CMPA411 TASK: (Medical-Surgical Nursing)

RATIONALIZATION
SUBMITTED BY: KYLE V. SABAY

Read and understand each item. Note that the answers are already given. Research on the
rationale for EACH of the choices to justify the reason for being an incorrect option and
reason for being the correct answer. Ensure to cite your source(s) and page(s). Upload in
the corresponding Course Task Submission in Canvas.

1. The nurse is taking care of an elderly male client who has shortness of breath, cough
and fluid in his pleural space. The physician asks the nurse to assist in the performance
of a therapeutic and diagnostic thoracentesis. Which of the following nursing
interventions should the nurse perform to assist this client?
A. Make certain the consents are signed, witnessed and filed in the chart.
B. Offer oral fluids, because the client will not be able to take a drink during the
procedure.
C. Help the client to lie flat with a pillow under his feet for comfort during the procedure.
D. Help the client to sit up and place his arms over a bedside table, encouraging
him to remain still during the procedure.

Rationale: According to Berman A., et al (2022), a nurse must position the patient that
allows easy access to the intercostal spaces. Positioning the patient in a sitting position
over a bedside table or leaning over a pillow will allow the intercostal spaces to spread to
facilitate removal of fluid from the chest.
Source: Audrey Berman, Shirlee Snyder, Geralyn Frandsen (2022) Kozier and Erb’s
Fundamentals of Nursing: Concepts, Process and Practice (Global Edition); Thoracentesis
p.828-p.829. Pearson

2. The nurse is taking care of an elderly client with left-sided heart failure. Which of the
following are the most appropriate nursing interventions to reduce the workload of the
heart and to promote comfort and rest? Select all that apply.
1) Assist the client on short walks at least two times per shift to increase circulation.
2) Provide a comfortable armchair or raise the head of the bed to increase the reserve of
the heart and to decrease the work of breathing.
3) Allow the client to lie flat to sleep.
4) Help the client walk to the bathroom rather than using a bedside commode.

A. 1 and 2 B. 2 only C. 1, 2 and 3 D. 1, 2, 3 and 4

Rationale: According to Hinkle & Cheever (2017), elevating the head of bed will decrease
respiratory effort, To conserve the patient’s energy the nurse must promote rest and
comfort.
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p.269, p.941-p.942

3. The nurse is conducting a home visit with a client who has a history of angina. Which of
the following best demonstrates that further teaching about nitroglycerin therapy is
required?
A. “I take a tablet about 10 minutes before I walk up the stairs.”
B. “I take up no more than 3 doses in a 15-minute period of time.”
C. “I keep the tablets in a glass dish on the windowsill so they are readily
available.”
D. “I will call my doctor immediately if I experience blurred vision.

Rationale: According to Hinkle & Cheever (2017), nitroglycerin is very unstable, it should
be carried securely in its original container (e.g., capped dark glass bottle); tablets should
never be removed and stored in metal or plastic pillboxes
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p.2071

4. Prior to administering digoxin 0.125 mg PO to a client with chronic heart failure, the
nurse determines that the apical pulse is 56. Which of the following should the nurse do
first?
A. Administer the drug and recheck the pulse in one hour.
B. Withhold the drug and notify the physician.
C. Obtain EKG.
D. Send a blood sample to the laboratory for a digoxin level.

Rationale: According to Hinkle & Cheever (2017), Digitalis toxicity’s manifestation is

bradycardia.
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p.2237

5. A client is admitted for pulmonary embolism and is receiving heparin 1,500 units/hour
IV. In case of a serious bleeding reaction, the nurse has which of the following drugs
readily available?
A. Vitamin K C. Promethazine hydrochloride
B. Protamine sulfate D. Protamine

Rationale: According to Hinkle & Cheever (2017), protamine sulfate is given to reverse
the effects of heparin
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p.2109

6. A middle-aged female client with a history of atherosclerosis is admitted with complaints

of abdominal tenderness during deep palpation. The nurse notices a pulsating mass in the
periumbilical area. Which of the following does the nurse suspect?
A. Appendicitis C. Acute cholecystitis
B. Abdominal aortic aneurysm D.Paralytic ileus

Rationale: According to Hinkle & Cheever (2017), the most common cause of abdominal
aortic aneurysm is atherosclerosis and is most prevalent in patients older than 65 years of
age. The most important diagnostic indication of an abdominal aortic aneurysm is a
pulsatile mass in the middle abdomen.
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p.2337

7. A client with Raynaud’s disease is experiencing an acute attack. The nurse should
anticipate which of the following assessment findings?
A. Involuntary muscle contractions and twitching.
B. Unilateral facial weakness and drooping mouth.
C. Numbness and tingling of fingers and blanching of the skin at the fingertips.
D. Photophobia
Rationale: According to Hinkle & Cheever (2017), Raynaud’s reveals pallor brought on by
sudden vasoconstriction. The skin then becomes bluish (cyanotic) because of pooling of
deoxygenated blood during vasospasm. The characteristic sequence of color change of
Raynaud phenomenon is described as white, blue, and red. Numbness, tingling, and
burning pain occur as the color changes. The manifestations tend to be bilateral and
symmetric and may involve toes and fingers.
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p.2349

8. The physician orders a CT scan of the client’s chest with IV contrast. Which of the
following
findings in the client’s history should the nurse report to the physician?
A. Hypertension B. Allergy to shellfish C. UTI D. Allergy to penicillin

Rationale: According to Hinkle & Cheever (2017), the common risks from IV contrast
agents include allergic reactions and acute kidney injury; therefore, patients must be
screened for these risks. Any allergies to contrast agents, iodine, or shellfish, the patient’s
current serum creatinine level, and pregnancy status in females must be determined
before administration of a contrast agent. Patients allergic to the contrast agent may be
premedicated with a corticosteroid and antihistamine.
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p.3281

9. The nurse is caring for a client with a diagnosis of COPD, bronchitis type, in the
long-term care facility. The client is wheezing and his oxygen saturation is 85%. Four hours
ago, the oxygen saturation was 88%. It is most important for the nurse to take which of
the following actions?
A. Administer beclomethasone, 2 puffs per metered dose inhaler.
B. Listen to breath sounds.
C. Increase oxygen to 4 L per mask.
D. Administer albuterol, 2 puffs per metered dose inhaler.

Rationale: According to Kizior R.J. & Hodgson K.J. (2019), Albuterol stimulates beta 2 -
adrenergic receptors in lungs, resulting in relaxation of bronchial smooth muscle. Its
therapeutic effect includes relieving bronchospasm and reduces airway resistance.
Source: Robert J. Kizior and Keith J. Hodgson (2019) Saunder;s Nursing Drug Handbook:
Albuterol p.273

10. The homecare nurse is performing chest physiotherapy on an elderly client with chronic
airflow limitations (CAL). Which of the following actions should the nurse take first?
A. Perform chest physiotherapy prior to meals.
B. Auscultate the chest prior to beginning of procedure.
C. Administer bronchodilators after the procedure.
D. Percuss each lobe prior to asking the client to cough.

Rationale: According to Hinkle & Cheever (2017), auscultation of the chest before and
after the procedure is used to identify the areas that need drainage and assess the
effectiveness of treatment.
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p.1464
11. A client is admitted to the hospital with a diagnosis of chronic bronchitis. He has a 10-
year history of emphysema. The nurse should place him in which of the following
positions?
A. Side-lying B. Supine C. High-fowler’s D.Semi-fowler’s

Rationale: According to Morrow B, et al. (2016), High Fowler’s position (60-90 degrees
angle) is the preferred position to combat dyspnea in patients with COPD. Due to the
positioning of the bed, the position allows for better chest expansion, improving breathing
by facilitating oxygenation.
Source: Morrow B, Brink J, Grace S, Pritchard L, Lupton-Smith A. The effect of positioning
and diaphragmatic breathing exercises on respiratory muscle activity in people with chronic
obstructive pulmonary disease. S Afr J Physiother. 2016 Jun 29;72(1):315. doi:
10.4102/sajip.v72i1.315. PMID: 30135892; PMCID: PMC6093095.

12. The nurse performs discharge teaching with a client with emphysema. Which
statement by the client indicates that teaching was successful?
A. “Cold weather will help my breathing problems.”
B. “I should eat 3 balanced meals but limit my fluid intake.”
C. “My outside activity should be limited when pollution levels are high.”
D. “An intensive exercise program is important in regaining my strength.”

Rationale: According to Hinkle & Cheever (2017), the nurse instructs the patient to avoid
extremes of heat and cold. Cold tends to promote bronchospasm. Thus, option A is
incorrect. Moreover, air pollutants such as fumes, smoke, dust, and even talcum, lint, and
aerosol sprays may initiate bronchospasm.
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p. 1806

13. The nurse assists the physician with the removal of the tube. Before the physician
removes the chest tube, which instruction should the nurse give to the client?
A. “Exhale and bear down.” C. “Inhale and exhale rapidly.”
B. “Hold your breath for 5 seconds.” D. “Cough as hard as you can.”

Rationale: Instruct patient to exhale and hold it while performing the Valsalva maneuver
for each tube removed. Valsalva maneuver is needed to provide positive pressure in the
pleural cavity and decrease the incidence of an involuntary gasp by the patient when the
tube is removed (American Association of Critical-Care Nurses, 2016).
Source: American Association of Critical-Care Nurses. (2016). AACN Procedure Manual for
High Acuity, Progressive, and Critical Care, 7th Edition. P 192

14. A man is brought to the emergency department reporting chest pain. The nurse
performs an assessment of the client. Which of the following symptoms would be most
characteristic of an acute myocardial infarction?
A. Colic-like epigastric pain.
B. Severe substernal pain radiating down the left arm.
C. Sharp, well-localized, unilateral chest pain
D. Sharp, burning chest pain moving from place to place.

Rationale: MI signs and symptoms include chest pain radiating to the neck, jaw, shoulder,
back or left arm. The first option indicates GI disorder, the third option is a symptom of
pneumothorax, while the fourth option indicates anxiety state.
Source: Kaplan Nursing. (2018). NCLEX-RN Prep 2018: Practice Test + Proven Strategies.
p. 372
15. A nurse is preparing to provide discharge instructions to a client with Raynaud’s
disease. The nurse plans to teach the client to do which of the following as the priority for
self- management?
A. Stop smoking because it causes vasospasm
B. Always wear warm clothing even in warm climates to prevent vasoconstriction
C. Use nail polish to protect nail beds from injury
D. Wear gloves for activities involving the use of both hands

Rationale: According to Hinkle & Cheever (2017), Raynaud’s is characterized by vasospasm

and fixed blood vessel obstructions that may lead to ischemia, ulceration, and gangrene.
Avoiding the particular stimuli (e.g., cold, tobacco) that provoke vasoconstriction is a
primary factor in controlling Raynaud phenomenon.
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p. 2349-2350

16. A home health care nurse plans to visit a client with Raynaud’s disease. The nurse
prepares a care plan for the client, which should of the following should the nurse keep in
mind regarding this disease?
A. Is more common in men between 60-80 years old
B. Causes connective tissue to collect in the veins
C. Causes vasospasm and pain in the digits when exposed to cold, vibration, or
stress
D. Produces a slow, irregular peripheral pulse rate

Rationale: According to Hinkle & Cheever (2017), Raynaud phenomenon is a form of

intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the
fingertips or toes. Episodes may be triggered by emotional factors or by unusual sensitivity
to cold.
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p. 2348-2349

17. The nurse has prepared medications for a 75-year-old client with hypertension. The
nurse notes that the client has an elevated serum potassium level. Which medication is
most important for the nurse to address with the healthcare provider before
administration?
A. Lisinopril 40 mg oral tablet C. Atorvastatin 20 mg oral tablet
B. Metoprolol 25 mg oral tablet D. Sertraline 25 mg oral tablet

Rationale: Elevated potassium levels is contraindicated and should be avoided by people

taking lisinopril (Zestril, Prinivil) ramipril (Altace) or other ACE inhibitors which can further
increase potassium levels or cause hyperkalemia as its drug interaction (Goyal, 2022).
Source: Amandeep Goyal. (2022). National Library of Medicine: ACE inhibitors.
https://www.ncbi.nlm.nih.gov/books/NBK430896/

18. At 0745 hours, the nurse is informed by the healthcare provider that a cardiac
catheterization is to be completed on the client at 1400 hours. Which intervention should
be the nurse’s priority?
A. Place the client on NPO status
B. Teach the client about cardiac catheterization.
C. Start an IV infusion of 0.9 NaCl.
D. Witness the client’s signature on the consent form.
Rationale: According to Hinkle & Cheever (2017), nursing responsibilities before cardiac
catheterization include instructing the patient to fast, usually for 8 to 12 hours, before the
procedure. The rationale of NPO in the setting of cardiac catheterization is to reduce the risk
of aspiration, and more so, of a patient needing emergent cardiac surgery.
Source: Janice L. Hinkle and Kerry H. Cheever (2017) Brunner and Suddarth's Textbook of
Medical Surgical Nursing p. 1932

19. A client is scheduled for hydrotherapy for a burn dressing. Which action should the
nurse take to ensure that the procedure is most tolerable for the client?
A. Ensure that the client has a robe and slippers.
B. Administer an analgesic 20 minutes before therapy.
C. Send dressing supplies with the client to hydrotherapy.
D. Administer the intravenous antibiotic 30 minutes before therapy.

Rationale: According to Silvestri (2018), the client should receive pain medication approx.
20 minutes before a dressing change. This will help the client tolerate painful procedure.
Source: Linda Anne Silvestri. (2018). Saunders Q&A Review for the NCLEX-RN ®
Examination p. 38

20. Which arterial blood gasses (ABGs) values should the nurse anticipate in the client with
a nasogastric tube attached to continuous suction?
A. pH 7.25, PCO2 55, HCO3 24 C. pH 7.48, PCO2 30, HCO3 23
B. pH 7.30, PCO2 38, HCO3 20 D. pH 7.49, PCO2 38, HCO3 30

Rationale: According to Silvestri (2018), the anticipated ABG finding in the client with
nasogastric tube to continuous suction is metabolic alkalosis resulting from loss of acid. In
uncompensated metabolic alkalosis, the pH will be greater than 7.45, bicarbonate is greater
than 27 and PCO2 will be most likely within normal limits.
Source: Linda Anne Silvestri. (2018). Saunders Q&A Review for the NCLEX-RN ®
Examination p. 52