Nurse Licensure Examination ______________________________________________________________________ Instruction: Select the correct answer for each of the following questions; mark

only one answer for each item by shading the box corresponding to the letter of your choice on the answer sheet provided. STRICTLY NO ERASURES ALLOWED. Use pencil number 2 only. Situation: a patient with long history of alcohol abuse is admitted in the ward. 1. a. b. c. d. 2. The nurse suspects an elderly client has become impacted when the client says: I have a lot of gas pains I don’t have much of an appetite I feel like I have to go and just can’t I haven’t had a bowel movement for 2 days

c. d. 4. a. b. c. 5. a. b. c. d. 6.

50 ml of saline and increase pressure of suction 15 ml of distilled water and disconnect suction for 30 mins

8. a.

While administering an enema, the maximum safe height at which the container of fluid can be held is: 30 cm ( 12 inches) 37 cm ( 93 inches) 45 cm ( 18 inches) 66 cm ( 26 inches) A client has peptic ulcer in the duodenum. He would probably describe the associated pain as: an ache radiating to the left side an intermittent colicky pain a gnawing sensation relieved by food a generalized abdominal pain intensified by moving

When performing a colostomy irrigation the nurse inserts the catheter into the stoma upto: 5 cm (2 inches) 10 cm ( 4 inches) 20 cm ( 8 inches) a client is to have an enema to reduce flatus. The rectal catheter should be inserted upto mark: 5 cm ( 2 inches) 10 cm ( 4 inches) 15 cm ( 6 inches) 45 cm ( 18 inches) When teaching a client to irrigate a colostomy, the nurse indicates that the distance of the container above the stoma should be no more than : b. 15 cm ( 6 inches)

b. c. d. 9. a. b. c. d.

10. Diagnosis of malabsortion syndrome is made in a client. Striking clinical improvement should be noted after administration of: a. b. c. d. Folic Acid Vitamin B12 Corticotropin A glutein free diet

a client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. With this evidence of impending hepatic coma, the diet would probably be changed to: a. b. c. d. 7.

15 cm (6 inches) 25 cm ( 10 inches) 30 cm ( 12 inches) 45 cm ( 18 inches) The physician has ordered a rectal tube to help a client relieve abdominal distention following surgery. To achieve maximum effectiveness, the nurse should leave it in place for a period of:

a. b. c. d. 3.

20 g protein, 2000 calories 80g protein, 2500 calories 70g protein, 1200 calories 100g protein, 1500 calories After a partial gastrectomy is performed, a client is returned to the unit with an IV solution infusing and a nasogastric tube in place. The nurse notes that there has been no drainage from the NG tube for an hour. There is an order to irrigate the nasogastric tube PRN. The nurse should insert:

11. A flat plate X-ray of the abdomen is ordered for a client. The nurse recognizes that the client should receive: a. b. c. d. no special preparation a low soapsuds enema nothing by mouth for 8 hrs a laxative the evening before the surgery

a. b. c. d.

15 minutes 30 minutes 45 minutes 60 minutes 12. a pancreatic pseudocyst is; a. b. c. d. generally malignant growth filled with pancreatic enzymes cyst containing necrotic tissue and blood a pouch of undigested food particles

a. b.

30 ml of saline and withdraw slowly 20 ml of air and clamp off suction for 1 hour

c. 18. the nurse should: 19. 14. c. c. c. d. b. kinking of the bowel onto itself a band of connective tissue compressing the bowel telescoping of the proximal loop of bowel into the distal loop a protrusion of an organ or part of an organ through the wall that contains it. these 8 amino acids can be made by the body because they are essential to life these 8 amino acids are essential in body process and the remaining 12 are not the body cannot synthesize these amino acids and thus they must be obtained from the diet After synthesizing these 8 amino acids. Twenty amino acids are involved in body metabolism. d. administer antacids such as sodium bicarbonate d. Barium salts used for GI series and barium enemas serves to: a. The laboratory test that would indicate that the liver of a client with cirrhosis is compromised and Neomycin enemas might be helpful is: a. A client with a hiatus hernia complains about having difficulty sleeping at night. The nurse questions this practice because: this vitamin is highly toxic even in small amounts a. a. easily digestible feedings allow selection of personally preferred foods d. c. a client complains of abdominal cramps during a colostomy irrigation. d. c. When teaching a client about intussusception. When caring for a client with nasogastric tube attached to suction. 24. Health teaching program for a client who has had a gastrectomy should include: a. c. fluoresce and thus illuminate the alimentary tract give off visible light and illuminate the alimentary tract dye the alimentary tract and thus provide for color contrast Absorb X-rays and thus give contrast to the soft tissues of the alimentary tract 16. A client has taken mega doses of Vitamin A.d. the nurse explains that it is: a. d. b. c. make the client sleep on two or three pillows eliminate carbohydrates from client’s diet suggest drinking a large glass of milk before retiring . Building various tissues. the wisest dietary would be to: increase intake of dietary roughage avoid oral feedings for a prolonged period gradually resume small. the nurse should: a. This means that: a. b. fro an elderly client who has had a subtotal gastrectomy . discontinue the irrigation lower the container fluid clamp the catheter for a few minutes advance the catheter about 2. an acute attack of pancreatitis may be precipitated by heavy drinking because: promotes the formation of calculi in the cystic duct the pancreas is stimulated to secrete more insulin than it can immediately produce the alcohol alters the composition of enzymes so they are capable of damaging pancreas alcohol increases enzymes secretion and pancreatic duct pressure. alanine aminotransaminase level 17. 21. c. Of these 8 are essential amino acids. b. 13. b. d. a. b. the body uses them in key processes essential for growth 20. d. which causes backflow of enzymes into the pancreas.5 cm (1 inch) 22. d. ammonia level white blood count culture and sensitivity a. b. b. c. Postoperative care for a client who has had a hemorrhoidectomy should include: occlusive dressings to the area encouraging showers when needed administration of laxatives and stool softeners administration of enemas to promote defecation c. a warning to avoid all gas forming foods an explanation of the therapeutic client of high roughage encouragement to resume previous eating habits as soon as possible a thorough explanation of the dumping syndrome and how to limit or prevent it 15. b. b. a. 23. irrigate the tube with normal saline use sterile technique when irrigating the tube withdraw the tube quickly when decompression is terminated allow the client to have small chips of ice or sips of water unless nauseated d. The appropriate nursing intervention would be: a. b.

d. milk baked chicken. and the excess amount would saturate the general body tissues although the body’s requirement for the vitamin is very large. mashed potatoes with gravy the liver in clients with hepatitis B is usually: a. omelet. b. the nurse should advice the client that the irrigations be done at the same time everyday. b. low in fiber content high in carbohydrate as close to normal as possible 33. b.A client with liver cancer complains of fatigue because a readily available from of energy although limited in amount. hydrochloric acid bile salts lipase amylase 28.noodles. even to toxic amounts this vitamin cannot be stored. d. c. in a client having bleeding esophageal varices is: a. d. encourage the client to eat foods high in residue explain that the drainage can be controlled with daily irrigation expect the stoma to start draining on the third postoperative day anticipate that emotional stress can increase intestinal peristalis 36. b. coffee creamed turkey on toast. green beans. isstored in the liver by conversion of glucose to: a. b. The nurse recognize that this may be the result of genetic deficiency of the enzyme: a. d. c. b. a. the cells can synthesize more as needed a. paracentesis. When caring for a client with an ileostomy the nurse would: a. A client who has had a colostomy should follow a diet that is: a. the liver has great storage capacity for the vitamin. c. d. glycerol b. The nurse explains that visualizations of the GI tract after a barium enema is made possible 31. green peas. b. c. rice. c. The earliest indication of parenchymal damage to a. Before the procedure the nurse should instruct the client to: empty the bladder eat foods low in fat remain NPO for 24 hour assume the supine position 25. c. baked potato. The time selected should: a. c. tissue fat d. c. b. A client with ascites has been ordered 29. a rise in bilirubin an alteration in proteins a rise in alanine aminotransaminase an elevation of alkaline phospatase 35. b. Which of the following is essential for absorption of fat soluble vitamins in the intestine? a. c. Be approximately 1 hour before breakfast Provide ample uninterrupted bath room use at home because: Barium physically colors the intestinal wall Barium has the X-ray absorbing properties Barium has X-ray transmitting properties Barium chemical interacts with electrolytes a. gastric lavage gastric suctioning balloon tamponade aminocaproic acid ( amicar) 27. carrot and tea cheese. d. The nurse would expect a client with cancer of the liver to have difficulty digesting fatty foods because the liver is involved in the production of: 32. d. roast beef. When teaching a client to care for a new colostomy. c. bile lipase cholesterol amylase b. d. d. A client complains of abdominal discomfort following ingestion of milk. d. b. The emergency medical treatment that is unrelated to the control of hemorrhage. lactase maltase sucrase amylase 34. glycogen c.b. rich in protein . c. amino acids 26. d. A typical food combination that can be served to a client with malabsorption syndrome is: 30.

d. b. Approximate the client’s usual daily time for elimination Be about halfway between the two large meals of the day a. d. When teaching a client with permanent colostomy. Vit. d. When a client has extensive carcinoma of the descending portion of colon with metastasis to the lymph nodes the operative procedure that would probably be performed is a ( an) : a. stimulant bulk-forming 45. c. K is required for the synthesis of: a. Vitamin B12 is only absorbed in the stomach The hemopoeitic factor is secreted in the stomach The parietal cell of the gastric mucosa secrete intrinsic factor Chief cells in the stomach secrete the extrinsic factor 39. Phospho-soda is cathartic. b. 41. c. chest pain shortness of breath shoulder discomfort bleeding oral ulceration a. thromboplastin d. clients with gastrectomy may develop pernicious anemia because: 38. b. c. c. prothrombin c. b. b. urine output bilirubin level serum glucose blood pressure 44. Levin tube Salem pump Miller-abbot Blakemore-sengstaken tube 46. c. c. d. The dumping syndrome refers to: nausea due to a full stomach rapid passage of osmotic fluid into the jejunum reflux of intestinal contents into the esophagus buildup of feces and gas within the large intestine 47. d.c. infection vomiting osteomyelitis bronchospasm a. If intubation is indicated in a client with bleeding varices. d. colectomy d. 40. d. c. A subtotal gastrectomy is performed to treat a client with cancer of the stomach. Assessment fro signs of respiratory complications is important following cholecystectomy because the: incision is in close proximity to the diaphragm length of time required for surgery is too prolonged c. The ejection of bile into the alimentary tract is controlled by the hormone: a. d. c. Before scheduling a client for endoscopic retrograde cholangiography (ERCP) the nurse should assess the client’s: a. Fractured mandible is usually immobilized with wires. In clients with cholecystitis. Ileostomy c. bilirubin b. b. Need for special clothing Importance of limiting activity Periodic dilation of the stoma Bland. colostomy b. classified as: a. the utilization of bile is interfered. d. The life threatening postoperative problem that can develop with this procedure is: a. low residue diet regimen 42. The chief complaint in clients with Vincent’s angina is: a. saline emollient c. cholecystokinin . d. This client develops dumping syndrome. cecostomy 37. gastrin secretin enterocrenin cholecystokinin 48 Before a cholecystectomy the physician order vitamin K. the type of tube most likely to be used would be (a) (an) : a. the nurse is expected to discuss the: a. b. client’s resistance is lowered because of bile in the blood bloodstream is invaded by microorganisms from the bleary tract b. b. b. 43. d.

The main role of liver in relation to fat metabolism is to: a. abdominal cramps. the decreased levels of ADH and aldosterone due to increasing metabolic activity in the liver d. anorexia. compression of the portal vein with resultant increased back pressure in the portal veins system 52. which indicates the probable presence of a fecal impaction in a client with limited mobility would be: a. "Has your doctor talked to you about the type of surgery "What questions do you have about your surgery?" "What type of surgery are you having and why are you "What do you know about what will be done to you?" you are having? What did the doctor say?" having it done?" . destroy intestinal bacteria b. Neomycin sulfate is administered to clients. cholecystokinin 50. Which of the following is the most appropriate initial question to ask this preoperative client? a. fever. Varicose veins can be expected in clients with cirrhosis. comparing the client’s body weight to the base line data 51. oxidize fatty acids to produce energy 49. acute appendicitis is a condition associated with a. anemia. evaluating the intake in relation to the output b. decreased plasma protein concentration resulting in the pooling of blood in the venous system 58. K c. abdominal cramps c. d. nausea and vomiting. poor dietary habits b. store fat for energy reserves 57. before colon surgery to: a. convert fat to lipoproteins for transport out into the body d. The nurse reinforces the client’s understanding of vagotomy by satting. toxic irritating products released into the blood from the diseased organs c. The symptoms associated with colitis are: a. decrease the incidence of any secondary infection d. a client is scheduled for pyloroplasty and vagotomy because of strictures caused by peptic ulcers. that the vagotomy serves to: a. increased plasma hydrostatic pressure in veins of the extremities b. eliminate pain sensations d. The nurse should assess the client with cirrhosis for signs of hepatic coma. anemia 60. pacreozymin c. the escape of lymph into abdominal cavity directly from the inflamed liver sinusoid b. density d. increase the production of Vit. fecal liquid seepage c.instilling air into the stomach while ausclutating d. The ascites seen in cirrhosis results in part from: a. A client is admitted three days back for a cerebral vascular accident. hemoptysis. anemia.c. produce phospholipids b. diarrhea. decrease the possibility of postoperative urinary tract infection 54. enterocrinin b. bright red blood in the stool d. Hormone that stimulates the flow of pancreatic enzymes is: a. decreased number of bowel movements 55. he is receiving intermittent feedings through nasogastric tube. ressed muscle reflex 59. aspirating the residual volume and reinstilling it c. The nurse evaluates if a prior feeding has been absorbed by: a. leucopenia. anorexia. infection of the bowel c. c. Hasten Gastric emptying c. This is because of: a. decrease secretions in the stomach d. hypertension and resultant edema d. weight loss. weight loss. digestibility 61. flapping hand tremors d. enterogastrone d. compromised circulation to the appendix 53. increase the heart rate b. diarrhea d. bile-colored stools b. The classic sign of hepatic coma is: a. elevated cholesterol c. weight loss b. increased plasma colloid osmotic pressure due to excessive liver growth and metabolism c. A client is being admitted to the hospital on the day before a scheduled surgery. color b. tympanites b. The terms saturated and unsaturated fatty acids relate to degree of: a. ballooning of vein walls from decreased venous pressure and incompetent valves 56. taste c. leukocystitis. b. The assessment finding.

The nurse is assessing the client on return to the hospital unit from the PACU and notes the presence of a drain in the surgical the subarachnoid space. d. What would the nurse suspect regarding the significance of this increased value? a. c. Anxiety Hypocalcemia d. The client is inside out. A client is being discharged following outpatient surgery. In spinal anesthesia. A family member observes the drain and asks why the tube was left in the wound. purulent material. event. The nurse would instruct the caregiver to report which of the following findings to the surgeon? preoperatively. 64. b. Which statement by the client indicates understanding of regional anesthesia? a. d. After the drug has been administered. pain. Risk for injury. d. Regional anesthesia produces analgesia and amnesia. While assessing the client. the spinal cord for epidural anesthesia. Allow drainage of excessive serosanguinous fluid and Allow healing to occur at a very rapid rate. the nurse needs to monitor the client for which of the following side effects? a. Perspiration. c. Fluid hematocrit. The client is in the operating room for a surgical procedure. The nurse has completed preoperative teaching to a pregnant nursing diagnosis for this client would be: woman. The nurse's answer would correctly reflect what information? a. The client loses consciousness and does not perceive b. The nurse is assessing: a. b. The client has shown a difficulty understanding the necessity for early ambulation. b.62 A pre-surgical client asks the nurse for more information about the advantages of a general anesthetic. The nurse in the operating room is monitoring the 68. During the discussion. b. d. c. Immune deficiency Malignancy b. 70. Knowledge deficit. Kidney dysfunction Dehydration 71. d. c. The nurse is providing the caregiver with instructions for wound care. b. The anesthetic agent is injected into the dura mater of The client is sedated and has some awareness of the wound. c. d. Determine client satisfaction with care received Assess client's emotional status Monitor asepsis in the environment Calculate fluid loss and its effects 65. a. 63 A benzodiazepine has been administered to a client The respiratory and circulatory functions are depressed. b. In what position is the unconscious client placed in the immediate postanesthetic stage? a. A client is in the postoperative stage and the physician has ordered ambulation. The client arrives in the PACU in an unconscious state. c. The nurse explains drains: a. Drainage from the tubes or drains. The client has been in the PACU unit for 1 hour. b. 66. Which of the following activities is most appropriate? a. Self-care deficit. c. the nurse checks the bedclothes underneath the client. the anesthetic agent is injected into 69. Scar formation Increased redness or drainage No odor of the wound drainage No unusual color of the drainage Extrapyramidal reactions A preoperative client has an elevated hemoglobin and a. The anesthetic agent is not rapidly excreted so that the General anesthesia reduces the chance that the client timing of surgery can be adjusted. d. . Have to be shortened to allow healing to occur from the Have to be connected to suction tubes. Hypotension now groggy but able to respond to voice commands. c. Ineffective coping. balance. c. Side lying with the face slightly down Side lying with a pillow under the client's head Semi-prone position with the head tilted to the side Dorsal recumbent with head turned to the side. suffers from amnesia. An appropriate physiological integrity of the client. d. 67. c. b. d. Hemorrhage. the nurse describes the different types of anesthesia available.

c. c." remember and comprehend what is happening." "It lessens the chance for decreased tissue perfusion. 77. Which of the following responses by a nurse to the client's concern is most therapeutic? a. 79. What is the most essential information to include in the discussion prior to the client signing the permission? a. b. d." "Have you had a bad experience in the OR?" "You're concerned about the personnel. c. d." personnel?" 73. Changes that the nurse makes in the informed consent process for this elderly client include which of the following? . d. Which of the following principles is true? admitting the client from the PACU (postanesthesia care unit) following a surgical procedure. c. Keep the hands above the elbows during the surgical completing the skin preparation." "It decreases the possibility for dermatitis. scrub. scrub. An 86-year-old client will be undergoing a surgical procedure. c. Be silent." d. "It reduces the risk of all postoperative complications. Providing adequate time for the client to process the Encouraging the family members to make the decision Encouraging the client to sign immediately before the Providing the client with reading material about the 78. When a client preparing for surgery suddenly bursts into tears." "It reduces the risk of postoperative wound infection. a. scrub. "The nurses are well-qualified for the job they do. Alternately contracting and relaxing the leg muscles Alternately flexing and extending the knees Raising and lowering the legs Alternately dorsiflexing and plantar flexing the feet upcoming procedure. The nurse observes the client performing the procedure and notes that client correctly understands the technique when the client is observed doing which of the following? a. b. c.72. Ask the client what is happening. d. to decrease the possibility of thrombophlebitis developing postoperatively. b. Presence of pustules or abrasions Absence of hair growth Presence of lanugo Absence of pulsation The client was taught calf-pumping exercises prior to surgery 74. Close the door and leave the room to provide privacy. Prior to need to worry. The nurse is demonstrating surgical scrub to a group of student nurses. b. Ask the client to explain the behavior. the nurse's most therapeutic initial approach is to do which of the following? a. d. b. The nurse knows the procedure will be performed under conscious sedation. c. The family member asks why the area around the surgical wound is orange. the nurse assesses the surgical site for which of the following? a. The client's diagnosis Treatment proposed and the cost The technical aspects of the procedure Right to withdraw consent A client asks the nurse about the planned anesthesia for an 80. The nurse has been instructed to obtain informed consent from a client who will be undergoing a surgical procedure. c. c. A client questions the surgical nurse about the personnel in the operating room. d. Which of the following statements should the nurse make to the client concerning conscious sedation? a." The nurse is preparing a client for surgery. d. during the surgical intervention." tolerate the pain. Only betadine can meet the requirements of the surgical b." 75. b. A family member is sitting at bedside and observes the nurse information for the client client forgets the purpose of the surgery surgery and the postoperative instructions 76. b. Microorganisms do not breed on the hands during a Keep the palms up throughout the scrub. "You will be able to breathe and respond appropriately to "Your pain threshold will be decreased so you can "You will have a patent airway and will be able to "You will not be awake but you will still feel slight pain verbal and physical stimuli. d. Which of the following statements about surgical skin preparation is the best response to the family member? a. but you have no "Can you tell me about why you are interested in the a. b.

A regular time period should be established with the client for massage therapy. d. Give the medication as soon as possible. The client with a terminal illness who is considered at end-of-life 88. A client with cancer-induced pain using distraction as a coping mechanism may have the best outcome from which of the following activities? a. The client who is nauseated and cannot tolerate oral analgesics The client experiencing breakthrough pain with wound The client who requires analgesia at nighttime to rest well debridement a. The client will consume four extra servings of high-fiber The client will call for assistance when getting out of bed. c. 85. reflex urinary Urinary elimination. urge Incontinence. 12 mg b. The client will maintain a heart rate under 100 bpm. d. Which of the following concepts would be used by the nurse d. 40 mg d. The physician orders urine output to be measured and recorded every 4 hours. Which nursing diagnosis is the most common for clients receiving opioid medications? a. b. Fentanyl (Duragesic) transdermal patch every 72 hours Hydromorphone (Dilaudid) 4 mg IV every 2 hours Hydrocodone (Lortab) one tablet every 4 hours Ibuprofen (Advil) 200 mg every 4 hours 89. citrate (OTFC or Actiq) for which client situation? a. Which response of the nurse is most likely to stimulate further discussion between the client and the nurse? 84. Obtain a complete set of vital signs on the client. d. A client had an epidural catheter placed for a continuous infusion of opioids for pain management. A client is receiving morphine 10 mg/hour as a continuous infusion. b. which is currently wrapped in several layers of elastic bandage and has an immobilizer device in place. A client has suffered a severe contusion injury to the lower-left forearm. b. b. b. 87. b. A preoperative client expresses anxiety to a nurse about upcoming surgery. d. c. The left hand area The upper-left arm The lower-right forearm The left axilla area expected for this individual? a. Ask the physician why an additional analgesic is needed. Risk for infection Constipation Ineffective breathing pattern Sleep pattern disturbance Using the WHO three-step analgesic ladder as a guideline for c. d. b. 86. A client has been receiving a nonsteroidal anti-inflammatory drug (NSAID) every 4 hours for pain related to a muscle strain following a sports injury. 24 mg c. c. The physician asks the nurse to give the client two acetaminophen with codeine (Tylenol #3) stat. the nurse would expect a client with moderate pain to receive which medication order? a. The nurse is planning care for a client taking codeine 60 mg tablets every 6 hours for pain. you. The client on bedrest must be able to move or turn in order to receive massages.” . c. Incontinence. c. Massage for relaxation should be done with circular movements and kneading of the tissues. “I will be happy to explain the entire surgical procedure to “ Let me tell you about the care you’ll receive after the surgery and the amount of pain you can anticipate . d. Reassess the client's pain. pain management. It is preferable for the client's family or significant other to provide the massage. b. scale between doses of the medication. altered Urinary retention 83. c. What is the appropriate action for the nurse to take next? a. The client will report pain rating as a "1" on a 1 to 10 food daily. 82. d. Which client goal would be 90. The nurse would anticipate using oral transmucosal fentanyl 91.81. Which of the following nursing diagnoses is most likely to apply to this client's situation? a. Which of the following sites would be least helpful for application of heat to assist with pain management? a. c. The nurse anticipates administering which of the following bolus doses of morphine for occurrence of breakthrough pain? a.” b. Writing a friend a letter Watching television with family Working on a needlepoint project Listening to classical music considering massage as a nonpharmaceutical method of pain management? a. c. 30 mg d. b.

Tamayao carefully for symptoms of digitalis toxicity and these are the following symptoms except: a. the optimum cardiac effect has been reached d. vomiting b. Mrs. the attaining of minimum cardiac effect from digitalis has been reached c. Mrs. practice postoperative breathing exercises 94. keep a loose seal between the lips and the mouthpiece b. Tamayao is receiving nitroglycerin. maintain aseptic technique when emptying the drain d. The nurse should take which of the following actions in the care of this client at this time? a. hypertrophy of the coronary vessels surgery?” 92. administered over a two week period of time b. The best results are achieved when sitting at least half-way or fully upright 93. after maximum inspiration. inhale as rapidly as possible c. tachycardia c. “If it’s any help. carbon dioxide retention c. The nurse should watch Mrs. Diagnosis is Angina Pectoris. Tamayao asks the clinic nurse. slowing of the pulse 99. A client is admitted to a surgical unit postoperatively with a wound drain in place. Which action would the nurse avoid in the care of the drain? a. fluid imbalance b. everyone is nervous before surgery. A nurse is conducting a preoperative teaching about the use of an incentive spirometer in the post operative period. cediland c. dyspnea d. Digitalis is ordered for Mrs. irregular rhythm of the cardiac rate c. Nausea and vomiting b. the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to: a. d. observe for bright red bloody drainage Situation: Mrs. The most common side effect is: a. verify that the client has not eaten for the last 24 hours d. Tamayao. administer all the daily medications b. “What is the cause of the chest pain that I experienced?” The nurse replied that angina pectoris results from: a. coronary artery obstruction d. digitoxin 100. Tamayao. The following are the digitalis preparation except: a. In formulating a response. pneumonia . A postoperative client asks the nurse why is it important to deep breathe and cough after the surgery. hold the breath for 10 seconds and exhale d. PRN. The nurse would include which of piece of information in discussions with the client? a. headache 97. mental alertness d. curl the drain tightly and tape firmly to the body c. inadequate oxygenation of the heart muscle c. a patient is said to be digitalized when: a. necrosis of the myocardium b. pulmonary edema d. A nurse is preparing a preoperative client for transfer to the operating room ( OR). ensure that the client has voided c.” “Can you share with me what you’ve been told about your 95. 96.c. digoxin b. antistine d. there is sufficient slowing of the pulse 98. age 50 has a blood pressure of 170/100 and heavy chest pain after a heavy physical exertion. check the drain for patency b.

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