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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

b. The nurse questions this practice because: this vitamin is highly toxic even in small amounts a. the nurse should: a. d. b. a client complains of abdominal cramps during a colostomy irrigation. c. d. c. b. c.5 cm (1 inch) 22. Health teaching program for a client who has had a gastrectomy should include: a. the body uses them in key processes essential for growth 20. c. b. 13. 24. b. the nurse should: 19. When teaching a client about intussusception. When caring for a client with nasogastric tube attached to suction. the wisest dietary would be to: increase intake of dietary roughage avoid oral feedings for a prolonged period gradually resume small. which causes backflow of enzymes into the pancreas. d.d. alanine aminotransaminase level 17. b. A client with a hiatus hernia complains about having difficulty sleeping at night. 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. b. b. This means that: a. d. a. The appropriate nursing intervention would be: a. Building various tissues. 21. b. fro an elderly client who has had a subtotal gastrectomy . 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. d. 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. ammonia level white blood count culture and sensitivity a. d. c. b. 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. make the client sleep on two or three pillows eliminate carbohydrates from client’s diet suggest drinking a large glass of milk before retiring . a. c. d. Twenty amino acids are involved in body metabolism. easily digestible feedings allow selection of personally preferred foods d. 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. Of these 8 are essential amino acids. c. administer antacids such as sodium bicarbonate d. The laboratory test that would indicate that the liver of a client with cirrhosis is compromised and Neomycin enemas might be helpful is: a. c. 14. b. c. the nurse explains that it is: a. 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. c. discontinue the irrigation lower the container fluid clamp the catheter for a few minutes advance the catheter about 2. 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 client has taken mega doses of Vitamin A. Barium salts used for GI series and barium enemas serves to: a. a. 18. 23.

c. the nurse should advice the client that the irrigations be done at the same time everyday. 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. b. b. d. The nurse recognize that this may be the result of genetic deficiency of the enzyme: a. baked potato. b. c. A client complains of abdominal discomfort following ingestion of milk. c. the cells can synthesize more as needed a. 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. c. d. glycogen c. d. isstored in the liver by conversion of glucose to: a. b. A client who has had a colostomy should follow a diet that is: a. tissue fat d. green peas. milk baked chicken. c. in a client having bleeding esophageal varices is: a. even to toxic amounts this vitamin cannot be stored. low in fiber content high in carbohydrate as close to normal as possible 33. A typical food combination that can be served to a client with malabsorption syndrome is: 30. d. rich in protein . The time selected should: a. b. b. bile lipase cholesterol amylase b. Which of the following is essential for absorption of fat soluble vitamins in the intestine? a. glycerol b. The emergency medical treatment that is unrelated to the control of hemorrhage. 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. a. the liver has great storage capacity for the vitamin. coffee creamed turkey on toast. b. carrot and tea cheese. amino acids 26. d. lactase maltase sucrase amylase 34. c. d. 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. hydrochloric acid bile salts lipase amylase 28. c. When caring for a client with an ileostomy the nurse would: a. rice. a rise in bilirubin an alteration in proteins a rise in alanine aminotransaminase an elevation of alkaline phospatase 35. When teaching a client to care for a new colostomy. d. c. green beans. d. d. b. gastric lavage gastric suctioning balloon tamponade aminocaproic acid ( amicar) 27. b. paracentesis. c. d.noodles. mashed potatoes with gravy the liver in clients with hepatitis B is usually: a. c. The nurse explains that visualizations of the GI tract after a barium enema is made possible 31. c. The earliest indication of parenchymal damage to a. roast beef. d.A client with liver cancer complains of fatigue because a readily available from of energy although limited in amount. b. and the excess amount would saturate the general body tissues although the body’s requirement for the vitamin is very large. A client with ascites has been ordered 29.b. omelet.

43. Vit. d. d. When teaching a client with permanent colostomy. stimulant bulk-forming 45. The chief complaint in clients with Vincent’s angina is: a. Ileostomy c. Fractured mandible is usually immobilized with wires. d. c. d. The life threatening postoperative problem that can develop with this procedure is: a. the utilization of bile is interfered. gastrin secretin enterocrenin cholecystokinin 48 Before a cholecystectomy the physician order vitamin K. 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. Need for special clothing Importance of limiting activity Periodic dilation of the stoma Bland. 41. thromboplastin d. c. b. saline emollient c. K is required for the synthesis of: a. client’s resistance is lowered because of bile in the blood bloodstream is invaded by microorganisms from the bleary tract b. the nurse is expected to discuss the: a. b. the type of tube most likely to be used would be (a) (an) : a. If intubation is indicated in a client with bleeding varices. infection vomiting osteomyelitis bronchospasm a. low residue diet regimen 42. d. b. Before scheduling a client for endoscopic retrograde cholangiography (ERCP) the nurse should assess the client’s: a. b. d. cecostomy 37. The ejection of bile into the alimentary tract is controlled by the hormone: a. 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. Levin tube Salem pump Miller-abbot Blakemore-sengstaken tube 46. In clients with cholecystitis. Phospho-soda is cathartic. d. c. cholecystokinin . c. b. c.c. b. prothrombin c. colostomy b. c. classified as: a. clients with gastrectomy may develop pernicious anemia because: 38. d. urine output bilirubin level serum glucose blood pressure 44. 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. A subtotal gastrectomy is performed to treat a client with cancer of the stomach. d. b. This client develops dumping syndrome. c. b. chest pain shortness of breath shoulder discomfort bleeding oral ulceration 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. bilirubin b. d. d. Approximate the client’s usual daily time for elimination Be about halfway between the two large meals of the day a. b. 40. colectomy d. c.

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

c. c. c. The client arrives in the PACU in an unconscious state. The nurse's answer would correctly reflect what information? a. d. The nurse has completed preoperative teaching to a pregnant nursing diagnosis for this client would be: woman. After the drug has been administered. Which of the following activities is most appropriate? a. a. 66. The client loses consciousness and does not perceive b. balance. the spinal cord for epidural anesthesia. . The nurse explains drains: a. During the discussion. Self-care deficit. Determine client satisfaction with care received Assess client's emotional status Monitor asepsis in the environment Calculate fluid loss and its effects 65. A client is being discharged following outpatient surgery. Allow drainage of excessive serosanguinous fluid and Allow healing to occur at a very rapid rate. Immune deficiency Malignancy b. Knowledge deficit. d. d. Which statement by the client indicates understanding of regional anesthesia? a. d. A family member observes the drain and asks why the tube was left in the wound. b. The nurse is assessing: a. the nurse describes the different types of anesthesia available. the nurse checks the bedclothes underneath the client. b. b. 64. d. The nurse would instruct the caregiver to report which of the following findings to the surgeon? preoperatively. c. d. pain. c. b. 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. Perspiration. 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. Drainage from the tubes or drains. the anesthetic agent is injected into 69. The client is inside out. The client has been in the PACU unit for 1 hour. b.62 A pre-surgical client asks the nurse for more information about the advantages of a general anesthetic. c. c. A client is in the postoperative stage and the physician has ordered ambulation. Risk for injury. Kidney dysfunction Dehydration 71. 63 A benzodiazepine has been administered to a client The respiratory and circulatory functions are depressed. Have to be shortened to allow healing to occur from the Have to be connected to suction tubes. What would the nurse suspect regarding the significance of this increased value? a. The client is in the operating room for a surgical procedure. In spinal anesthesia. suffers from amnesia. c. the nurse needs to monitor the client for which of the following side effects? a. The nurse in the operating room is monitoring the 68. 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. Regional anesthesia produces analgesia and amnesia. d. d. event. b. 70. In what position is the unconscious client placed in the immediate postanesthetic stage? a. b. Hemorrhage. While assessing the client. Hypotension now groggy but able to respond to voice commands. purulent material. c. An appropriate physiological integrity of the client. d. 67. The client has shown a difficulty understanding the necessity for early ambulation. Anxiety Hypocalcemia d. Ineffective coping. b. Fluid hematocrit. The nurse is providing the caregiver with instructions for wound care. c. The anesthetic agent is injected into the dura mater of The client is sedated and has some awareness of the wound. The anesthetic agent is not rapidly excreted so that the General anesthesia reduces the chance that the client timing of surgery can be adjusted.

An 86-year-old client will be undergoing a surgical procedure. The nurse has been instructed to obtain informed consent from a client who will be undergoing a surgical procedure." "It lessens the chance for decreased tissue perfusion. Which of the following responses by a nurse to the client's concern is most therapeutic? a. b. c." "Have you had a bad experience in the OR?" "You're concerned about the personnel. Close the door and leave the room to provide privacy. "The nurses are well-qualified for the job they do. during the surgical intervention. to decrease the possibility of thrombophlebitis developing postoperatively. c. d. b. c. c. Ask the client to explain the behavior." tolerate the pain. What is the most essential information to include in the discussion prior to the client signing the permission? a. b." d. c. c. but you have no "Can you tell me about why you are interested in the a. 77." personnel?" 73. Be silent. When a client preparing for surgery suddenly bursts into tears. d. b. Which of the following statements about surgical skin preparation is the best response to the family member? a. The nurse is demonstrating surgical scrub to a group of student nurses.72. c. Which of the following statements should the nurse make to the client concerning conscious sedation? a." 75. d. Prior to need to worry. The nurse knows the procedure will be performed under conscious sedation." "It decreases the possibility for dermatitis. d. scrub. scrub." remember and comprehend what is happening. d. 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. The family member asks why the area around the surgical wound is orange. d. 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. 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. 79. Only betadine can meet the requirements of the surgical b. "It reduces the risk of all postoperative complications. b. c. A client questions the surgical nurse about the personnel in the operating room. a. Which of the following principles is true? admitting the client from the PACU (postanesthesia care unit) following a surgical procedure. c. Changes that the nurse makes in the informed consent process for this elderly client include which of the following? . Microorganisms do not breed on the hands during a Keep the palms up throughout the scrub. the nurse's most therapeutic initial approach is to do which of the following? a. Ask the client what is happening. the nurse assesses the surgical site for which of the following? a. d. scrub." "It reduces the risk of postoperative wound infection." The nurse is preparing a client for surgery. d. 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. 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. 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. "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. b. Keep the hands above the elbows during the surgical completing the skin preparation.

b. b. Risk for infection Constipation Ineffective breathing pattern Sleep pattern disturbance Using the WHO three-step analgesic ladder as a guideline for c. c. Which of the following concepts would be used by the nurse d.” . b. A client has suffered a severe contusion injury to the lower-left forearm. which is currently wrapped in several layers of elastic bandage and has an immobilizer device in place. b. The client will maintain a heart rate under 100 bpm. The nurse anticipates administering which of the following bolus doses of morphine for occurrence of breakthrough pain? a. 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. d. A regular time period should be established with the client for massage therapy. 86. The client on bedrest must be able to move or turn in order to receive massages. Massage for relaxation should be done with circular movements and kneading of the tissues. urge Incontinence. Reassess the client's pain. Give the medication as soon as possible. A client with cancer-induced pain using distraction as a coping mechanism may have the best outcome from which of the following activities? a. b. 82. Which of the following sites would be least helpful for application of heat to assist with pain management? a. Which response of the nurse is most likely to stimulate further discussion between the client and the nurse? 84. Which of the following nursing diagnoses is most likely to apply to this client's situation? a. 87. 85. pain management. Incontinence. b. c. The left hand area The upper-left arm The lower-right forearm The left axilla area expected for this individual? a. A client had an epidural catheter placed for a continuous infusion of opioids for pain management. d. the nurse would expect a client with moderate pain to receive which medication order? a. 24 mg c. Ask the physician why an additional analgesic is needed. 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. The nurse would anticipate using oral transmucosal fentanyl 91. c. d. The nurse is planning care for a client taking codeine 60 mg tablets every 6 hours for pain. 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 physician asks the nurse to give the client two acetaminophen with codeine (Tylenol #3) stat. b. 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. Which nursing diagnosis is the most common for clients receiving opioid medications? a. c. 40 mg d. Which client goal would be 90. c. Obtain a complete set of vital signs on the client. d. citrate (OTFC or Actiq) for which client situation? a. The client with a terminal illness who is considered at end-of-life 88. What is the appropriate action for the nurse to take next? a. A preoperative client expresses anxiety to a nurse about upcoming surgery. The client will report pain rating as a "1" on a 1 to 10 food daily. 12 mg b. b. scale between doses of the medication.” b. d. 30 mg d. reflex urinary Urinary elimination. c. you. d. The physician orders urine output to be measured and recorded every 4 hours. A client is receiving morphine 10 mg/hour as a continuous infusion. “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 . b. d.81. It is preferable for the client's family or significant other to provide the massage. c. The client will consume four extra servings of high-fiber The client will call for assistance when getting out of bed. altered Urinary retention 83. c.

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