Manila Adventist College: REFERENCE For Your Answers. Best If You Will Use Your Book Reference

Manila Adventist College
School of Nursing
Online Assignment
Name: Kheak,Kimlay
Instruction: Answer the following questions by CHANGING THE FONT COLOR TO RED and provide
REFERENCE for your answers. Best if you will use your book reference.
Example
Maslow’s hierarchy of need is useful to nurses who continually prioritize a client’s nursing care needs.
The most basic or first-level needs include;
A. Esteem and self-esteem needs C. Love and belonging
B. Self-actualization D. Air, water, and food
Reference: Maslow suggested that the first and most basic need people have is the need for survival:
their physiological requirements for food, water to drink, and a place to call home before they can think
about anything else.
-D Martin and K. Joomis, Building Teachers: A Constructivist Approach to Introducing Education,
(Belmont, CA: Wadsworth, 2007)pp.72-75
1. A client has been admitted with symptoms of urinary burning and urgency. Which of the
following diagnostic test can the nurse anticipate will be ordered to diagnose the possibility of
UTI?
a. Clean catch urine c. intravenous pyelography

b. Catheterized urine d. random urines specimen
Reference:
Clean-catch or midstream voided specimens are collected when a urine culture is ordered when a
urine culture is ordered to identify microorganisms causing urinary tract infection.
-Kozier & Erbs: (Fundamentals of Nursing Eight Edition Volume Two) Pp.811
2. A client is scheduled for bone marrow aspiration to assist with the diagnosis of multiple
myeloma. Prior to bone marrow aspiration, the most important communication from the nurse
to the client is which of the following?
a. The client must be still during the procedure.
b. This test will help diagnosed multiple myeloma.
c. You will feel sharp pain for a few minute.
d. You will receive a sedative, so you will be asleep
Reference:
The procedure usually takes 15-30 minutes. Explain when and where the procedure will occur, who
will occur, who will be present, and which site will be used.
3. The nurse should monitor the results of which of the following laboratory tests to determine the
status of the client with heparin therapy?
a. Platelet count
b. Lee-White coagulation time
c. Partial thromboplastin time(PTT)
d. Prothrombin time(PT)
Reference:
Partial thromboplastin time(PTT) or aPTT measures the activity of the intrinsic pathway and is used
to assess the effects of unfractionated heparin.
-Brunner and Suddarth’s : Textbook of Medical Surgical Nursing 12 th Edition Pp. 706
4. A medication order reads: “Digoxin, 0.125 mg PO qod”. The nurse correctly gives this drug;
a. Daily before bedtime
b. By mouth every other day
c. Twice a day by an oral route
d. Once a week after recording apical rate.
Reference:
p.o - orally
q.o.d. -every other day
5. You are to administer a medication to Mr. Reyes. In addition to checking his identification
bracelet, you can correctly verify his identity by:
a. Asking the patient name
b. Reading the patient’s name on the sign over his bed
c. Asking the patient’s roommate to verify his name
d. Asking, “are you Mr. Reyes?”
Reference:
This goal requires a nurse to use at least two client identifiers whenever administering
medications. Neither identifier can be the client’s room number. Acceptable identifiers may be the
person’s name, assigned identification number, telephone number, photograph, or other person-
specific identifier
-Kozier & Erbs: (Fundamentals of Nursing Eight Edition Volume Two) Pp.848-849
6. You are to administer a medication using nasogastric tube. Before giving the medication, you
should:
a. Crush the enteric coated pill for mixing in a liquid.
b. Flush open the tube with 60 ml of very warm water
c. Check for proper placement of the nasogastric tube
d. Check the patient’s vital sign
Reference:
If medications do not come in liquid form, check to see if they may be crushed. (Note that enteric-
coated, sustained action, buccal, and sublinggual medications should never be crushed.) Making
choices A an incorrect answer.
-Kozier & Erbs: (Fundamentals of Nursing Eight Edition Volume Two) Pp. 857 & Pp. 1268
7. The nurse manager on your unit prepared the medication to Mr. Cruz. She is called to the phone
and ask you to give his medications. Which is the best response to this request;
a. Give Mr. Cruz the medication and record it in his chart.
b. Tell the manager that you don’t have time and ask her to get someone else.
c. Tell that you did not pour the medication, you cannot administer it
d. Give the medication to Mr. Cruz, but have the manager chart it.
Reference:
Administer only medications personally prepared.
-Kozier & Erbs: (Fundamentals of Nursing Eight Edition Volume Two) Pp. 846
8. Why the intravenous method of medication is called the “most dangerous route of
administration”?
a. The vein can only take a small amount of fluid at a time.
b. The vein may harden and become non-functional
c. Blood clot may become a serious problem
d. The drug is placed directly into the blood stream, and it’ action is immediate.
Reference:
 Because intravenous (IV) medications enter the client’s blood-stream directly by the way of a vein,
they are appropriate when a rapid effect is required. This route is also appropriate when
medications are too irritating to tissues to be given by other routes.
9. Mr. Lopez is receiving heparin subcutaneously, which of the following demonstrate a correct
technique for this procedure?
a. Aspirate before giving and gently massage after the injection.
b. Do not aspirate, massage the site for 1 minute.
c. Do not aspirate before or massage after the injection
d. Massage the site of the injection, aspirate is not necessary, but will do no harm.
Reference:
Do not aspirate when giving heparin by subcutaneous injection. Aspiration can possibly damage the
surrounding tissue and cause bleeding as well as bruising.
10. Mrs. Aquino refuses to take her noon medication, saying that she did not need it. Which of the
following would be the best response?
a. Tell her that she must take the medication because the doctor orders it.
b. Tell her that you went through a lot of preparation to get her medication ready, and it is at
least she can do.
c. Tell her that you don’t care if she takes the medication or not
d. Tell that you will return the medication to the cart, but would like to discuss her reasons for
refusing to take medications.
Reference:
Right to refuse
Adult clients have the right to refuse any medication.
11. Nurse Liza discovers she has made a medication error. Which of the following would be the best
response?
a. Record the error on the medication sheet.
b. Notify the physician regarding course of action
c. Check the patient’s condition to note any possible effect of the error.
d. Complete the incident report, explaining how mistake was made.
Reference:
When a medication error is made, report it immediately to the nurse in charge, the primary care
provider, or both.
12. The nurse takes an 8 am medication to the patient and properly identifies her. The patient asks
the nurse to leave the medication on the bedside table and states that she will take it with
breakfast when it comes. What is best response to this request?
a. Leave the medication and return later to make sure it was taken.
b. Tell he it is against the rules, and take the medication with you
c. Tell her that you cannot leave the medication, but will return with it when breakfast arrives.
d. Take the drug from the room and record it as refuse.
Reference:
The nurse always identifies the client appropriately before administering a medication and stays with
the client until the medication is taken.
13. Mr. Guanzon requires surgery for treatment of a ruptured spleen as the result of an automobile
accident. This type of surgery belongs with which of the following categories?
a. Minor, diagnostic
b. Minor, elective
c. Major, emergency
d. Major, palliative
Reference:
Since the rupture of spleen the Emergency surgery is performed immediately to preserve function or the
life of the client. Surgeries to control internal hemorrhage or repair a fracture are examples of
emergency surgeries.
-Kozier & Erbs: (Fundamentals of Nursing Eight Edition Volume Two) Pp. 940-941
14. A general anesthetics is given for specific purposes during a surgical procedure. Which one of
the following purposes is not included?
a. Loss of consciousness c. reduction of reflex action
b. Relaxation of the skeletal muscles d. localized loss of sensation
Reference:
General anesthesia is the loss of all sensation and consciousness. Under general anesthesia,
protective reflexes such as cough and gag reflexes are lost. A general anesthesia acts by blocking
the awareness center of the brain so that amnesia (loss of memory),
15. You have been asked to witness a patient signature on an informed consent from the surgery.
You recognized that the document is valid for which of the following?
a. A 92 year old patient who is severely confused
b. A 45 year old patient who is oriented and alert
c. A 10 year old patient who is oriented and alert
d. A 36 year old patient who has had narcotic premedication
Reference:
There are three major elements of Informed consent:
1. The consent must be given voluntarily.
2. The consent must be given by a client or individual with the capacity and competence to understand.
3. The client or individual must be given enough information to be the ultimate decision maker.
-Kozier & Erbs: (Fundamentals of Nursing Eight Edition Volume One) Pp. 60
16. Mrs. Esteban is scheduled for surgery. Although she may be taking any number of medications
before surgery, which of the following categories of drugs would be most likely increase surgical
risks?
a. Anti-coagulant c. laxatives
b. Antacids d. sedatives
Reference:
Anticoagulants increase blood coagulation time.
17. Mr. Moreno has had a surgical procedure that necessitates a thoracic incision. You anticipate
that he will be a higher risk for preoperative complications involving which body system?
a. Respiratory system c. digestive system
b. Circulatory system d. nervous system
Reference:
Elders are at greater risk for postoperative complications, such as pneumonia.
18. Mrs. Angeles tells you that he is having pain in her right lower leg. You assess the presence of
thromphlebitis by;
a. Palpating the skin over the tibia and fibula
b. Measuring and documenting calf circumference daily
c. Taking and recording vital signs four time a day
d. Noting difficulty in ambulation
Reference:
The circumferences of the thighs and calves are measured and recorded daily; further diagnostic studies
are performed if a significant increase is noted. Patients remain at high risk for thrombophlebitis for
several months after the initial injury.
-Brunner and Suddarth’s : Textbook of Medical Surgical Nursing 12 th Edition Pp. 1940
19. Gas pains are common postoperative discomfort. Which of the following nursing actions
implemented in the plan of care would be most likely to relieve gas pain?
a. Coughing and deep breathing every 2 hours.
b. Maintain NPO status for 48 hours
c. Encourage frequent ambulation
d. Take vital signs every 4 hours.
Reference:
Deep breathing exercise help remove mucus, which can form and remain in the lungs due to the effects
of general anesthetic and analgesics. These drugs depress the action of both the cilia of the mucous
membranes lining the respiratory tract and the respiratory center in the brain.
-Kozier & Erbs: (Fundamentals of Nursing Eight Edition Volume Two) Pp. 962-963
20. Which of the following surgical patient is at greater risk for alterations in body image?
a. Female, age 19 years old, large facial alteration
b. Female, age 42 year old, gall bladder surgery
c. Male, 14 years old, fracture clavicle
d. Male, 52 year old, hernia repair
Reference:
If surgery to the face interferes with eating or talking , then this may further reinforce feelings of
unattractiveness and helplessness.
-Rosemary Pudner: Nursing the Surgical Patient 2nd Edition Pp. 87
21. The rationale for the use of leg exercises after surgery, is that exercises:
a. Promote respiratory function
b. Maintain functional stability
c. Provide diversional activities
d. Increase venous return
Reference:
preventing thrombophlebitis and thrombus formation.
22. Which intervention would be appropriate to include in the plan of care for a patient wearing
anti embolism stockings?
a. Measuring the legs before applying stockings to ensure proper fit.
b. Apply stockings while patient is sitting in a chair
c. Massage the legs while the stocking are removed
d. Leaving stocking in place for 1 week interval
Reference:
Stockings that are too large for the client do not place adequate pressure on the legs to facilitate
venous return, and may bunch,
23. During the bath, the nurse observes that the patient has dry skin. Which action would be best?
a. Bathe the client more frequently
b. Use an emollient on the dry skin
c. Massage the skin with alcohol
d. Encourage fluid intake
Reference:
Dry is best treated with moisturizing lotions applied while the skin is moist after bathing.
24. Which recommendation by the nurse to an adolescent patient with acne would be most
appropriate?
a. Wash the skin frequently with soap
b. Use cosmetics liberally to cover black heads
c. Use emollient on the area
d. Squeeze blackheads as they appear
Reference:
Wash the face frequently with soap or detergent and hot water to remove oil and dirt.
25. Which action would be the priority when administering using an oral care to a dependent
patient?
a. Assisting the patient to the dorsal recumbent position
b. Wearing disposable gloves
c. Using a firm toothbrush to cleanse the teeth and gums
d. Irrigating forcefully with hydrogen peroxide
Reference:
When providing mouth care for partially or totally dependent clients, the nurse should wear gloves to
guard against infections.
Part II- Case study
This is the case of a 19 year old male, with three weeks history of constipation associated with
abdominal pain and progressive abdominal distention. He had delayed passage of meconium at birth
and was managed successfully with soap and water enema. Developmental milestones had been normal
but he was much smaller than his other siblings – none of which has similar complaints. His chest and
vital signs were normal, but he had asymmetrically distended abdomen with visible peristalsis.
DIAGNOSIS: HIRSCHSPRUNG’S DISEASE
ACTIVITY:
1. Review the anatomy and physiology of gastrointestinal system
2. Based on the signs and symptoms presented, make a simple pathophysiology
3. Discuss the surgical/medical interventions can be done for this case
4. Formulate 2 nursing care plan based on the signs and symptoms presented
God bless
1. anatomy and physiology of gastrointestinal system:
The human gastrointestinal tract refers to the stomach and intestine, and sometimes to all the
structures from the mouth to the anus.
Upper Gastrointestinal Tract
The upper gastrointestinal tract consists of the esophagus, stomach, and duodenum. The exact
demarcation between upper and lower can vary. Upon gross dissection, the duodenum may appear to
be a unified organ, but it is often divided into two parts based upon function, arterial supply, or
embryology.
The upper gastrointestinal tract includes the:
 Esophagus, the fibromuscular tube that food passes through—aided by peristaltic contractions
—the pharynx to the stomach.
 Stomach, which secretes protein -digesting enzymes called proteases and strong acids to aid in
food digestion, before sending the partially digested food to the small intestines.
 Duodenum, the first section of the small intestine that may be the principal site for iron
absorption.
Lower Gastrointestinal Tract
The lower gastrointestinal tract includes most of the small intestine and all of the large intestine.
According to some sources, it also includes the anus.
The small intestine has three parts:
 Duodenum: Here the digestive juices from the pancreas ( digestive enzymes ) and the
gallbladder ( bile ) mix together. The digestive enzymes break down proteins and bile and
emulsify fats into micelles. The duodenum contains Brunner’s glands that produce bicarbonate,
and pancreatic juice that contains bicarbonate to neutralize hydrochloric acid in the stomach.
 Jejunum: This is the midsection of the intestine, connecting the duodenum to the ileum. It
contains the plicae circulares and villi to increase the surface area of that part of the GI tract.
 Ileum: This has villi, where all soluble molecules are absorbed into the blood ( through the
capillaries and lacteals).
The large intestine has four parts:
a. Cecum, the vermiform appendix that is attached to the cecum.
b. Colon, which includes the ascending colon, transverse colon, descending colon, and sigmoid
flexure. The main function of the colon is to absorb water, but it also contains bacteria that
produce beneficial vitamins like vitamin K.
c. Rectum.
d. Anus.
2. Pathophysiology:
New born and Diet, activity, race

adult
Male>female
Absence of ganglion
3. Medical and surgical management:
 Decompression. Decompression can be accomplished through placement of a nasogastric

tube and either digital rectal examination or normal saline rectal irrigations 3-4 times daily.
 Diet. A special diet is not required; however, preoperatively and in the early postoperative
period, infants on a nonconstipated regimen, such as breast milk, are more easily managed.
Pharmacologic Management
Drug therapy currently is not a component of the standard of care for this disease itself; however, some
medications may be used to treat complications of Hirschsprung disease.
 Antibiotics. Administer broad-spectrum antibiotics to patients with enterocolitis.
Ostomy surgery
In children who are very ill, surgery might be done in two steps.
First, the abnormal portion of the colon is removed and the top, healthy portion of the colon is
connected to an opening the surgeon creates in the child's abdomen. Stool then leaves the body
through the opening into a bag that attaches to the end of the intestine that protrudes through the hole
in the abdomen (stoma). This allows time for the lower part of the colon to heal.
Once the colon has had time to heal, a second procedure is done to close the stoma and connect the
healthy portion of the intestine to the rectum or anus.
4. nursing care plan
proble Diagno Planning Intervention Rational Evaluation

m sis
Consti Consti After 8 hours Determine stool color, con Assists in identifying c After 8 hours

pation pation of nursing inter sistency, frequency, ausative of nursing interv
related ventions, the and amount. or contributing factors entions, the
to patient and appropriate interve patient was able
change will demonstrat ntion. to demonstrate c
in e changes hanges
digesti in behavior in behavior
ve as necessitated as necessitated
proces by causative Auscultate bowel sounds. Bowel sounds are by causative
s
and contributin generally increased and contributing
g factors in constipation. factors
Monitor intake and output May identify dehydrati

(I&O) with on, excessive loss of
specific attention to fluids or aid in
food or fluid intake. identifying dietary defici
encies.

Recommend avoiding Decreases gastric
gas forming foods. distress and
abdominal distension.

After 8 hrs of
Assess perianal skin intervention
condition frequently, Prevents skin excoriatio patient was be
able to
noting changes n and breakdown.
relieved from
or beginning breakdown. E
pain
ncourage or assist
with perineal care after
each bowel movement.
Discuss use of stool Facilitates defecation
softeners, mild when constipated is
stimulants, enemas
Acute
pain rt
Abdom to
intesti After 8 hrs of
inal
nal intervention Observe and document
pain
obstuc the patient location of the pain, Provide information
tion will be Pain scale(0-10) and about disease
relieved from character of pain progression
pain development of
complications
Promote bed rest To reduce intra

abdominal pressure
To minimize dermal
Control environmental
discomfort
temperature
Encourage use of To promote rest

relaxation technique redirects attention
To reduce severs
Administer medication
pain
as indicated

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a. Clean catch urine c. intravenous pyelography

Administer only medications personally prepared.

Adult clients have the right to refuse any medication.

-Rosemary Pudner: Nursing the Surgical Patient 2nd Edition Pp. 87

DIAGNOSIS: HIRSCHSPRUNG’S DISEASE

1. anatomy and physiology of gastrointestinal system:

Upper Gastrointestinal Tract

The upper gastrointestinal tract includes the:

Lower Gastrointestinal Tract

New born and Diet, activity, race

 Decompression. Decompression can be accomplished through placement of a nasogastric

4. nursing care plan

proble Diagno Planning Intervention Rational Evaluation

Consti Consti After 8 hours Determine stool color, con Assists in identifying c After 8 hours

Monitor intake and output May identify dehydrati

Promote bed rest To reduce intra

Encourage use of To promote rest

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