1. Answer: C.

Rationale: This is primarily caused by the trauma of intestinal manipulation and

the depressive effects anesthetics and analgesics

2. Answer: A.
rationale: Pressure applied in the puncture site indicates that a biliary vessel was
puncture which is a common complication after liver biopsy.
3. Answer: B.
Rationale: Hepatitis A is primarily spread via fecal-oral route. Sewage polluted
water may harbor the virus
4. Answer: B.
Rationale: Amylase concentration is high in the pancreas and is elevated in the
serum when the pancreas becomes acutely inflamed and also it distinguishes
pancreatitis from other acute abdominal problems.
5. Answer: A.
Rationale: Tetany may occur after thyroidectomy if the parathyroid glands are
accidentally injured or removed.
6. Answer: D.
Rationale: Hard candy will relieve thirst and increase carbohydrates but does not
supply extra fluid.
7. Answer: B.
Rationale: Compression of the lung by fluid that accumulates at the base of the
lungs reduces expansion and air exchange.
8. Answer: C.
Rationale: Assessment of a client with Hodgkin’s disease most often reveals
enlarged, painless lymph node, fever, malaise and night sweats.
9. Answer: A.
Rationale: The adult with normal cerebrospinal fluid has no red blood cells.

10. Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks
The client should avoid lifting heavy objects and any strenuous activity for 4-6
weeks after surgery to prevent stress on the inguinal area. There is no special
 diet required. The fluid intake of eight glasses a day is good advice but is not a
priority in this case.
11. Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea
Burns located in the upper torso, especially resulting from thermal injury related
to fires can lead to inhalation burns. This causes swelling of the respiratory
mucosa and blistering which can lead to airway obstruction manifested by
hoarseness, noisy and difficult breathing. Maintaining a patent airway is a
primary concern.
12. Answer: (B) recognize that Kathy is experiencing denial, a normal stage of
the grieving process
A person grieves to a loss of a significant object. The initial stage in the grieving
process is denial, then anger, followed by bargaining, depression and last
acceptance. The nurse should show acceptance of the patient’s feelings and
encourage verbalization.
13. Answer: (D) assessing her VS especially her RR
Shock is characterized by reduced tissue and organ perfusion and eventual
organ dysfunction and failure. Checking on the VS especially the RR, which
detects need for oxygenation, is a priority to help detect its progress and provide
for prompt management before the occurrence of complications.
14. Answer: (B) Urine output of 30 to 50 ml/hr.
Hypovolemia is a decreased in circulatory volume. This causes a decrease in
tissue perfusion to the different organs of the body. Measuring the hourly urine
output is the most quantifiable way of measuring tissue perfusion to the organs.
Normal renal perfusion should produce 1ml/kg of BW/min. An output of 30-50
ml/hr is considered adequate and indicates good fluid balance
15. Answer: (B) speak to both parents together and encourage them to
support each other and express their emotions freely
Sudden death of a family member creates a state of shock on the family. They go
into a stage of denial and anger in their grieving. Assisting them with information
they need to know, answering their questions and listening to them will provide
the needed support for them to move on and be of support to one another.
16. Answer: (C) lower half of the sternum
The exact and safe location to do cardiac compression is the lower half of the
sternum. Doing it at the lower third of the sternum may cause gastric
compression which can lead to a possible aspiration.
17. Answer: (D) sexual intercourse
To reduce increases in IOP, teach the client and family about activity restrictions.
Sexual intercourse can cause a sudden rise in IOP.
18. Answer: (D) Ineffective airway clearance related to muscle weakness
Myasthenia gravis causes a failure in the transmission of nerve impulses at the
neuromuscular junction which may be due to a weakening or decrease in
acetylcholine receptor sites. This leads to sporadic, progressive weakness or
abnormal fatigability of striated muscles that eventually causes loss of function.
The respiratory muscles can become weak with decreased tidal volume and vital
capacity making breathing and clearing the airway through coughing difficult. The
respiratory muscle weakness may be severe enough to require and emergency
airway and mechanical ventilation.
19. Answer: (D) “Does it help you to joke about your illness?”
This non-judgmentally on the part of the nurse points out the client’s behavior.
20. Answer: (B) Refocus the conversation on his fears, frustrations and anger
about his condition
This provides the opportunity for the client to verbalize feelings underlying
behavior and helpful in relieving anxiety. Anxiety can be a stressor which can
activate the sympathoadrenal response causing the release of catecholamines
that can increase cardiac contractility and workload that can further increase
myocardial oxygen demand.