Med- Surg Quiz 1

Answer and Rationale

1. Answer: (C) “With a pillow, apply pressure against the incision.”

Applying pressure against the incision with a pillow will help lessen the intra-abdominal
pressure created by coughing which causes tension on the incision that leads to pain.

2. Answer: (C) experience reduced sensory perception

Degenerative changes occur in the elderly. The response to pain in the elderly maybe
lessened because of reduced acuity of touch, alterations in neural pathways and
diminished processing of sensory data.

3. Answer: (C) This is normal side-effect of AtSO4

Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and
increases the heart rate.

4. Answer: (D) Administer Demerol 50mg IM q4h

Administering Demerol, which is a narcotic analgesic, can depress respiratory and
cardiac function and thus not given to a patient in shock. What is needed is promotion
for adequate oxygenation and perfusion. All the other interventions can be expected to
be done by the nurse.

5. Answer: (D) "Mr. Pablo, you appear anxious to me. How are you feeling about
tomorrow's surgery?"
The client is showing signs of anxiety reaction to a stressful event. Recognizing the
client’s anxiety conveys acceptance of his behavior and will allow for verbalization of
feelings and concerns.

6. Answer: (C) Check the patency of the nasogastric tube for any obstruction.
Nausea is one of the common complaints of a patient after receiving general anesthesia.
But this complaint could be aggravated by gastric distention especially in a patient who
has undergone abdominal surgery. Insertion of the NGT helps relieve the problem.
Checking on the patency of the NGT for any obstruction will help the nurse determine
the cause of the problem and institute the necessary intervention.

7. Answer: (C) Handle him gently when assisting with required care
Patients with cancer and bone metastasis experience severe pain especially when
moving. Bone tumors weaken the bone to appoint at which normal activities and even
position changes can lead to fracture. During nursing care, the patient needs to be
supported and handled gently.
 8. Answer: (B) Take his vital signs again in 15 minutes.
Monitoring the client’s vital signs following surgery gives the nurse a sound information
about the client’s condition. Complications can occur during this period as a result of the
surgery or the anesthesia or both. Keeping close track of changes in the VS and
validating them will help the nurse initiate interventions to prevent complications from
occurring.

9. Answer: (C) Bleeding from ears

The nurse needs to perform a thorough assessment that could indicate alterations in
cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding
from the ears occurs only with basal skull fractures that can easily contribute to
increased intracranial pressure and brain herniation.

10. Answer: (D) “I smoke 1 1/2 packs of cigarettes per day.”

Smoking has been considered as one of the major modifiable risk factors for coronary
artery disease. Exercise and maintaining normal serum cholesterol levels help in its
prevention.

11. Answer: (B) The positive inotropic effect will decrease urine output
Inotropic effect of drugs on the heart causes increase force of its contraction. This
increases cardiac output that improves renal perfusion resulting in an improved urine
output.

12. Answer: (A) Use of stool softeners.

Straining or bearing down activities can cause vagal stimulation that leads to
bradycardia. Use of stool softeners promote easy bowel evacuation that prevents
straining or the valsalva maneuver.

13. Answer: (D) may engage in contact sports

The client should be advised by the nurse to avoid contact sports. This will prevent
trauma to the area of the pacemaker generator.

14. Answer: (D) “Place one Nitroglycerine tablet under the tongue every five minutes
for three doses. Go to the hospital if the pain is unrelieved.
Angina pectoris is caused by myocardial ischemia related to decreased coronary blood
supply. Giving nitroglycerine will produce coronary vasodilation that improves the
coronary blood flow in 3 – 5 mins. If the chest pain is unrelieved, after three tablets,
there is a possibility of acute coronary occlusion that requires immediate medical
attention. Angina pectoris – is a medical term for chest pain or discomfort due to
coronary heart disease. It occurs when the heart muscle doesn’t get as much blood as it
needs. This usually happens because one or more of the heart’s arteries is narrowed or
blocked, also called Ischemia.
 15. Answer: (B) Canned sardines
Canned foods are generally rich in sodium content as salt is used as the main
preservative.
16. Answer: (C) Instruct the client about the need for bed rest.
In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the
extremity which can lead to pulmonary embolism.

17. Answer: (B) It prevents conversion of factors that are needed in the formation of
clots.
Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It
does not dissolve a clot.

18. Answer: (D) Cough or change in a chronic cough

Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium.
The irritation causes the cough which initially maybe dry, persistent and unproductive.
As the tumor enlarges, obstruction of the airways occurs and the cough may become
productive due to infection.

19. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for
breathing.
COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2
stimulation for breathing. The hypoxic state of the client then becomes the stimulus for
breathing. Giving the client oxygen in low concentrations will maintain the client’s
hypoxic drive.

20. Answer: (C) Suction until the client indicates to stop or no longer than 20 second
One hazard encountered when suctioning a client is the development of hypoxia.
Suctioning sucks not only the secretions but also the gases found in the airways. This
can be prevented by suctioning the client for an average time of 5-10 seconds and not
more than 15 seconds and hyperoxygenating the client before and after suctioning.

21. Answer: (D) Delay resistance and increase the tuberculostatic effect
Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. A
prolonged treatment duration is necessary to ensure eradication of the organisms and to
prevent relapse. The increasing prevalence of drug resistance points to the need to begin
the treatment with drugs in combination. Using drugs in combination can delay the
drug resistance.

22. Answer: (B) Facilitate ventilation of the left lung.

Since only a partial pneumonectomy is done, there is a need to promote expansion of
this remaining Left lung by positioning the client on the opposite unoperated side.

23. Answer: (D) Slowly breath out through the mouth with pursed lips after inhaling
the drug.
If the client breathes out through the mouth with pursed lips, this can easily force the
just inhaled drug out of the respiratory tract that will lessen its effectiveness.

24. Answer: (A) Food and fluids will be withheld for at least 2 hours.
Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to
minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the
client food and drink after the procedure without checking on the return of the gag
reflex can cause the client to aspirate. The gag reflex usually returns after two hours.

25. Answer: (C) Lower the oxygen rate.

The client with COPD is suffering from chronic CO2 retention. The hypoxic drive is his
chief stimulus for breathing. Giving O2 inhalation at a rate that is more than 2-3L/min
can make the client lose his hypoxic drive which can be assessed as decreasing RR.
26. Answer: (C) Impaired gas exchange.
Pneumonia, which is an infection, causes lobar consolidation thus impairing gas
exchange between the alveoli and the blood. Because the patient would require adequate
hydration, this makes him prone to fluid volume excess.

27. Answer: (D) posterior neck fat pad and thin extremities
“Buffalo hump” is the accumulation of fat pads over the upper back and neck. Fat may
also accumulate on the face. There is truncal obesity but the extremities are thin. All
these are noted in a client with Cushing’s syndrome.

28. Answer: (B) “I must take this medicine exactly as my doctor ordered it. I
shouldn’t skip doses.”
The possible side effects of steroid administration are hypokalemia, increase tendency to
infection and poor wound healing. Clients on the drug must follow strictly the doctor’s
order since skipping the drug can lower the drug level in the blood that can trigger acute
adrenal insufficiency or Addisonian Crisis.

29. Answer: (C) Blood pressure

Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion
of catecholamines that can elevate the blood pressure.

30. Answer: (D) Give the guest a glass of orange juice

In diabetic patients, the nurse should watch out for signs of hypoglycemia manifested by
dizziness, tremors, weakness, pallor diaphoresis and tachycardia. When this occurs in a
conscious client, he should be given immediately carbohydrates in the form of fruit
juice, hard candy, honey or, if unconscious, glucagons or dextrose per IV.
Glucagon – hormone formed in the pancreas which promotes the breakdown of
glycogen in the liver.

31. Answer: (C) “The medication will block the cardiovascular symptoms of Grave’s
disease.”
Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular
manifestations brought about by increased secretion of the thyroid hormone in Grave’s
disease.

32. Answer: (A) Checking the back and sides of the operative dressing
Following surgery of the thyroid gland, bleeding is a potential complication. This can
best be assessed by checking the back and the sides of the operative dressing as the
blood may flow towards the side and back leaving the front dry and clear of drainage.

33. Answer: (C) Progressive weight gain

Hypothyroidism, a decrease in thyroid hormone production, is characterized by
hypometabolism that manifests itself with weight gain.

34. Answer: (C) Lipodystrophic areas can result, causing erratic insulin absorption
rates from these
Lipodystrophy is the development of fibrofatty masses at the injection site caused by
repeated use of an injection site. Injecting insulin into these scarred areas can cause the
insulin to be poorly absorbed and lead to erratic reactions.

35. Answer: (C) Keep legs elevated on 2 pillows while sleeping

The client with DM has decreased peripheral circulation caused by microangiopathy.
Keeping the legs elevated during sleep will further cause circulatory impairment.

36. Answer: (B) Assess gag reflex prior to administration of fluids

The client, after gastroscopy, has temporary impairment of the gag reflex due to the
anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and
food at this time can lead to aspiration.

36.Answer: (B) Assess gag reflex prior to administration of fluids

The client, after gastroscopy, has temporary impairment of the gag reflex due to the
anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and
food at this time can lead to aspiration.

37. Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric area that is
relieved by food intake
Duodenal ulcer is related to an increase in the secretion of HCl. This can be buffered by
food intake thus the relief of the pain that is brought about by food intake.
38. Answer: (B) Notify the MD of your findings
The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is
thick are signs of possible abdominal distention caused by obstruction of the NGT. This
should be reported immediately to the MD to prevent tension and rupture on the site of
anastomosis caused by gastric distention.

39. Answer: (A) Sit upright for at least 30 minutes after meals
The dumping syndrome occurs within 30 mins after a meal due to rapid gastric
emptying, causing distention of the duodenum or jejunum produced by a bolus of food.
To delay the emptying, the client has to lie down after meals. Sitting up after meals will
promote the dumping syndrome.

40. Answer: (A) Treatment will include Ranitidine and Antibiotics

One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the
gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid
digestion. Giving antibiotics will control the infection and Ranitidine, which is a
histamine-2 blocker, will reduce acid secretion that can lead to ulcer.

41. Answer: (B) Empty bladder before procedure

Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a
puncture made below the umbilicus. The client needs to void before the procedure to
prevent accidental puncture of a distended bladder during the procedure.

42. Answer: (A) “The liver cannot rid the body of ammonia that is made by the
breakdown of protein in the digestive system.”
The largest source of ammonia is the enzymatic and bacterial digestion of dietary and
blood proteins in the GI tract. A protein-restricted diet will therefore decrease ammonia
production.

43. Answer: (C) Meperidine

Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as
well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice
because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which
is spasmogenic.

44. Answer: (B) encouraging the client to cough and deep breathe
Cholecystectomy requires a subcostal incision. To minimize pain, clients have a
tendency to take shallow breaths which can lead to respiratory complications like
pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent
such complications.

45. Answer: (A) Deflate the esophageal balloon

When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it
means the tube is displaced and the inflated balloon is in the oropharynx causing airway
obstruction

46. Answer: (B) Ulcerative colitis

Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration
affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as
10-20 times a day that is filled with blood, pus and mucus. The other symptoms
mentioned accompany the problem.

47. Answer: (A) Give laxative the night before and a cleansing enema in the morning
before the test
Barium enema is the radiologic visualization of the colon using a die. To obtain accurate
results in this procedure, the bowels must be emptied of fecal material thus the need for
laxative and enema.
 48. Answer: (D) “I will include more fresh fruits and vegetables in my diet.”
Numerous aspects of diet and nutrition may contribute to the development of cancer. A
low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the
diet, slows transport of materials through the gut which has been linked to colorectal
cancer.

49. Answer: (A) Cover the wound with sterile, moist saline dressing
Dehiscence is the partial or complete separation of the surgical wound edges. When this
occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The
wound should be covered to protect it from exposure and the dressing must be sterile to
protect it from infection and moist to prevent the dressing from sticking to the wound
which can disturb the healing process.

50. Answer: (B) Ambulate.

Free unattached stones in the urinary tract can be passed out with the urine by
ambulation which can mobilize the stone and by increased fluid intake which will flush
out the stone during urination.

51. Answer: (A) Hyponatremia

The normal serum sodium level is 135 – 145 mEq/L. The client’s serum sodium is below
normal. Hyponatremia also manifests itself with abdominal cramps and nausea and
vomiting.

52. Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
Chronic renal failure is usually the end result of gradual tissue destruction and loss of
renal function. With the loss of renal function, the kidneys ability to regulate fluid and
electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to
excrete phosphate, potassium and hydrogen ions are retained.

53. Answer: (B) Avoid taking blood pressure measurements or blood samples from
the affected arm.
In the client with an external shunt, don’t use the arm with the vascular access site to
take blood pressure readings, draw blood, insert IV lines, or give injections because
these procedures may rupture the shunt or occlude blood flow causing damage and
obstructions in the shunt.

54. Answer: (D) He will be pain free.

Surgical interventions involve an experience of pain for the client which can come in
varying degrees. Telling the pain that he will be pain free is giving him false reassurance.

55. Answer: (C) right lower quadrant

To be exact, the appendix is anatomically located at the Mc Burney’s point at the right
iliac area of the right lower quadrant.
56. Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks
The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks
after surgery to prevent stress on the inguinal area. There is no special diet required.
The fluid intake of eight glasses a day is good advice but is not a priority in this case.
 57. Answer: (C) 31%
Using the Rule of Nine in the estimation of total body surface burned, we allot the
following: 9% - head; 9% - each upper extremity; 18%- front chest and abdomen; 18% -
entire back; 18% - each lower extremity and 1% - perineum.

58. Answer: (D) Fluid shift from intravascular space to the interstitial space
This period is the burn shock stage or the hypovolemic phase. Tissue injury causes
vasodilation that results in increase capillary permeability making fluids shift from the
intravascular to the interstitial space. This can lead to a decrease in circulating blood
volume or hypovolemia which decreases renal perfusion and urine output.
59. Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea
Burns located in the upper torso, especially resulting from thermal injury related to fires
can lead to inhalation burns. This causes swelling of the respiratory mucosa and
blistering which can lead to airway obstruction manifested by hoarseness, noisy and
difficult breathing. Maintaining a patent airway is a primary concern.

60. Answer: (D) Helping the client to rest in the position of maximal comfort
Mobility and placing the burned areas in their functional position can help prevent
contracture deformities related to burns. Pain can immobilize a client as he seeks the
position where he finds less pain and provides maximal comfort. But this approach can
lead to contracture deformities and other complications.
61. Answer: (D) fluid and electrolyte monitoring
Total parenteral nutrition is a method of providing nutrients to the body by an IV route.
The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace
minerals and sterile water based on individual client needs. It is intended to improve the
clients nutritional status. Because of its composition, it is important to monitor the
clients fluid intake and output including electrolytes, blood glucose and weight.
62. Answer: (D) Aluminum hydroxide
Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat
hyperphosphatemia. All the other medications mentioned help treat hyperkalemia and
its effects.

63. Answer: (A) 0.45% NaCl

Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and
D5W are isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic
with a higher tonicity than the blood.

64. Answer: (A) hypertension

In hypovolemia, one of the compensatory mechanisms is activation of the sympathetic
nervous system that increases the RR & PR and helps restore the BP to maintain tissue
perfusion but not cause a hypertension. The SNS stimulation constricts renal arterioles
that increases release of aldosterone, decreases glomerular filtration and increases
sodium & water reabsorption that leads to oliguria.
 65. Answer: (B) assessing Maria's expectations and doubts
Assessing the client’s expectations and doubts will help lessen her fears and anxieties.
The nurse needs to encourage the client to verbalize and to listen and correctly provide
explanations when needed.

66. Answer: (B) recognize that Kathy is experiencing denial, a normal stage of the
grieving process
A person grieves to a loss of a significant object. The initial stage in the grieving process
is denial, then anger, followed by bargaining, depression and last acceptance. The nurse
should show acceptance of the patient’s feelings and encourage verbalization.

67. Answer: (B) it affects both normal and tumor cells

Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But
these agents cannot differentiate the abnormal actively proliferating cancer cells from
those that are actively proliferating normal cells like the cells of the bone marrow, thus
the effect of bone marrow depression.

68. Answer: (C) CT scanning uses magnetic fields and radio frequencies to provide
cross-sectional view of tumor
CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic
fields and radio frequencies to detect tumors.

69. Answer: (D) frequently elevating the arm of the affected side above the level of
the heart.
Elevating the arm above the level of the heart promotes good venous return to the heart
and good lymphatic drainage thus preventing swelling.

70. Answer: (B) “My 7 year old twins should not come to visit me while I’m receiving
treatment.”
Children have cells that are normally actively dividing in the process of growth.
Radiation acts not only against the abnormally actively dividing cells of cancer but also
on the normally dividing cells thus affecting the growth and development of the child
and even causing cancer itself.

71. Answer: (B) Rapid cell catabolism

One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid
destruction of large number of tumor cells. . Intracellular contents are released,
including potassium and purines, into the bloodstream faster than the body can
eliminate them. The purines are converted in the liver to uric acid and released into the
blood causing hyperuricemia. They can precipitate in the kidneys and block the tubules
causing acute renal failure.

72. Answer: (C) Low residue diet

It is important for the nurse to remember that the implant be kept intact in the cervix
during therapy. Mobility and vaginal irrigations are not done. A low residue diet will
prevent bowel movement that could lead to dislodgement of the implant. Patient is also
strictly isolated to protect other people from the radiation emissions.

73. Answer: (A) Avoid BP measurement and constricting clothing on the affected arm
A BP cuff constricts the blood vessels where it is applied. BP measurements should be
done on the unaffected arm to ensure adequate circulation and venous and lymph
drainage in the affected arm.

74. Answer: (C) Hypovolemia, wide fluctuations in serum sodium and potassium
levels.
The second phase of ARF is the diuretic phase or high output phase. The diuresis can
result in an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur.

75. Answer: (A) A rapid pulse and increased RR

The fight or flight reaction of the sympathetic nervous system occurs during stress like
in a motor vehicular accident. This is manifested by increased in cardiovascular function
and RR to provide the immediate needs of the body for survival.

76. Answer: (D) assessing her VS especially her RR

Shock is characterized by reduced tissue and organ perfusion and eventual organ
dysfunction and failure. Checking on the VS especially the RR, which detects need for
oxygenation, is a priority to help detect its progress and provide for prompt
management before the occurrence of complications.

77. Answer: (B) Urine output of 30 to 50 ml/hr.

Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue
perfusion to the different organs of the body. Measuring the hourly urine output is the
most quantifiable way of measuring tissue perfusion to the organs. Normal renal
perfusion should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is considered
adequate and indicates good fluid balance.
78. Answer: (D) Pericardial tamponade
Pericardial tamponade occurs when there is presence of fluid accumulation in the
pericardial space that compresses on the ventricles causing a decrease in ventricular
filling and stretching during diastole with a decrease in cardiac output. . This leads to
right atrial and venous congestion manifested by a CVP reading above normal.

79. Answer: (A) administering an irritant that will stimulate vomiting

Swallowing of corrosive substances causes severe irritation and tissue destruction of the
mucous membrane of the GI tract. Measures are taken to immediately remove the toxin
or reduce its absorption. For corrosive poison ingestion, such as in muriatic acid where
burn or perforation of the mucosa may occur, gastric emptying procedure is
immediately instituted, This includes gastric lavage and the administration of activated
charcoal to absorb the poison. Administering an irritant with the concomitant vomiting
to remove the swallowed poison will further cause irritation and damage to the mucosal
lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is
swallowed.

80.Answer: (C) Palpable carotid pulse

Presence of a palpable carotid pulse indicates the return of cardiac function which,
together with the return of breathing, is the primary goal of CPR. Pulsations in arteries
indicates blood flowing in the blood vessels with each cardiac contraction. Signs of
effective tissue perfusion will be noted after.

81. Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or preferably
sterile water
Prompt treatment of ocular chemical burns is important to prevent further damage.
Immediate tap-water eye irrigation should be started on site even before transporting
the patient to the nearest hospital facility. In the hospital, copious irrigation with
normal saline, instillation of local anesthetic and antibiotic is done.

82. Answer: (A) Force air out of the lungs

The Heimlich maneuver is used to assist a person choking on a foreign object. The
pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an
artificial cough that expels the aspirated material.

83. Answer: (B) speak to both parents together and encourage them to support each
other and express their emotions freely
Sudden death of a family member creates a state of shock on the family. They go into a
stage of denial and anger in their grieving. Assisting them with information they need to
know, answering their questions and listening to them will provide the needed support
for them to move on and be of support to one another.

84. Answer: (C) relax the bronchial smooth muscle

Acute asthmatic attack is characterized by severe bronchospasm which can be relieved
by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an
adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth
muscles.

85. Answer: (C) lower half of the sternum

The exact and safe location to do cardiac compression is the lower half of the sternum.
Doing it at the lower third of the sternum may cause gastric compression which can lead
to a possible aspiration.

86. Answer: (B) “As one ages, visual changes are noted as part of degenerative
changes. This is normal.”
Aging causes less elasticity of the lens affecting accommodation leading to blurred
vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less
completely so that it takes the older person to adjust when going to and from light and
dark environment and needs brighter light for close vision.

87. Answer: (D) sexual intercourse

To reduce increases in IOP, teach the client and family about activity restrictions. Sexual
intercourse can cause a sudden rise in IOP.
 88.Answer: (C) Speak clearly in a loud voice or shout to be heard
Shouting raises the frequency of the sound and often makes understanding the spoken
words difficult. It is enough for the nurse to speak clearly and slowly.

89. Answer: (D) Force fluids before and after the procedure.
LP involves the removal of some amount of spinal fluid. To facilitate CSF production,
the client is instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48
hrs after the procedure.
90. Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding.
Angiography involves the threading of a catheter through an artery which can cause
trauma to the endothelial lining of the blood vessel. The platelets are attracted to the
area causing thrombi formation. This is further enhanced by the slowing of blood flow
caused by flexion of the affected extremity. The affected extremity must be kept straight
and immobilized during the duration of the bedrest after the procedure. Ice bag can be
applied intermittently to the puncture site.

91. Answer: (D) progression from restlessness to confusion and disorientation to

lethargy
The first major effect of increasing ICP is a decrease in cerebral perfusion causing
hypoxia that produces a progressive alteration in the LOC. This is initially manifested by
restlessness.
92. Answer: (D) Aspirin is used in the acute management of a completed stroke.
The primary goal in the management of CVA is to improve cerebral tissue perfusion.
Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke
but is not used in the acute management of a completed stroke as it may lead to
bleeding.

93. Answer: (D) Encourage the client to speak at every possible opportunity.
Expressive or motor aphasia is a result of damage in the Broca’s area of the frontal lobe.
It is amotor speech problem in which the client generally understands what is said but is
unable to communicate verbally. The patient can best he helped therefore by
encouraging him to communicate and reinforce this behavior positively.

94. Answer: (C) altered cerebral tissue perfusion

The observations made by the nurse clearly indicate a problem of decrease cerebral
perfusion. Restoring cerebral perfusion is most important to maintain cerebral
functioning and prevent further brain damage.

95. Answer: (D) Ineffective airway clearance related to muscle weakness

Myasthenia gravis causes a failure in the transmission of nerve impulses at the
neuromuscular junction which may be due to a weakening or decrease in acetylcholine
receptor sites. This leads to sporadic, progressive weakness or abnormal fatigability of
striated muscles that eventually causes loss of function. The respiratory muscles can
become weak with decreased tidal volume and vital capacity making breathing and
clearing the airway through coughing difficult. The respiratory muscle weakness may be
severe enough to require and emergency airway and mechanical ventilation.
 96. Answer: (C) Test for glucose
The CSF contains a large amount of glucose which can be detected by using glucostix. A
positive result with the drainage indicate CSF leakage.

97. Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal
end of the affected limb.
The “shrinker” bandage is applied to prevent swelling of the stump. It should be applied
with the distal end with the tighter arms. Applying the tighter arms at the proximal end
will impair circulation and cause swelling by reducing venous flow.

98. Answer: (D) Place items so that it is necessary to bend or stretch to reach them.
Patients with osteoarthritis have decreased mobility caused by joint pain. Over-reaching
and stretching to get an object are to be avoided as this can cause more pain and can
even lead to falls. The nurse should see to it therefore that objects are within easy reach
of the patient.

99. Answer: (D) Ensure an intake of at least 3000 ml of fluid per day.
Gouty arthritis is a metabolic disease marked by urate deposits that cause painful
arthritic joints. The patient should be urged to increase his fluid intake to prevent the
development of urinary uric acid stones.

100.Answer: (B) Before log rolling, remove the pillow from under the client's head and
use no pillows between the client's legs.
Following a laminectomy and spinal fusion, it is important that the back of the patient
be maintained in straight alignment and to support the entire vertebral column to
promote complete healing.