1.Answers: B and F

Rationale:

Post supratentorial craniotomy clients must be positioned in semi-fowlers to promote venous drainage from the head. These clients should also be lying with the head in a midline position to prevent extreme hip or neck flexion. Positioning these clients on the operative side must never be done as well since it can cause the displacement of cranial contents.

2.Answer: B

Rationale:

a. Nifedipine
This is a Calcium Antagonist that produces relaxation of coronary and vascular smooth muscles and dilates coronary arteries which lower blood pressure.
b. Dobutamine
Dobutamine is not included in the treatment because this is an inotropic agent that increases heart rate and raises blood pressure.
c. Terazosin
It is an alpha-blocker used in the management of hypertension.
d. Nitroglycerine paste
This topical paste is very convenient and safe to use to decrease blood pressure. It can be wiped off as the blood pressure begins to normalize.

3.Answer: B

Rationale:

a. Client is given pain medication as pain is initially common after surgery.
The client will not feel any significant pain because the size of the neck incision is so small.
b. The client will receive fluid and nutrients through a small thin tube.
The thin tube which is an intravenous (IV) catheter will provide the client with the necessary nutrients postoperatively.
c. The client may resume physical activities immediately after surgery.
The client usually can begin normal physical activities several weeks after the surgery.
d. The client may return home on the same day of the operation.
The client has to stay in the hospital for 1-2 days so that the physician can monitor the client’s progress.

4.Answer: C

Rationale:

a. A permanent change in voice.
Nerve injury produces hoarseness of the voice but this usually returns after a month.
b. Sleep apnea or nose breathing.
This is a possible complication of tonsillectomy, not nerve injury after carotid endarterectomy.
c. Numbness in the face or tongue.
This is brought about by nerve damage to the neck.
d. Bleeding.
This is not expected after surgery because of the small neck incision.

5.Answers: A, C, E, F

Rationale:

a. Avoid stressful situations.
The client should try to avoid too much stress as this can trigger a seizure.
b. Take a bath instead of showers.
Taking a bath is dangerous due to the risk of drowning during a seizure. Taking a shower is considered safer.
c. Wear a medical alert or ID bracelet.
Wearing an identification card is important in case of emergency because it will help bystanders know what to do.
d. Keep seizure medicines in your dressing table or within reach.
Seizure medicines should be kept in a safe place to prevent children from taking it.
e. Keep your bathroom and bedroom doors unlocked.
This enables the family members to access the room immediately in case the client has seizure attacks.
f. Going to the gym is generally okay.
Activities like going to the gym, jogging, hiking, aerobics and bowling are safe activities for clients with seizures.

6.Answers: B, D, E and F

Rationale:

Chronic bronchitis is a respiratory condition characterized by the premature onset of cough, copious purulent mucus production, mild weight loss, and mild attacks of dyspnea whereas, scarce mucus production and distinctive amount of weight loss are mainly associated with pulmonary emphysema, along with other symptoms such as marked dyspnea attacks and late-onset of cough. Barrel chest can occur over time.

7.Answer: C

Rationale:

a. Increased amount of vasodilation in the lungs
RDS is characterized by poor gas exchange and ventilatory failure.
b. Small surface area of the premature lungs
Premature infants are born with numerous underdeveloped and many uninflatable alveoli.
c. Decrease amount of surfactant in the infant’s lungs
RDS refers to a condition of surfactant deficiency and physiologic immaturity of the thorax.
d. Increase in the amount of surfactant in the infant’s lungs
There is a decreased amount of surfactant in the infant’s lungs.

8.Answer: A

Rationale:

a. Notify the physician and document initial findings.
The nurse must notify the attending physician and relay the findings. Documentation is one of the essential responsibilities of a nurse that should not be missed. Baseline data helps in making clinical decisions.
b. Facilitate chest X-ray.
The nurse cannot facilitate any diagnostic or laboratory test without the physician’s advice.
c. Start a thorough physical examination and history.
A physical examination and history taking have already been done. A thorough examination is unnecessary and time-wasting.
d. Recheck the client after five minutes and see if there are changes.
There is a significant finding that should be relayed to the physician as soon as possible, so delayed care is avoided.

9.Answer: C

Rationale:

a. Peak flow meter
Peak Flow Meter measures how air flows from the lungs but does not determine tissue perfusion rate or oxygen saturation. The most important determinant to initiate intubation is the percentage of oxygen in the blood.
b. Partial Oxygen Saturation in Arterial Blood Gas
Although this is a more accurate reading of oxygen saturation, obtaining ABG before intubation is time-wasting and causes treatment delay. It is not an ideal measurement tool in an emergency set-up.
c. Oxygen Saturation in Pulse Oximeter
Getting oxygen saturation through a pulse oximeter is quick and easy. This is a non-invasive test and is the ideal tool to determine episodes of failing respiratory function requiring immediate intubation.
d. Lung Function test
This is a breathing test that measures how much air can be blown out of the lungs and how quickly. This does not measure the amount of oxygen present in tissues/cells.

10.Answer: C

Rationale:

a. Mild Intermittent
Symptoms occur less than once a week, episodes are short, lasting only a few hours, symptoms are present at night no more frequently than twice per month.
b. Mild Persistent
Symptoms occur more than once per week, symptoms are present at night more than twice per month and episodes affect activity and sleep.
c. Moderate Persistent
Symptoms occur daily, episodes affect activity and sleep, and symptoms are present at night more than once per week.
d. Severe Persistent
Symptoms occur daily, episodes are frequent, and symptoms are present at night frequently.

11.Answer: C

Rationale:

a. Allergic reaction
An allergic reaction occurs after initial exposure to an allergen. This manifests on people who were previously exposed to the drug and have developed antibodies.
b. Cumulative effect
This reaction occurs when the body develops drug tolerance and needs to increase the drug quantity to achieve the desired effect.
c. Idiosyncratic effect
Idiosyncratic effect is defined as the peculiar or abnormal response of the body to the drug. There could be a heightened or decreased reaction. Other people will manifest with a different response from the expected outcome.
d. Synergistic effect
Synergistic effect refers to the combination of drugs that produces a greater effect compared to a single drug administration.

12.Answer B

Rationale:

Aminophylline preparation is 250mg/10 ml. Since the physician ordered 500 mg, divide it with 250 mg to get 2 ampules: 500mg / 250 mg = 2 ampules.

13.Answer C

Rationale:

Given : Weight = 10 kg
Required dose = 100 mg/kg/day
Concentration = 40 mg/ml
Step 1 – Calculate the drug in mg. —— 10 kg x 100 mg/kg/day = 1000 mg/day
Step 2 – Divide the dose by the frequency. —- 1000 mg/day ÷ 1 (day) = 1000 mg/dose
Step 3 – Compute mg/dose to ml. —— 1000 mg/dose ÷ 40 mg/ml = 25ml

14.Answer: A

Rationale:

a. Client will develop a trusting relationship with the nurse
Agreement and the formation of trust in the helping relationship are made during the orientation phase and not on the working phase.
b. Client will actively participate in the helping relationship
Active participation is a part of the working phase.
c. Client will participate in activities geared towards attaining the goal
In the working phase, the client and the nurse will work towards achieving acceptable goals.
d. Client will express feelings and concerns to the nurse
Client expression of feelings and concern are important aspect of the working relationship.

15.Answer: C

Rationale:

a. Cardiac output
Cardiac output is the medical term referring to the quantity of blood circulated every minute.
b. Preload
Preload is the medical term referring to the blood volume in the ventricles at the end of diastole.
c. Afterload
Afterload is medically defined as the force opposing ventricular ejection.
d. Vascular resistance
Vascular resistance is medically defined as the opposite of the vascular bed to the volume of blood ejected.

16.Answer: B

Rationale:

a. Respiratory distress
Clients with acute respiratory distress are immediately intubated.
b. Prolonged mechanical ventilation
Clients who are expected to have longer mechanical ventilation need a tracheostomy, not an endotracheal tube.
c. High risk of aspiration
Endotracheal intubation is needed for clients who are at high risk of aspiration at the ICU.
d. Ineffective clearance of secretions
ICU clients who are unable to effectively clear airways secretions need endotracheal intubation.

17.Answer: A

Rationale:

a. Delirium
Delirium is an altered state of awareness manifesting symptoms of disorientation, confusion, restlessness, hallucination, and agitation.
b. Dementia
Dementia is the state of awareness wherein the client has difficulty regarding memory, orientation, and language.
c. Stupor
Stupor is a more severe alteration in the state of awareness wherein the client is mostly unconscious but can be aroused with painful or repetitive stimuli.
d. Confusion
The client in the state of awareness has a reduced awareness or is easily distracted.

18.Answer: C

Rationale:

a. Dull
A dull tone is normally noted over the liver and diaphragm.
b. Flat
A flat tone is usually noted over the sternum and thighs.
c. Tympanic
Tympanic is the characteristic tone of the abdomen on percussion. Tympany is an expected finding since the client is on the first operative day and the client’s gastrointestinal tract is filled with air postoperatively.
d. Resonant
Resonance is a tone particularly noted over the normal lung.

19.Answer: D

Rationale:

a. 20/20 vision
A 20/20 vision is considered a perfect vision.
b. Eye usually blinks 20 per minute
This is a normal assessment.
c. There are 5-35 bowel sounds
This is normal for a bowel sound.
d. There is a negative knee jerk
There should be a positive knee jerk.

20.Answer: C

Rationale:

a. High pitch sound
Wheezes are usually the type of breathing with high pitch sound.
b. Unpredictable
Biot’s respiration is an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea.
c. Intermittent on inspiration
Rales may happen during inspiration and is characterized by crackles which may be due to fluid in the lungs.
d. Constriction
Wheezing is caused by constriction or narrowing of airways.

21.Answer: B

Rationale:

a. Right upper quadrant
Liver and gallbladder are located here.
b. Right lower quadrant
The appendix and Ileocecal valve can be found here.
c. Left upper quadrant
Spleen and pancreas are present in this quadrant.
d. Left lower quadrant
The colon can be found here.

22.Answer: D

Rationale:

a. Whisper test
The whisper test does not use a tuning fork during the procedure.
b. Rinne test
Rinne test is performed by placing the tuning fork over the mastoid process and not on the client’s head.
c. Audiometer
An audiometer is a diagnostic tool and is different from a tuning fork.
d. Weber test
Weber test is performed by activating the tuning fork and placing it on top of the client’s head.

23.Answer: D

Rationale:

a. 2nd ICS, Right sternal border
This is the landmark for the aortic area.
b. 2nd ICS, Left sternal border
This is the landmark for the pulmonic area.
c. 5th ICS, Left sternal border
This is the landmark for the tricuspid area.
d. 5th ICS, Medial to the midclavicular line
The mitral area is located at the 5th ICS which is medial to the midclavicular line.

24.Answer: C

Rationale:

a. “Check client’s temperature.”
The task is not communicated in a clear and complete manner.
b. “Attend to the client who buzzed the emergency button.”
The task should be communicated with clear directions and a set of parameters to resolve the confusion.
c. “Turn the client every 2 hours following this schedule for tonight and report any skin changes.”
The nurse should communicate the task in a clear, correct, complete, and concise manner. The nurse should also communicate the parameters expected. After communicating the task, the nurse should clarify and ask for the delegate’s input.
d. “Provide mouth care to intubated clients in the ward for the morning shift.”
The parameter in this statement is unclear and incomplete.

25.Answer: A

Rationale:

a. Hypoactive bowel sounds
Normal serum calcium level ranges from 8.5 – 10 mg/dL. The condition of the client is called hypocalcemia. Hyperactive bowel sounds are expected not hypoactive.
b. Muscle cramping
This is a sign of hypocalcemia.
c. Numbness in hands and feet
This is a sign of hypocalcemia.
d. Positive Chvostek’s sign
This refers to the sustained twitching of facial muscles after tapping the cheekbone. This is a hallmark of hypocalcemia.

26.Answer: B

Rationale:

a. Elevate the head of the bed 90 degrees.
The head of the bed must be elevated 30 to 45 degrees to avoid strain on the eyes.
b. Suggest the client to sleep on the non-operative side.
This decreases the pain and swelling that the client may experience.
c. Assist the client in a sitting position to promote blood circulation every 15 minutes.
The client must be instructed to avoid bending, coughing and sitting, as it will cause an increase in the intraocular pressure, which may further strain the eyes of the client.
d. Educate the client about the importance of aerobic and weight lifting exercises for a more rapid recovery.
The client should be instructed to avoid any strenuous exercises like weight lifting to avoid an increase in intraocular pressure.

27.Answer: A

Rationale:

Option A: This describes how TURP is performed.
Option B: This refers to how Cystocopy is performed.
Option C: This refers to how Prostatectomy is performed.
Option D: This refers to how Cryosurgery for prostate cancer is performed.

28.Answer: A

Rationale:

Option A: In THR, general anesthesia is used to sedate the client. The client will be unable to bear weight on the operated hip right away hence a Foley catheter will be in place for urination and a tube for drainage. To prevent rotation of the hip or crossing of legs, a firm pillow will be placed in between the legs.
Option B: The implant will remain in the hip joint for a lifetime and will only be replaced when it gets infected and causes complications.
Option C: Laparoscopic surgery for THR has a minimally invasive approach to reduce bleeding and trauma on soft tissues and muscles. Hence, blood transfusion is not expected unless medically necessary.
Option D: Full recovery for THR may take years. Most individuals can return to the usual ambulation for 12 weeks.

29.Answer: A

Rationale:

a. Place a trochanter roll outside the thigh.
This stabilizes the hip in a neutral position.
b. Perform a resistive range of motion of the affected leg.
This does not prevent external leg rotation.
c. Adduct and internally rotate the left leg.
This does not change external rotation.
d. Maintain the left leg in a neutral position.
To maintain a neutral position, a trochanter roll is necessary.

30.Answer: B

Rationale:

a. Instruct client to avoid washing with water.
Washing with water only is advisable during treatment to avoid irritation.
b. Instruct client to avoid powder and creams to the area.
Creams and powders may further irritate the skin which is already sensitive due to radiation therapy.
c. Instruct client to apply a heating pad to the site.
Heating the area is not recommended since sensitive skin is more prone to burn and irritation.
d. Instruct client to cover the area with an air-tight dressing.
The treated area should be left open to allow air to circulate through it.

31.Answer: C

Rationale:

a. Using an electronic razor.
An electric razor is preferable to prevent the risk of cutting and bleeding.
b. Eating a high-protein diet.
A high-protein diet is preferable to aid tissue growth and healing.
c. Taking children to crowded places.
People undergoing radiation therapy should avoid crowds because of the increased risk of infection.
d. Eating dry crackers.
Eating dry crackers helps reduce the occurrence of nausea and vomiting resulting from radiation therapy.

32.Answer: B

Rationale:

a. Encourage intake of three meals in a day.
Small frequent meals enhance client cooperation and are better tolerated by clients rather than large meals.
b. Present the food in a more pleasing manner.
Clients develop anorexia as a side effect of the treatment; this may be accompanied by mucositis and taste alterations which limit the client’s food choices. Food presented in a more pleasing manner or environment will increase the client’s desire for eating and drinking.
c. Encourage a low-protein diet.
Small frequent intake of high-protein and high-calorie diet is better tolerated.
d. Allow liquid diet if tolerated.
A liquid diet is not recommended for anorexic clients because it has limited nutritional content.

33.Answer: A

Rationale:

a. Local infection and irritation
Infection is a concern regarding antineoplastic medications administered through the IV route. However, infection and irritation are not classic signs of IV extravasation.
b. Tissue breakdown
Extravasation of chemotherapeutic drugs can present with tissue breakdown and necrosis.
c. Redness and heat on the site
Heat (calor) and redness (rubor) on the IV site are part of the classic signs of extravasation.
d. Pain on the IV site
Pain (dolor) is the cardinal sign of IV extravasation.

34.Answer: D

Rationale:

a. The first day of every month
Menopausal clients are advised to perform BSE on the first day of every month to keep them reminded of the monthly screening procedure.
b. The first day of menstruation
Inaccurate results are taken when BSE is performed during the first day of menstruation.
c. Before menstruation
The breasts are swollen a week before menstruation. There may be lump formation due to normal physiologic processes. Performing BSE before menstruation will yield inaccurate results.
d. After menstruation
There are less breast changes occurring after menstruation and is the best time to perform BSE.

35.Answer: D

Rationale:

a. Irregular pattern of constipation and diarrhea
A sudden change in the bowel and bladder habits of a person is a warning sign of cancer.
b. Blood in the stools
The presence of unusual bleeding or discharges from any body orifice is a warning sign.
c. Difficulty in swallowing
Indigestion or difficulty in swallowing is a warning sign of cancer.
d. Frequent vomiting
This is a generalized symptom and is not a warning sign of cancer.

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