12 hours. It turned greenish yellow in less than 24 hours. It was dark red in the immediate postoperative period. Bloody drainage from the nasogastric tube more than 12 hours after surgery should be considered unusual and reported to the surgeon. Prolonged bleeding may be indicative of a slow bleeder, a blood dyscrasia, or problems with incisional closure. Any of these may increase blood loss and lead to shock. Answers 1, 3, and 4 are incorrect because they are normal findings in the early postgastrectomy period. The key element is a time factor, not color (i.e., not greenish-yellow, red). Choose an answer indicating the greatest risk to the patient (prolonged bleeding). Fluid therapy postburn may necessitate as much as 7 liters of fluid in 24 hours for a 70 kg individual. Using a 15 gtt/mL administration set, the drops per minute that the nurse would set to deliver this volume would be: 48 gtt/min. 75 gtt/min. 60 gtt/min. 90 gtt/min. Calculating the correct rate requires computation of the hourly volume (290 mL) and the minute volume (5 mL), and then multiplying the rate, in mL/min, by the drop factor (15 gtt/mL). (The hourly and minute volumes have been rounded to the nearest whole number.) Answers 1 and 3 are not fast enough to deliver this large a volume in the prescribed period. Answer 4 is too rapid. A quick method of computing the drip rate is to use the first two numbers in the 24-hour fluid volume, i.e., 7000 mL in 24 hours = 70 gtt/min. This shortcut may be useful when initially starting an infusion, before mathematically calculating the rate. Use only with 15 gtt/mL factor. Use basic IV calculation. Eliminate the extremes (#1 and #3 are too slow; #4 is too fast); select the midpoint here. The nurse anticipates that osteoporosis may result from prolonged immobilization because of: Lack of weight bearing, which decreases osteoblastic activity. Decreased dietary calcium intake. Deposition of excess calcium phosphate salts. Lack of weight bearing, which increases bone formation. Osteoblastic activity (bone growth) requires the stress and strain of weight bearing to be proportional to osteoclastic activity (bone breakdown). When the patient is immobilized for an extended period of time, bone breakdown takes place. Although dietary intake is important, it is not recommended that there be an increase in calcium intake (Answer 2) due to the potential for kidney stones as a result of immobilization. Osteoporosis is related to a deficit of calcium, not an excess (Answer 3). Bone growth is dependent on weight bearing, not lack of it (Answer 4). Focus on two options with "lack of weight bearing." Recognize expected outcome of immobilization—look for loss of bone density. The nurse knows that in a patient who has deep partial or full-thickness burns, the hematocrit is reduced due to: Lack of erythropoietin factor. Hemodilution and volume overload. Metabolic acidosis. Hypoalbuminemia. Hematocrit is reduced due to hemodilution and volume overload resulting from the interstitial-to-plasma fluid shift. Erythropoietin factor (Answer 1) is produced by the kidneys and would only be reduced if there were kidney failure. Metabolic acidosis (Answer 3) does increase red blood cell fragility, but it is not applicable in this situation. Hypoalbuminemia (Answer 4) causes loss of oncotic pressures in the vascular compartment. The primary effect of this phenomenon is movement of fluid from the vascular compartment to the interstitial space, the outcome of which is hemoconcentration. Read answers to find clues—low hematocrit and hemodilution. Following gastrectomy surgery the nurse must observe for signs of pernicious anemia, which may be a problem after gastrectomy because: The extrinsic factor is produced in the stomach. The extrinsic factor is absorbed in the antral portion of the stomach. The intrinsic factor is produced in the stomach. Decreased hydrochloric acid production inhibits vitamin B12 reabsorption. Pernicious anemia may occur following subtotal gastrectomy (when large portions of the stomach are removed) due to the loss of tissue that produces the intrinsic factor. Loss of this factor necessitates the parenteral administration of vitamin B12, the extrinsic factor. Answer 1 is incorrect because the extrinsic factor is found in food. Answers 2 and 4 are incorrect because it is the loss of intrinsic factor that results in the malabsorption of vitamin B12. Note the pattern in the responses: two extrinsic factors, one intrinsic; choose the one that is different. Need to know reason for expected problem. Which nursing intervention can aid in reducing the gastric side effects of pyridostigmine bromide (Mestinon) and neostigmine bromide (Prostigmin)? Give with milk, soda crackers, or antacids. Push fluids and encourage ambulation. Keep room cool and discourage visitors. Encourage food high in potassium. The gastric distress that occurs as a side effect of these medications can be reduced by administering the drugs along with milk, soda crackers, or antacids. The nursing actions in Answer 2 are consistent with elimination problems (urinary retention); those in Answer 3 are consistent with central nervous system excitation (flushing, irritability); and the action in Answer 4 is consistent with cardiac arrhythmias (palpitations, PVCs). Relate the system affected (GI) to the intervention (food). The nurse would recognize a generalized tonic-clonic seizure if which of the following occurred? Brief, abrupt loss of consciousness lasting 10-20 seconds. Loss of consciousness for several minutes, with sustained and intermittent contractions of all motor muscle groups. Sustained and intermittent contractions of selected motor groups in a somewhat confined area. Twitching of facial muscles. Generalized tonic-clonic (grand mal) seizures are characterized by auras preceding the convulsive spasms of all muscle groups, loss of consciousness, and loss of sphincter control. Brief, abrupt loss of consciousness, with a characteristic "blank stare," is indicative of absence (petit mal) seizures (Answer 1). Focal or partial seizures usually involve only a portion of the brain and reflect the area of the brain activated by abnormal discharge (such as tonic and clonic contractions of the large muscles in an arm or leg) (Answer 3). Localized twitching of facial muscles, especially of the angle of the mouth, or within a finger or toe, is characteristic of a jacksonian seizure (Answer 4). Look at "minutes" vs. "seconds"; "generalized" in the stem goes with the longer time period. Look for key words in stem and answer—"generalized" and "all motor muscle groups." When testing the sensory response of a 75-year-old patient to dull or sharp objects, which finding would be considered normal? The patient is: Able to identify location of touch correctly but not the type of sensation. Able to identify type of sensation correctly but not the location. Able to identify both type and location correctly, but the response is slow. Unable to identify sensation in any area. The speed (velocity) of nerve impulses decreases with aging, making responses slower. The amount of change varies with individuals, so a specific change according to age is not predictable (Answers 1 and 2). Sensory conduction decreases faster over time compared with motor conduction; some areas are less sensitive (ankle malleolus), but the change is not generalized throughout the body (Answer 4). The key word in the stem is "normal," and the correct choice must apply to all older adults. Choose the most inclusive Answer: #3 includes #1 and #2. A patient is awaiting surgery for reduction of a fractured right femur. Skeletal traction has been applied. Which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome for the patient? Risk for impaired skin integrity. Pain (acute). Impaired physical mobility. Risk for fracture deformity. Pain management requires the nurse and physician to collaborate to achieve optimal relief for the patient. The use of analgesics for pain requires a physician's order. The nurse assesses the patient's response to drug therapy and alerts the MD to needed changes. The nurse may also recommend nondrug interventions to promote patient comfort (progressive relaxation, massage). Answers 1 and 3 are manageable by independent nursing actions—careful assessment, ROM, proper positioning. Answer 4 is not a nursing diagnosis, but a medical problem to be corrected by surgery. The key words in the stem are best outcome and collaboratively. Although independent nursing actions could be planned for each option, look for the one that requires physician's orders to implement care. Most adverse drug effects in the elderly occur because: The amount of body water is decreased. Hormone activity is generally diminished. The amount of body fat tends to increase with age. CNS effects decrease in the elderly. There is an increase in body fat and a decrease in lean muscle mass, which increases the duration of drug effects. There is a decrease in the percentage of body water (Answer 1) in the elderly; however, it is the changes in the kidney that affect drug excretion, resulting in drug toxicity. Enzymes in the liver, not hormones (Answer 2) are diminished, which affects the metabolism of drugs. The CNS effects (Answer 4) are usually increased in the elderly because of problems with drug accumulation, duration of effects, and toxicity. Eliminate the options that are not true first (#2, #4). Know normal processes of drug metabolism regardless of age. Which nursing diagnosis would be the priority in the care of a patient with acquired immunodeficiency syndrome (AIDS)? Impaired skin integrity. Anxiety (death). Pain (acute). Ineffective breathing pattern. All of the diagnoses are problems in the AIDS patient. Providing optimum pain management and keeping the patient comfortable must be a priority, particularly over skin integrity (Answer 1). Pain control will also have an impact on patient anxiety (Answer 2) and breathing (Answer 4). When all the answers are correct, use Maslow's hierarchy to establish priorities. With three good choices, choose the one that could cover two other options (#3 covers #2 and #4). Which of the following is most important to include in teaching a patient about preventing heat cramps when working outside in hot weather? Prior history of heat sensitivity. Need to maintain sodium level in body. Importance of drinking fluids to stay cool. Risk of potassium and magnesium loss. Heat cramps occur when fluids are lost through excessive sweating and water is replaced without sodium replacement. A balanced solution or sources of water and sodium should be ingested. Sodium chloride tablets may be taken, but they may cause stomach irritation. If there was a prior history (Answer 1) and another admission, there is still a need for patient teaching. Answers 3 and 4 are not incorrect; fluids are important for evaporative cooling, and potassium and magnesium may be lost, but the role of sodium is most important to prevent future problems. The stem asks for the most important. When all of the options are correct, use a process of elimination to select the one that will make the greatest difference— prevent harm (#2)—or incorporates other options. Which signs and symptoms indicate that the patient is experiencing hypovolemic shock? Increased heart rate and decreased urine output. Decreased urine output and pitting edema. Fever and furrowed tongue. Bounding pulse and crackles in the chest. Tachycardia and urine output less than 30 mL per hour are classic indicators of low circulating volume—hypovolemic shock. Both the cardiac and renal systems are compensating for the low perfusion state. Answer 2 is partially correct; pitting edema, however, is seen with fluid retention and volume excess. Answer 3 indicates dehydration, also a state of fluid deficit, but the signs would not be classic of shock. Answer 4 describes a state of fluid volume excess. Turn each option into a true-or-false question: e.g., would a patient in shock have an increased pulse? True? Or false? Which sign is the best indicator of early infection in a patient who is immunosuppressed? Fever. Sore throat. Elevated sedimentation rate. Decreased urine output. In a patient who is immune-suppressed, the oral mucous membranes are often a source of infection; therefore, a complaint of a sore throat is an important early indication of a potential problem. With immunosuppression the body is often unable to respond to an infection with the characteristic indicators, such as a fever (Answer 1). The drugs used to suppress the immune system mask the signs of infection (Answer 3). Answer 4 is not a sign of infection. The key word is early. Know the concept of immunosuppression and what this may affect (e.g., mask some infections, reduce ability to fight infection with fever, allow opportunistic infections to take hold [mucous membranes]). The most important information to include when teaching a patient who is being discharged on continuous ambulatory peritoneal dialysis (CAPD) would be the need to: Use sterile technique to prevent infection. Increase protein in the diet. Record blood pressure and weight daily. Wear a medical identification bracelet. Peritonitis is the most serious complication of CAPD. How to maintain aseptic or sterile technique to prevent bacteria from entering the peritoneal cavity is the most important information to teach the patient. Answer 2, 3, and 4 are also important to teach the CAPD patient after the nurse determines that the patient will be able to safely perform sterile technique. This is a "rank order of priority" question. When all of the options are correct, which one prevents the patient from the greatest potential risk? A patient complaining of severe indigestion while walking in the hall, grabs his chest and falls to the floor. The first assessment to make would be to determine: Unresponsiveness. Breathing pattern. Blood pressure. Presence of a pulse. A witnessed or unwitnessed cardiac arrest starts with establishing the state of consciousness of the patient. It is important to determine if the patient is awake before proceeding with emergency CPR. Answers 2 and 4 are the next steps in initiating CPR. Answer 3, although not part of the ABCs of CPR, would be done after establishing a pulse. This is a "rank order of priority" question. Remember "shake and shout," then your ABCs. A patient has hypotension, jugular venous distention, and muffled heart sounds on auscultation. The nurse would anticipate that the patient's treatment will be directed at: Reversing cardiogenic shock. Improving left ventricular function. Reducing the degree of ventricular hypertrophy. Managing pericardial effusion or tamponade. The patient's signs are consistent with an increase in venous pressure. Pericardial effusion or cardiac tamponade impairs the ventricles from adequately filling during diastole. Venous pressure increases and stroke volume decreases. Answers 1 and 2 would result in signs and symptoms consistent with left-sided heart failure, and difficulty breathing would likely be present. Hypertrophy (Answer 3) is not reduced, but rather managed through drug therapy. Look for patterns in the options. Three of the choices involve the ventricles—how could you choose just one? On admission of a patient with status epilepticus who has been having a seizure for over 2 hours, the most important assessment data would be: Total time unconscious. Time of last meal. Current arterial blood gases. Time of last dose of anticonvulsant medication. The priority with status epilepticus is the adequacy of the patient's airway and breathing. Measuring the patient's blood gases would be important in determining the need for more aggressive management. Answers 1, 2, and 4 are not priority concerns. This is a priority question—if airway is affected, assessing the status will be the best answer. Also note a pattern in the responses: three options have "time," one does not. Choose the one that is different (#3). Which nursing assessment would identify the earliest indication of increasing intracranial pressure? Temperature over 102 F. Change in level of consciousness. Widening pulse pressure. Unequal pupils. As cerebral hypoxia develops, the patient becomes restless and drowsy well before any of the characteristic signs and symptoms of increasing intracranial pressure are present. Answers 1, 3, and 4 are all consistent with increasing intracranial pressure but occur much later, after there has been significant cerebral herniation and distortion of the brain. The key word in the stem is early. A "change" in level of consciousness (could be restlessness or a lack of responsiveness) is almost always the best answer with neurological problems. A key word in the best option is change. What is the most common reaction to an epidural narcotic for postoperative pain management that a nurse would observe? Slowing of the respiratory rate. Increase in the heart rate. Increased urinary urgency. Itching. Frequently patients complain of severe itching from the opioids used with epidural analgesia. Antihistamines and comfort measures are effective for many patients, as well as reduction in the dosage or administering Narcan to control itching without reversing the analgesic effects. Respiratory depression (Answer 1) is not a common problem with careful titration of standard dosages. Only when the patient becomes sedated does the respiratory function become a concern. Answers 2 and 3 are not expected side effects (however, postural hypotension and constipation are potential problems). The clue in the stem is "most common." Look for something annoying but not serious. Otherwise epidural analgesia would not be used as often as it is. Which nursing diagnosis would be a postoperative priority for a patient being transferred from postanesthesia recovery to the surgical floor? Decreased cardiac output related to blood loss. Pain related to large abdominal incision. Risk for infection related to surgical wound. Risk for activity intolerance related to surgery. Maintaining perfusion is the priority in the early postoperative period. Pain Answer 2) would also be important; however, it is not life threatening. Answers 3 and 4 are also important nursing diagnoses, but they are not actual problems, although there is risk potential. This is a priority question. Consider the greatest risk to the patient, meaning the possibility of a life-threatening problem (cardiac). Before administering oxygen therapy, the nurse would: Review patient's history for indications of COPD. Observe patient's respiratory pattern. Draw arterial blood gases. Auscultate bilateral breath sounds. There is a risk to the patient with COPD if the O2 flow rate is too high. The patient with COPD has a hypoxic respiratory drive. If the liter flow is above 2 L, there is a risk for respiratory depression. Answers 2, 3, and 4 are important nursing actions to determine the effectiveness of oxygen therapy. Look for patterns in the options. Three options assess the effectiveness of the treatment. One validates the appropriateness of the order. Choose the one that is different. The priority nursing action for a patient admitted with a productive cough, weight loss, and a suspected diagnosis of tuberculosis is: Instruction on preventing disease transmission. Planning for frequent rest periods. Recording accurate intake and output. Reviewing current dietary patterns. Tuberculosis is an airborne infectious disease. Preventing further spread of the disease would be a priority for care. Covering the mouth when coughing, proper disposal of tissues, and hand washing must be reinforced. Answers 2, 3, and 4 are important actions after preventing disease transmission. This is a priority question. Think prevention before treatment. A patient who is suspected of experiencing respiratory distress from a left-sided pneumothorax should be positioned: On the left side. On the right side. In semi-Fowler's position. Prone. A pneumothorax exerts a "pushing" pressure on the heart and unaffected lung. Function is compromised. Semi-Fowler's is optimal positioning for chest expansion. Answers 1, 2, and 4 would inhibit chest expansion partially. Visualize each position and how ventilation would be affected. The best position is one that maximizes ventilation and minimizes lung restriction. The most important nursing diagnosis for a patient admitted with an intestinal obstruction is: Risk for aspiration. Risk for fluid volume deficit. Altered nutrition, more than body requirements (hyperkalemia). Nausea. Intestinal obstructions are medical emergencies because of the risk for severe fluid and electrolyte imbalance and the development of hypovolemia. The obstruction prevents normal fluid and electrolyte reabsorption in the small intestine. Although there may be gastric distention and vomiting, which might result in aspiration (Answer 1), it is not a priority or a direct result of the obstruction. Nutrition would be altered (Answer 3), but there would be a deficit of electrolytes (hypokalemia). Nausea (Answer 4) may be present, but it is neither a priority nor stated as a nursing diagnosis. This is a priority question (fluid volume deficit vs. aspiration). Look at the direct result of the obstruction. Following a myocardial infarction and the development of left ventricular failure, a decrease in which of the following laboratory values would be expected? Alanine aminotransferase (ALT). White blood cell count. Creatine kinase isoenzyme. Arterial pH. The post-MI patient with left-sided heart failure, which is also cardiogenic shock, would be experiencing metabolic acidosis. The pH would decrease, consistent with acidosis. Answers 1, 2, and 3 would all increase as a result of the myocardial damage. Note the key word: decrease. Know the clinical relevance of laboratory tests. Think what effect myocardial damage would have on each test. The patient becomes pulseless with a monitored rhythm of sinus tachycardia following a motor vehicle accident and a fractured right femur. The nurse should prepare for: Mechanical ventilation and administration of sodium bicarbonate. CPR and epinephrine IV push. Atropine IV and intubation with mechanical ventilation. Isoproterenol (Isuprel) followed by CPR. The patient is most likely in shock. Bicarbonate is needed with metabolic acidosis, which will develop. The compensatory tachycardia will result in poor oxygenation. Although the question does not indicate difficulty breathing, the patient is not being perfused well (pulselessness) and may go into cardiac arrest if emergency treatment is not begun. CPR (Answers 2 and 4) would not be done because there is a heart rhythm, although perfusion is ineffective. Atropine (Answer 3) would not be given because it increases heart rate. Use a process of elimination—CPR is not indicated. Therefore, eliminate #2 and #4. Do you give atropine or sodium bicarbonate for shock? Which of the following symptoms experienced by a patient following an acute MI will most likely be relieved by oxygen administration? Metabolic alkalosis and an elevated CK-MB. Arrhythmias and related hypotension. Sweating and hyperoxemia. Hypertension and AV conduction problems. Oxygen therapy is important to the prevention and treatment of life threatening arrhythmias, which occur often as a result of myocardial ischemia. The ineffective contraction of the heart may result in reduced cardiac output and poor perfusion, leading to hypotension. Acid-base abnormalities and enzymes (Answer 1) do not improve with O2. Hyperoxemia (Answer 3) would not require additional oxygen. Hypertension (Answer 4) is not expected with an Ml; and conduction defects are due to damage to the conduction system and do not respond to O2. Phrase each option as a true-false question and determine if oxygen would improve the patient problem. The blood pressure of a patient, who is scheduled for a femoral-popliteal bypass of the right leg, is 168/120. The most appropriate nursing action would be to: Give the prescribed antihypertensive agent regardless of surgery. Check vital signs frequently to determine further changes in BP. Call the MD to see if surgery can be postponed. Administer an antianxiety agent IV per order. Surgery is usually a stressful situation that increases anxiety. Administration of an anxiolytic such as midazolam (Versed), lorazepam (Ativan), or diazepam (Valium) during the preoperative period may be necessary to lower the blood pressure and prevent any complications. Antihypertensive agents (Answer 1) are usually held before surgery to reduce the risk of hypotension from an adverse interaction with anesthesia. Checking vital signs (Answer 2), although not wrong, would not resolve the patient's preoperative anxiety and stress. An elevated BP possibly related to preoperative stress would not be a reason to cancel surgery (Answer 3). That may only further increase the patient's stress. Do something for the patient's stress first. Only one option deals with the preoperative stress. A patient is scheduled for cardioversion to treat sustained atrial fibrillation. The nursing priority before the procedure would be to: Auscultate the heart sounds. Administer medication for sedation. Give the prescribed analgesic. Start an antibiotic IV per order. During cardioversion the patient is awake but sedated. The anticipation of the procedure may be anxiety producing. Auscultation (Answer 1) would not be necessary, because the patient will be monitored. There should not be any pain (Answer 3) or infection (Answer 4). Look at the time frame. Choose an option that addresses the patient need before the procedure. The nurse determines that the expected normal urine output in 24 hours for a healthy adult is: 720 mL. 840 mL. 1500 mL. 3000 mL. Total normal output for a 24-hour period is 2500 mL, with 1500 mL from urine and 1000 mL from skin, lungs, and feces. Answer 1 is the minimum amount of urine output that is acceptable for a 24-hour period. Answer 2 is accept able, but not normal, and Answer 4 would be excessive; it occurs with diuresis or diabetes insipidus (2-3 L in 24 hours) The key word is normal. Recall that the minimum amount of urine desired for 1 hour is 30 mL, and 3 L is excessive. When numbers (i.e., amounts) are involved, avoid the extremes (too low and too high). The patient's arterial blood gases are as follows: pH 7.43, Po2 83; Pco2 29; HC03 29. The nurse would instruct the patient to: Turn, cough, and deep breathe at least every 2 hours. Get up and walk at least three times a day to improve 02 level. Try to breathe more slowly. Drink more fluids to flush the kidneys. The blood gases are consistent with compensated respiratory alkalosis. The patient is hyperventilating, breathing rapidly and blowing off carbon dioxide. A slower rate, not deeper, will increase the CO2 level. Answer 1 will prevent hypoventilation. Answer 2 will prevent complications from immobility (e.g., pneumonia), which would produce an elevated CO2, not O2, level. Fluids (Answer 4) will not improve a blood gas alteration that is the result of a respiratory response. Look at the two options that deal with breathing (deep breaths, breathe slowly). Consider how each option will increase CO2 level. Know normal blood gas ranges. A person who is diabetic is brought into the emergency department by a friend who found him on the floor unconscious. The first nursing action would be to: Ask the friend what happened and how long the patient was unconscious. Assess the patient for signs of head trauma when he collapsed. Obtain a blood sugar level and start an IV infusion. Contact the patient's immediate family to come to the hospital. The first action is to measure the glucose level, start an IV, and prepare to give glucose or insulin. A dangerously low blood sugar level is life threatening and must be corrected immediately. Answers 1, 2, and 4 are not incorrect nursing actions; however, they are not the first priority. The key word is, first. Only one option takes a direct action to determine the cause of unconsciousness. A patient with AIDS is afraid of getting toxoplasmosis. The most important precaution to take would be to: Wash all vegetables before cooking. Wear gloves when gardening. Wear a mask when traveling to foreign countries. Avoid contact with cats and birds. Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The oocysts remain infectious in moist soil for about 1 year. Eating raw or undercooked meat, not vegetables (Answer 1), is a mode of transmission. The parasite is transmitted through ingestion, not air (Answer 3). Ingestion of oocysts from cat feces is the most common mode of oral infection in the United States. Cats do not have to be avoided (Answer 4), but handling of litter should be avoided, and hand washing would be essential for a patient who is immunocompromised. When preventing infection, two options are usually desirable choices—-wearing gloves and hand washing. Which information about recommended adult immunizations is accurate to include in health teaching? Tetanus and diphtheria booster is needed at least every 5 years. Pneumococcal pneumonia vaccine may be given once for lifetime protection. Influenza A and B vaccine are given one time, unless high risk. Measles and mumps vaccine are given to college-age students only. Pneumoccocal pneumonia vaccine is given to anyone at high risk for pneumococcal pneumonia or its complications. One immunization is recommended for lifetime protection, although revaccination every 6 years should be considered for high-risk patients. A booster for tetanus and diphtheria (Answer 1) is only needed every 10 years to maintain life long immunity. Answer 3, influenza, is given annually for high-risk individuals. Measles and mumps (Answer 4) is indicated for anyone born after 1956 with an uncertain immune status. Use the process of elimination and what you know about normal pediatric immunization patterns to figure out adult variations. The laboratory findings for a patient with polycythemia vera include major and minor criteria. Which of the following is the major or defining hematological finding? Leukocytosis >12,000/mm3. Thrombocytosis >400,000/mm3. RBC count >6 million/mm3. Elevated leukocyte alkaline phosphatase. Polycythemia vera is a chronic myeloproliferative disorder characterized mainly by erythrocytosis (increased RRC mass). Hemoglobin and hematocrit will be elevated. Answers 1, 2, and 4 are also laboratory findings, but they are considered minor criteria in this condition. Know the major physiological abnormality and important diagnostic indicator. Which patient, experiencing a change in cardiac rhythm after a myocardial infarction, would the nurse assess first? A conversion from normal sinus rhythm to atrial fibrillation. An increase in the PR interval to 0.26 seconds. Sinus tachycardia, rate of 110. One unifocal premature ventricular contraction in 1 minute. The development of atrial fibrillation, although not life threatening, will have the greatest impact on hemodynamics; and the patient may experience chest pain, dyspnea, and heart failure following an MI. The patient may automatically revert back to a sinus rhythm; however, the effect of the rhythm change must be assessed. Answers 2, 3 and 4 do not indicate the need for treatment or immediate response on the part of the nurse. Consider which change presents the greatest risk to the patient (e.g., fibrillation). Know the acceptable parameters of cardiac functioning (i.e., what is OK vs. not OK). Preoperative teaching for a patient scheduled for surgery to repair a detached retina will include the following information: Eye patches may be used postoperatively. No eye pain is expected postoperatively. Semi-Fowler's position will be used to reduce pressure in the eye. Return of normal vision is expected following surgery. Use of eye patches may be continued postoperatively, depending on surgeon preference. This is done to achieve >90% success rate of the surgery. A moderate amount of pain is expected (Answer 2). Positioning (Answer 3) depends on the location and severity of the detachment; prone or face down positioning may be required. Vision is usually blurred because accommodation has been paralyzed. A return to normal vision (Answer 4) cannot be predicted pre-operatively. Time sequence (preoperative) points to the best choice. Only one option says "may" be done; the other choices are too definitive ("is expected," "will be used"). When ambulating a patient who is blind, the nurse should be positioned: Behind the patient, holding the patient's elbows. In front, with the patient holding the nurse's arm at elbow. On the patient's side, holding the dominant hand. On the patient's side, holding the nondominant hand. The nurse leading, without holding, the patient is the correct approach. The nurse is the "sight" for the patient, and being ahead of the individual who is blind is more secure and safe for the patient. Answers 1, 3, and 4 all have the nurse holding the patient, rather than the patient holding onto the nurse. Look for patterns in the options. Only one has the patient being led by the nurse. The greatest reduction in falls and improved safety for the elderly patient with Parkinson's disease would occur with: Discouraging the patient from wearing slippers. Buying shoes that fit snugly. Raising the height of toilet seats. Patient holding hands behind back when walking. Most falls in the elderly, including those with Parkinson's disease, occur in the bathroom. There is a loss of muscle strength in legs with normal aging. Combined with muscle rigidity and postural instability in Parkinson's, the risk for falls is great. Answers 1 and 2, as stated, are not the most important ways to reduce falls. Nonskid soles and proper fit (not necessarily snug) are safety concerns. Answer 4 improves posture, not necessarily reducing the risk for falling. Visualize each option and how stability would be improved. Assessment of a patient following a recent fracture of the left humerus revealed increasing pain with extension of the fingers of the left hand. Distal pulse is strong in the limb. Capillary refill is brisk, and there does not appear to be any restriction of the fingers from the cast. The most likely explanation of the pain is: Possible development of compartment syndrome. Disuse syndrome from immobility. Normal response to sudden movement of fingers. Compression of nerve at fracture site. Pain from passive movement or stretching of the fingers is characteristic of the development of compartment syndrome. The cast is acting as a "space-limiting" sleeve around the muscle, nerves, and blood vessels, resulting in increased tissue pressure. Skin color, temperature, capillary refill, and quality of peripheral pulses are not reliable clinical indicators of compartment syndrome. The fracture is too recent for disuse (Answer 2). Increasing pain is not normal (Answer 3). Nerve compression (Answer 4) would cause paresthesia or paralysis. Use process of elimination and knowledge of usual signs and symptoms of circulatory, sensory, and motor impairment.