1. Answer: 2.

 Start an intravenous line

Advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one
or both of the antecubital spaces.

 Options A, C, and D: Calling the physician, obtaining a portable chest radiograph, and drawing
blood are important but secondary to starting the intravenous line.

2. Answer: 4. Myocardial infarction

Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred.
Myoglobin is generally detected about one hour after a heart attack is experienced and peaks within
four (4) to six (6) hours after infarction (Remember, less than 90 mg/L is normal).

3. Answer: 1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial
contractility, and conduction.

Propranolol hydrochloride is a beta-adrenergic blocking agent. Actions of propranolol hydrochloride

include reducing heart rate, decreasing myocardial contractility, and slowing conduction.

4. Answer: 3. Make a commitment to long-term therapy

Compliance is the most critical element of hypertensive therapy. In most cases, hypertensive clients
require lifelong treatment and their hypertension cannot be managed successfully without drug
therapy. Stress management and weight management are important components of hypertension
therapy, but the priority goal is related to compliance.

5. Answer: 1. Cerebrovascular accident

Hypertension is referred to as the silent killer for adults, because until the adult has significant damage
to other systems, hypertension may go undetected. CVA’s can be related to long-term hypertension.

 Option B and D: Liver or pulmonary disease is generally not associated with hypertension.

 Option C: Myocardial infarction is generally related to coronary artery disease.

6 Answer: 3. Take a nitroglycerin tablet before climbing the stairs.

Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to
help the client remain pain-free.

 Option A: Visiting her friend early in the day would have no impact on decreasing pain episodes.

 Option B: Resting before or after an activity is not as likely to help prevent an activity-related
pain episode.

7. Answer: 1. A change in the pattern of her pain

The client should report a change in the pattern of chest pain. It may indicate increasing severity of CAD.

8. Answer: 2. Assess the extent of arterial blockage

Cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the
coronary artery blockage, A decision about medical management, angioplasty, or coronary artery
bypass surgery will be based on the catheterization results.

9. Answer: 3. Vasodilation of peripheral vasculature

Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and
demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the
ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not
have an effect on pericardial spasticity or conductivity in the myocardium.

10. Answer: 1. Headache

Because of the widespread vasodilating effects, nitroglycerin often produces such side effects as
headache, hypotension, and dizziness. The client should lie or sit down to avoid fainting. Nitro does not
cause shortness of breath or stomach cramps.

11. Answer: 3. Take one (1) tablet, then an additional tablet every five (5) minutes for a total of three
(3) tablets. Call the physician if pain persists after three tablets.

The correct protocol for nitroglycerin used involves immediate administration, with subsequent doses
taken at 5-minute intervals as needed, for a total dose of three (3) tablets. Sublingual nitroglycerin
appears in the bloodstream within two (2) to three (3) minutes and is metabolized within about 10
minutes.

12. Answer: 2. Enhance myocardial oxygenation

Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of
cardiac compromise. Without adequate oxygenation, the myocardium suffers damage.

 Options A and D: Although educating the client and decreasing anxiety are important in care
delivery, neither are priorities when a client is compromised.

 Option C: Sublingual nitroglycerin is administered to treat acute angina, but the administration
isn’t the first priority.

13. Answer: 3. Oral medication therapy

Oral medication administration is a noninvasive, medical treatment for coronary artery disease.

 Option A: Cardiac catheterization isn’t a treatment, but a diagnostic tool.

 Options B and D: Coronary artery bypass surgery and percutaneous transluminal coronary
angioplasty are invasive, surgical treatments.

14. Answer: 1. Chest pain

The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart.

 Option B: Dyspnea is the second most common symptom, related to an increase in the
metabolic needs of the body during an MI.

 Option C: Edema is a later sign of heart failure, often seen after an MI.

 Option D: Palpitations may result from reduced cardiac output, producing arrhythmias.

15. Answer: 4. Pulmonary

Pulmonary pain is generally described by these symptoms.

 Options A and B: Cardiac and GI pains don’t change with respiration.

 Option C: Musculoskeletal pain only increases with movement.

16. Answer: 1. Activate the resuscitation team

Immediately after establishing unresponsiveness, the nurse should activate the resuscitation team. The
next step is to open the airway using the head-tilt, chin-lift maneuver and check for breathing (looking,
listening, and feeling for no more than 10-seconds). If the client isn’t breathing, give two slow breaths
using a bag mask or pocket mask. Next, check for signs of circulation by palpating the carotid pulse.

17. Answer: 2. Ineffective tissue perfusion; cardiopulmonary

MI results from prolonged myocardial ischemia caused by reduced blood flow through the coronary
arteries. Therefore, the priority nursing diagnosis for this client is Ineffective tissue perfusion
(cardiopulmonary).

 Options A, C, and D: Anxiety, acute pain, and ineffective therapeutic regimen management are
appropriate but don’t take priority.

18. Answer: 1. Pulmonary edema

SOB, tachypnea, low BP, tachycardia, crackles, and a cough producing pink, frothy sputum are late signs
of pulmonary edema.

19. Answer: 4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and
is receiving IV diltiazem (Cardizem).

The client with A-fib has the greatest potential to become unstable and is on IV medication that requires
close monitoring. After assessing this client, the nurse should assess the client
with thrombophlebitis who is receiving a heparin infusion, and then go to the 58-year-old client
admitted 2-days ago with heart failure (her s/s are resolving and don’t require immediate attention). The
lowest priority is the 89-year-old with end stage right-sided heart failure, who requires time-consuming
supportive measures.

20. Answer: 1. “Report fever, anorexia, and night sweats to the physician.”

An essential teaching point is to report signs of relapse, such as fever, anorexia, and night sweats, to the
physician.

 Option B: To prevent further endocarditis episodes, prophylactic antibiotics are taken before
and sometimes after dental work, childbirth, or GU, GI, or gynecologic procedures.

 Options C and D: A potassium-rich diet and daily pulse monitoring aren’t necessary for a client
with endocarditis.

21. Answer: A. Eggs

One of the microcytic, hypochromic anemias is iron-deficiency anemia. A rich source of iron is needed in
the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats;
shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried
fruits, and beans; oatmeal; and sweet potatoes.

 Options B and C: Dark green leafy vegetables and citrus fruits are good sources of vitamin C.

 Option D: Cheese is a good source of calcium.

22. Answer: C. Meats and dairy products

Good sources of vitamin B12 include meats and dairy products.

 Option A: Whole grains are a good source of thiamine.

  Option B: Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors
of vitamin A).

 Option D: Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).

23. Answer: D. Folate, 1.5 ng/mL

The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900
pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic
acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such
as methotrexate, oral contraceptives, antiseizure drugs, and alcohol.

 Options A, B, and C: The total bilirubin, serum creatinine, and hemoglobin values are within
normal limits.

24. Answer: A. Erythrocytes

Anemia is defined as a decreased number of erythrocytes (red blood cells).

 Option B: Granulocytopenia is a decreased number of granulocytes (a type

of white blood cells).
 Option C: Leukopenia is a decreased number of leukocytes (white blood
cells).
 Option D: Thrombocytopenia is a decreased number of platelets.

25. Answer: C. Oxygen

Anemia stems from a decreased number of red blood cells and the resulting
deficiency in oxygen and body tissues. Clotting factors, such as factor VIII, relate to
the body’s ability to form blood clots and aren’t related to anemia, not is carbon
dioxide of T antibodies.

26. Answer: D. “Take the medication on an empty stomach.”

Preferably, ferrous gluconate should be taken on an empty stomach.

 Options A, B, and C: Ferrous gluconate should not be taken with antacids,

milk, or whole-grain cereals because these foods reduce iron absorption.

27. Answer: C. Reticulocyte count

A diagnosis is established based on a complete blood count, examination for

sickled red blood cells in the peripheral smear, and hemoglobin
electrophoresis. Increased reticulocyte counts occur in children with sickle cell
disease because the life span of their sickled red blood cells is shortened.
  Options A, B, and D: Laboratory studies will show decreased hemoglobin and
hematocrit levels and a decreased platelet count, and increased reticulocyte
count, and the presence of nucleated red blood cells.

28. Answer: C. Fluid overload

Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or

physical or emotional stress. The mother of a child with sickle cell disease should
encourage fluid intake of 1 ½ to 2 times the daily requirement to
prevent dehydration.

29. Answer: D. Red blood cells that are microcytic and hypochromic

The results of a CBC in children with iron deficiency anemia will show decreased
hemoglobin levels and microcytic and hypochromic red blood cells. The red blood
cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

30. Answer: D. Hemophilia A results from a deficiency of factor VIII

Hemophilia A results from a deficiency of factor VIII. Hemophilia B

(Christmas disease) is a deficiency of factor IX.

 Option A: Hemophilia is inherited in a recessive manner via a genetic defect

on the X-chromosome.

 Options B and C: Males inherit hemophilia from their mothers, and females
inherit the carrier status from their fathers.

31. Answer: 1. Altered mental status and dehydration

Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are the common
symptoms of pneumonia, but elderly clients may first appear with only an altered
mental status and dehydration due to a blunted immune response.

32. Answer: 4. Inflammation

The most common feature of all types of pneumonia is an inflammatory pulmonary

response to the offending organism or agent. Atelectasis and bronchiectasis
indicate a collapse of a portion of the airway that doesn’t occur with pneumonia. An
effusion is an accumulation of excess pleural fluid in the pleural space, which may
be a secondary response to pneumonia.

33. Answer: 1. Acute asthma

Based on the client’s history and symptoms, acute asthma is the most likely
diagnosis. He’s unlikely to have bronchial pneumonia without a productive cough
and fever and he’s too young to have developed COPD or emphysema.

34. Answer: 3. Inspiratory and expiratory wheezing

Inspiratory and expiratory wheezes are typical findings in asthma. Circumoral

cyanosis may be present in extreme cases of respiratory distress. The nurse would
expect the client to have a decreased forced expiratory volume because asthma is
an obstructive pulmonary disease. Breath sounds will be “tight” sounding or
markedly decreased; they won’t be normal.

35. Answer: 3. Intrinsic

Intrinsic asthma doesn’t have an easily identifiable allergen and can be triggered by

the common cold. Asthma caused be emotional reasons is considered to be in the
extrinsic category. Extrinsic asthma is caused by dust, molds, and pets; easily
identifiable allergens. Mediated asthma doesn’t exist.

36. Answer: 2. Bronchodilators

Bronchodilators are the first line of treatment for asthma because

bronchoconstriction is the cause of reduced airflow. Beta-adrenergic blockers aren’t
used to treat asthma and can cause bronchoconstriction. Inhaled or oral steroids
may be given to reduce the inflammation but aren’t used for emergency relief.

37. Answer: 2. Give a bronchodilator by nebulizer

The client is having an acute asthma attack and needs to increase oxygen delivery
to the lung and body. Nebulized bronchodilators open airways and increase the
amount of oxygen delivered. First, resolve the acute phase of the attack ad how to
prevent attacks in the future. It may not be necessary to place the client on a
cardiac monitor because he’s only 19-years-old, unless he has a past medical
history of cardiac problems.

38. Answer: 3. Chronic obstructive bronchitis

Because of his extensive smoking history and symptoms, the client most likely has
chronic obstructive bronchitis. Clients with ARDS have acute symptoms of and
typically need large amounts of oxygen. Clients with asthma and emphysema tend
not to have a chronic cough or peripheral edema.

39. Answer: 3. Chronic obstructive bronchitis

Clients with chronic obstructive bronchitis appear bloated; they have large barrel
chests and peripheral edema, cyanotic nail beds and, at times, circumoral cyanosis.
Clients with ARDS are acutely short of breath and frequently need intubation for
mechanical ventilation and large amounts of oxygen. Clients with asthma don’t
exhibit characteristics of chronic disease, and clients with emphysema appear pink
and cachectic (a state of ill health, malnutrition, and wasting).

40. Answer: 4. Emphysema

Because of the large amount of energy it takes to breathe, clients with emphysema
are usually cachectic. They’re pink and usually breathe through pursed lips, hence
the term “puffer”. Clients with ARDS are usually acutely short of breath. Clients with
asthma don’t have any particular characteristics, and clients with chronic
obstructive bronchitis are bloated and cyanotic in appearance.

41. Answer: 4. Bronchospasm

If a biopsy was performed during a bronchoscopy, blood-streaked sputum is

expected for several hours. Frank blood indicates hemorrhage. A dry cough may be
expected. The client should be assessed for signs of complications, which would
include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension,
tachycardia, and arrhythmias. Hematuria is unrelated to this procedure.

42. Answer: 2. 10 seconds

Hypoxemia can be caused by prolonged suctioning, which stimulates

the pacemaker cells within the heart. A vasovagal response may occur causing
bradycardia. The nurse must preoxygenate the client before suctioning and limit
the suctioning pass to 10 seconds.

43. Answer: 3. Stop the procedure and reoxygenated the client

During suctioning, the nurse should monitor the client closely for side effects,
including hypoxemia, cardiac irregularities such as a decrease in HR resulting from
vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side
effects develop, especially cardiac irregularities, this procedure is stopped and the
client is reoxygenated.

44. Answer: 1. Metabolic acidosis

In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a

low bicarbonate level along with the pH would indicate a metabolic state.

45. Answer: 3. A hyperinflated chest on x-ray film

Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on

exertion and at rest, oxygen desaturation with exercise, and the use of accessory
muscles of respiration. Chest x-ray films reveal a hyperinflated chest and a
flattened diaphragm is the disease is advanced.

46. Answer: 1. Venturi mask

The venture mask delivers the most accurate oxygen concentration. The Venturi
mask is the best oxygen delivery system for the client with chronic airflow limitation
because it delivers a precise oxygen concentration. The face tent, the aerosol mask,
and the tracheostomy collar are also high-flow oxygen delivery systems but most
often are used to administer high humidity.

47. Answer: 1. “I will take the medication on an empty stomach.”

Theo-Dur is a bronchodilator. The medication should be administered with food

such as milk and crackers to prevent GI irritation.

48. Answer: 2. 2 L/min

One to 3 L/min of oxygen by nasal cannula may be required to raise to PaO2 to 60

to 80 mm Hg. However, oxygen is used cautiously and should not exceed 2 L/min.
Because of the long-standing hypercapnia, the respiratory drive is triggered by low
oxygen levels rather than increased carbon dioxide levels, as is the case in normal
respiratory system.

49. Answer: 3. pH of 7.30

50. Answer: 4. Promote carbon dioxide elimination

Pursed lip breathing facilitates maximum expiration for clients with obstructive lung
disease. This type of breathing allows better expiration by increasing airway
pressure that keeps air passages open during exhalation.

51. Answer: 4. Ineffective airway clearance related to retained secretions.

Pneumonia is an acute infection of the lung parenchyma. The inflammatory

reaction may cause an outpouring of exudate into the alveolar spaces, leading to an
ineffective airway clearance related to retained secretions.

52. Answer: 2. A cough with the expectoration of mucoid sputum

One of the first pulmonary symptoms includes a slight cough with the
expectoration of mucoid sputum.

53. Answer: 2. Group living

Clients with chronic illnesses generally have poor immune systems. Often, residing
in group living situations increases the chance of disease transmission.

54. Answer: 4. Inflammation

The common feature of all type of pneumonia is an inflammatory pulmonary

response to the offending organism or agent. Atelectasis and bronchiectasis
indicate a collapse of a portion of the airway that doesn’t occur in pneumonia. An
effusion is an accumulation of excess pleural fluid in the pleural space, which may
be a secondary response to pneumonia.

55. Answer: 3. Streptococcus  pneumoniae

Pneumococcal or streptococcal pneumonia, caused by streptococcus pneumoniae,

is the most common cause of community-acquired pneumonia. H. influenzae is the
most common cause of infection in children. Klebsiella species is the most common
gram-negative organism found in the hospital setting. Staphylococcus aureus is the
most common cause of hospital-acquired pneumonia.

56. Answer: 1. Positive

The client with HIV+ status is considered to have positive results on PPD skin test
with an area greater than 5-mm of induration. The client with HIV is
immunosuppressed, making a smaller area of induration positive for this type of
client.

57. Answer: 4. High-grade fever

The client with TB usually experiences cough (non-productive or

productive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort
or pain, chills and sweats (which may occur at night), and a low-grade fever.

58. Answer: 1. Meats and citrus fruits

The nurse teaches the client with TB to increase intake of protein, iron, and vitamin
C.

59. Answer: 1, 3, 5.

A respiratory assessment, which includes auscultating breath sounds and assessing

the color of the nail beds, is a priority for clients with pneumonia. Assessing for the
presence of chest pain is also an important respiratory assessment as chest pain
can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds
and assessing for peripheral edema may be appropriate assessments, but these
are not priority assessments for the patient with pneumonia.
60. Answer: 3. Frequent linen changes

Frequent linen changes are appropriate for this client because of diaphoresis.
Diaphoresis produces general discomfort. The client should be kept dry to promote
comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning
is not indicated with the client’s productive cough. Frequent offering of a bedpan is
not indicated by the data provided in this scenario.

61. Answer: 4. Decreased oxygenation of the blood.

A client with pneumonia has less lung surface available for the diffusion of gases
because of the inflammatory pulmonary response that creates lung exudate and
results in reduced oxygenation of the blood. The client becomes cyanotic because
blood is not adequately oxygenated in the lungs before it enters the peripheral
circulation.

62. Answer: 3. Irritability

Clients who are experiencing hypoxia characteristically exhibit irritability,

restlessness, or anxiety as initial mental status changes. As the hypoxia becomes
more pronounced, the client may become confused and combative. Coma is a late
clinical manifestation of hypoxia. Apathy and depression are not symptoms of
hypoxia.

63. Answer: 4. Provide fluid intake of 3 L/day

A fluid intake of at least 3 L/day should be provided to replace any fluid loss
occurring as a result the fever and diaphoresis; this is a high-priority intervention.

64. Answer: 2. The ability to perform ADL’s without dyspnea

An expected outcome for a client recovering from pneumonia would be the ability
to perform ADL’s without experiencing dyspnea. A respiratory rate of 25 to 30
breaths/minute indicates the client is experiencing tachypnea, which would not be
expected on recovery. A weight loss of 5-10 pounds is undesirable; the expected
outcome would be to maintain normal weight. A client who is recovering from
pneumonia should experience decreased or no chest pain.

65. Answer: 1. Weight loss

TB typically produces anorexia and weight loss. Other signs and symptoms may
include fatigue, low-grade fever, and night sweats.

66. Answer: 1. Auscultation of breath sounds

Because the client is short of breath, listening to breath sounds is a good idea. He
may need a chest x-ray and an ECG, but a physician must order these tests. Unless
a cardiac source for the client’s pain is identified, he won’t need an echocardiogram.

67. Answer: 4. Spontaneous pneumothorax

A spontaneous pneumothorax occurs when the client’s lung collapses, causing an

acute decrease in the amount of functional lung used in oxygenation. The sudden
collapse was the cause of his chest pain and shortness of breath. An asthma attack
would show wheezing breath sounds, and bronchitis would have rhonchi.
Pneumonia would have bronchial breath sounds over the area of consolidation.

68. Answer: 3. Chest tube placement

The only way to re-expand the lung is to place a chest tube on the right side so the
air in the pleural space can be removed and the lung re-expanded.

69. Answer: 3. Take a chest x-ray

A chest x-ray will show the area of collapsed lung if pneumothorax is present as
well as the volume of air in the pleural space. Listening to breath sounds won’t
confirm a diagnosis. An IS is used to encourage deep breathing. A needle
thoracostomy is done only in an emergency and only by someone trained to do it.

70. Answer: 3. Percentage of hemoglobin carrying oxygen

The pulse oximeter determines the percentage of hemoglobin carrying oxygen. This
doesn’t ensure that the oxygen being carried through the bloodstream is actually
being taken up by the tissue.

71. Answer: 1. Placing the client on the back with a small pillow under the
head.

A helpless client should be positioned on the side, not on the back. This lateral
position helps secretions escape from the throat and mouth, minimizing the risk
of aspiration.

 Option B: It may be necessary to suction, so having suction equipment at the

bedside is necessary.

 Option C: Padded tongue blades are safe to use.

 Option D: A toothbrush is appropriate to use.

72. Answer: 3. Schedule for A STAT computer tomography (CT) scan of the
head.

A CT scan will determine if the client is having a stroke or has a brain tumor or

another neurological disorder. This would also determine if it is a hemorrhagic or
ischemic accident and guide the treatment because only an ischemic stroke can use
rt-PA. This would make (1) not the priority since if a stroke was determined to be
hemorrhagic, rt-PA is contraindicated.

 Option A: rt-PA is contraindicated.

 Options B and D: Discuss the precipitating factors for teaching would not be
a priority and slurred speech would as indicate interference for teaching.
Referring the client for speech therapy would be an intervention after the
CVA emergency treatment is administered according to protocol.

73. Answer: 3. Time of onset of current stroke.

The time of onset of a stroke to t-PA administration is critical. Administration within

3 hours has better outcomes.

 Option A: Current medications are relevant, but the onset of current stroke
takes priority.

 Option B: A complete history is not possible in emergency care.

 Option D: Upcoming surgical procedures will need to be delay if t-PA is

administered.

74. Answer: 3. Blood pressure

Controlling the blood pressure is critical because an intracerebral hemorrhage is

the major adverse effect of thrombolytic therapy. Blood pressure should be
maintained according to physician and is specific to the client’s ischemic tissue
needs and risks of bleeding from treatment. Other vital signs are monitored, but
the priority is blood pressure.

75. Answer: 2. Pupil size and pupillary response

It is crucial to monitor the pupil size and pupillary response to indicate changes
around the cranial nerves.

 Option A: Cholesterol level is an assessment to be addressed for long-term

healthy lifestyle rehabilitation.
  Option C: Bowel sounds need to be assessed because an ileus
or constipation can develop, but is not a priority in the first 24 hours.

 Option D: An echocardiogram is not needed for the client with a thrombotic

stroke.

76. Answer: B. Ineffective airway clearance

In Parkinson’s crisis, dopamine-related symptoms are severely exacerbated,

virtually immobilizing the client. A client confined to bed during such a crisis is
at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of
airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective
airway clearance takes highest priority. Although the other options also are
appropriate, they aren’t immediately life-threatening.

77. Answer: A. Stay with the client and encourage him to eat.

Staying with the client and encouraging him to feed himself will ensure adequate
food intake. A client with Alzheimer’s disease can forget how to eat.

 Options B, C, and D: Allowing privacy during meals, filling out the menu, or
helping the client to complete the menu doesn’t ensure adequate nutritional
intake.

78. Answer: C. Cerebral function

The mental status examination assesses functions governed by the cerebrum.

Some of these are orientation, attention span, judgment, and abstract reasoning.

 Option A: Cerebellar function testing assesses coordination, equilibrium, and

fine motor movement.

 Option B: Intellectual functioning isn’t the only cerebral activity.

 Option D: Sensory function testing involves assessment of pain, light-touch

sensation, and temperature discrimination.

79. Answer: B. Determine whether the client is allergic to iodine, contrast

dyes, or shellfish.

Because CT commonly involves the use of a contrast agent, the nurse should
determine whether the client is allergic to iodine, contrast dyes, or shellfish.

 Option A: Neck immobilization is necessary only if the client has a suspected

spinal cord injury.
  Option C: Placing a cap over the client’s head may lead to misinterpretation
of test results; instead, the hair should be combed smoothly.

 Option D: The physician orders a sedative only if the client can’t be expected
to remain still during the CT scan.

80. Answer: B. Support the joint where the tendon is being tested.

To prevent the attached muscle from contracting, the nurse should support the
joint where the tendon is being tested.

 Option A: The nurse should use the flat, not pointed, end of the reflex
hammer when striking the Achilles’ tendon. (The pointed end is used to strike
over small areas, such as the thumb placed over the biceps tendon.)

 Option C: Tapping the tendon slowly and softly wouldn’t provoke a deep
tendon reflex response.

 Option D: The nurse should hold the reflex hammer loosely, not tightly,
between the thumb and fingers so it can swing in an arc.

81. Answer: A. Hepatitis A

Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected

food handlers. Hepatitis B, C, and D are transmitted most commonly via infected
blood or body fluids.

82. Answer: B. Elevated serum bilirubin level

Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated

serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia.
An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin
level is unrelated to this diagnosis.

83. Answer: C. Morphine sulfate for pain

Meperidine (Demerol) rather than morphine sulfate is the medication of choice to

treat pain because morphine sulfate can cause spasms in the sphincter of Oddi.
Options A, B, and D are appropriate interventions for the client with acute
pancreatitis.

84. Answer: A. Fast for 8 hours before the test

A barium swallow is an x-ray study that uses a substance called barium for contrast
to highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to
12 hours before the test, depending on physician instructions. Most oral
medications also are withheld before the test. After the procedure, the nurse must
monitor for constipation, which can occur as a result of the presence of barium in
the gastrointestinal tract.

85. Answer: C. Listens to bowel sounds in all for quadrants

The appropriate sequence for abdominal examination is inspection, auscultation,

percussion, and palpation. Auscultation is performed after inspection to ensure
that the motility of the bowel and bowel sounds are not altered by percussion or
palpation. Therefore, after inspecting the skin on the abdomen, the nurse
should listen for bowel sounds.

86. Answer: C. Rebound tenderness

Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur

in ulcerative colitis. Because of the blood loss, the client may be hypotensive and
the hemoglobin level may be lower than normal. Signs of peritonitis must be
reported to the physician.

87. Answer: B. Body image, disturbed

Body image, disturbed relates to loss of bowel control, the presence of a stoma, the
release of fecal material onto the abdomen, the passage of flatus, odor, and the
need for an appliance (external pouch). No data in the question support options A
and C. Nutrition: less than body requirements, imbalanced is the more likely
nursing diagnosis.

88. Answer: A. Diarrhea

Crohn’s disease is characterized by nonbloody diarrhea of usually not more than

four to five stools daily. Over time, the diarrhea episodes increase in frequency,
duration, and severity. Options B, C, and D are not characteristics of Crohn’s
disease.

89. Answer: B. Stop the irrigation temporarily

If cramping occurs during a colostomy irrigation, the irrigation flow is stopped

temporarily and the client is allowed to rest. Cramping may occur from an infusion
that is too rapid or is causing too much pressure. The physician does not need to
be notified. Increasing the height of the irrigation will cause further discomfort.
Medicating the client for pain is not the appropriate action in this situation.

90. Answer: A. Increase fluid intake

To enhance effectiveness of the irrigation and fecal returns, the client is instructed
to increase fluid intake and to take other measures to prevent constipation.
Options B, C and D will not enhance the effectiveness of this procedure.

91. Answer: B. inspection, auscultation, palpation, percussion

Auscultation is done before palpation to avoid stimulating peristaltic movements

and distorting auscultatory sounds.

92. Answer: D. peptic ulcer disease

Perforation is a life-threatening complication of peptic ulcer disease and can result

in peritonitis.

93. Answer: A. Ineffective Individual Coping

The patient is dealing with a disturbance in self-concept and difficulty coping with
the newly established stoma.

94. Answer: B. increased heart rate.

Tachycardia is an early sign of compensation for patients with esophageal varices.

95. Answer: A. knee-chest position

Flexion of the trunk lessens the pain and decreases restlessness. Other positions
do not decrease the pain.

96. Answer: D. Cullen’s sign

Cullen’s sign is associated with pancreatitis when a hemorrhage is suspected. Grey-

Turner’s sign is ecchymosis in the flank area suggesting retroperitoneal bleed.
Homan’s sign is cal pain elicited by the dorsiflexion of the foot and suggests deep
vein thrombosis. Rovsing’s sign is associated with appendicitis when pain is felt with
pressure at McBurney’s point.

97. Answer: 2. Red and moist

Good circulation causes tissues to be moist and red, so a healthy, well-healed

stoma appears red and moist.

98. Answer: 1. Formed

A colostomy in the sigmoid colon produces a solid, formed stool.

99. Answer: 4. Yogurt

High-fiber foods stimulate peristalsis, and a result, flatus. Yogurt reduces gas
formation

100. Answer: 4. Keeping her NPO until the return of peristalsis.

After surgery, she remains NPO until peristaltic activity returns. This decreases the
risk for abdominal distention and obstruction.