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Practice Nursing test with answers and rationale
1. When assessing a client with chest pain, the nurse obtains a
thorough history. Which statement of the patient is most suggestive
of anginal pectoris?
a. The pain lasted for about 45 minutes
b. The pain resolved after I ate sandwich
c. The pain worsened when I took a deep breath
d. The pain occurred while I was mowing the loan
2. After experiencing a transient ischaemic attack (TIA), a
client is prescribed aspirin 80 mg p.o daily. The nurse should
teach the client that this medication has been prescribed to
a. Control headache pain
b. Enhance immune response
c. Prevent intracranial bleeding
d. Decrease platelet coagulation
3. The physician prescribes several drugs for a client with
hemorrhagic stroke . which drug order should the nurse
question.
a. Heparin sodiim (heplock)
b. Dexamethasone ( decadron)
c. Methyldopa (aldomet)
d. Phentoin (dilantin)
4. A client with peptic ulcer is about to begin a therapeutic
regimen that includes a bland diet,antacids and ranitindine hcl
(zantac). Which instructions should the nurse provide before this
client is discharged.
a. Eat a three balanced meal everyday
b. Stop taking the drug when the symptoms subside
c. Avoid aspirin and products that contain aspirin
d. Increase the intake of fluids containing caffeine
5. The nurse is assessing a client with Cushings disease. Which
observation should be reported to the physician immediately.
a. Pitting edema of the legs
b. Irregular apical pulse
c. Dry mucous membrane
d. Frequent urination
6. A client with myasthenia gravis is receiving continuous
mechanical ventilation. When the high pressure alarm on the
ventilator sounds, what should the nurse do?
a. Check the presence of the apical pulse
b. Suction the patients artificial airway
c. Increase the oxygen percentage
d. Ventilate using a manual resuscitation bag
7. Which of the following takes the highest priority for
parkinsons crisis?
a. Altered nutrition: less than body requirements
b. Ineffective airway clearance
c. Altered urinary elimination
d. Risk for injury
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8. Which nursing diagnosis is most appropriate for a client with
Addisons disease?
a. Risk for infection
b. Fluid volume excess
c. Urinary retrention
d. Hypothermia
9. Which of these signs suggest that a client with Symptom if
Inappropriate Antidiuretic Hormone(SIADH) has developed
complications?
a. Titanic contractions
b. Neck vein distention
c. Weight loss
d. Polyuria
10.Which of these findings best correlates with a diagnosis of
osteoarthritis?
a. Joint stiffness that decreases with activity
b. Eythema and edema over the affected joints
c. Anorexia and weight loss
d. Fever and malaise
11.When communicating with a client with (sensory) receptive
aphasia, the nurse should?
a. Allow time for the client to respond
b. Speak loudly and articulate clearly
c. Give the client a writing pad
d. Use short, simple sentences
12.Which outcome indicates that treatment for diabetes insipidus
is effective?
a. Fluid intake of less than 2500 ml in 24 hours
b. Urine output of more than 200 ml/hr
c. Blood p ressure of 90/50
d. Pulse rate of 126 beats/min
13.Which action should the nurse include in the plan of care for
a client with a fiberglass cast on the right hand?
a. Keep the casted arm with a light blanket
b. Avoid handling the cast for 24 hrs or until dry
c. Assess pedal and tibial pulses every 24 hrs
d. Assess movement and sensation in the fingers of the right
hand.
14.A client is admitted with a serum glucose level of 618 mg/dl.
The client is awake and oriented, with hot, dry skin, a temperature
of 100.6 F(38.1 C)PR of 116 bpm, and BP of 108/70 mmhg. Based on
these findings, which nursing diagnosis receive the highest
priority?
a. Fluid volume deficit r/t osmotic diuresis
b. Decreased cardiac output r/t increased HR
c. Altered nutrition : less than body requirements r/t to
insulin deficiency
d. Ineffective thermoregulation r/t to dehydration.
15.Which nursing action should take the highest priority when
caring for a client with hemiparesis caused by cerebrovascular
accident?
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a. Perform passive range of motion exercise
b. Place the client on the affected side
c. Use handrolls or pillows to support
d. Apply antiembolic stockings
16.Then nurse should include which instruction when teaching a
client about insulin administration?
a. Administer insulin after the first meal of the day
b. Administer insulin at a 45 degree angle into the deltoid
muscle
c. Shake the vial of the insulin vigorously before withdrawing
the medication
d. Draw up clear insulin when mixing two types of insulin in one
syringe.
17.The nurse should expect a client with hypothyroidism to
report which of these health concerns?
a. Increased appetite and weight loss
b. Puffiness of the face and hands
c. Nervousness and tremors
d. Increasing exophthalmos
18.A client with hypothyroidism is receiving levothyroxine
sodium(synthroid), 50 mcg. P.O daily. Which of these findings
should the nurse recognize as an adverse effect?
a. Dysuria
b. Leg cramps
c. Tachycardia
d. Blurred vision
19.A client ABG values are pH=7.12, PaCO2= 40 mmHg, and HCO3=
15
mEq/L. which disorder these ABG values suggests?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic alkalosis
d. Metabolic acidosis
20.A client is admitted to the ER with suspected overdose of
unknown drug. The client ABG values indicates respiratory acidosis,
what should the nurse do first?
a. Prepare to assist with ventilation
b. Monitor the clients heart rhythm
c. Prepare to begin gastric lavage
d. Obtain urine for drug screening
21.A client is being returned to the room after subtotal
thyroidectomy. Which piece of equipment is important to the nurse
to bring to the clients bedside?
a. Indwelling folley catherer kit
b. Tracheostomy set
c. Cardiac monitor
d. Humidifier
22.Which of these findings is an early sign of bladder
cancer?
a. Painless hematuria
b. Occasional polyria
c. Nocturia
d. Dysuria
23.Which statement from a client who takes Nitroglycerin (
Nitrostat) as needed for angina pain indicates that further
teaching is necessary?
a. I store the tablets in a dark bottle
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b. I take the tablet in a full glass of water
c. I check for my tongue to tingle when I take a tablet
d. Ill go to the hospital if 3 tablets, 5 minutes apart dont
relieve the pain
24.The nurse is assessing the puncture site of a client who has
received a purified protein derivative test. Which finding
indicates a need for further evaluation?
a. 15 mm induration
b. Reddened area
c. 10 mm bruise
d. Blister
25.A client must take streptomycin sulfate for TB. Before the
therapy begins, the nurse should inform the client to inform the
physician if which of the following symptoms occur?
a. Decreased color discrimination
b. Increased urinary frequency
c. Decreased hearing acuity
d. Increased appetite.
26.During a late stage of AIDS, a client demonstrates signs of
AIDS related dementia. The nurse should give highest nursing
prioroity to which of the following nursing diagnosis?
a. Bathing or hygiene self care deficit
b. Impaired cerebral perfusion
c. Dysfunctional grieving
d. Risk for injury
27.A client with gout is receiving Probenecid. The nurse should
monitor
which laboratory test when caring for this patient?
a. RBC count
b. Serum uric acid
c. Serum potassium
28.A client has been diagnosed with type 1 insulin dependent DM.
which clients comment correlates best with this disorder?
a. I was thirsty all the time. I just couldnt get enough to
drink
b. It seemed like I had no appetite. I had to get myself eat
c. I had cough and cold that jjust didnt seem to go away
d. I noticed a pain when I went to the bathromm
29.A client is receing chemotherapy for breast cancer. Which
assessment finding indicates chemotherapy induced fluid and
electrolyte imbalance?
a. Urine output of 400 ml in 8 hrs
b. Serum potassium level of 3.6 mEq/L
c. BP of 120/64 to 130/72 mmHg
d. Dry oral mucous membrane and cracked lips
30.After chemotherapy, a client develops N/V . for this client,
the nurse should give the highest priority to which action in the
plan of care?
a. Serve small portions of bland food
b. Encourage rhythmic breathing exercise
c. Administer metoclopromide and dexamethasone as prescribed
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d. Withould fluid for the the first 4-6 hrs
31.A client is receiving Zidovdine (Retrovir) to treat AIDS, for
this client, the nurse should monitor the value of which laboratory
test?
a. RBC count
b. Fasting blood glucose
c. Serum calcium
d. Platelet count
32.A client seeks care for low back pain of 2 weeks duration.
Which assessment finding suggests a herniated intervertebral
disk?
a. Pain that radiates down the posterior thigh
b. Back pain when the knees are flexed
c. Atrophy of the lower legs
d. Positive Homans sign
33.For a client with hepatitis b, the nurse should monitor
closely for the onset development of which clinical
manifestation?
a. Jaundice
b. Arm and leg pruritus
c. Fatigue during ambulation
d. Irritability and drowsiness
34.A client is recovering from ileostomy that was performed to
treat inflammatory bowel disease. During the teaching discharge,
the nurse should stress:
a. Increasing fluid intake to prevent dehydration
b. Wearing appliance pouch only at bedtime
c. Consuming a high protein , high fiber diet
d. Taking only enteric medications
35.To prevent esophageal reflux in a client with hiatus hernia,
the nurse should provide which discharge instructions?
a. Lie down after meals to promote digestion
b. Avoid coffee and alcoholic beverages
c. Consuming low protein, high fiber diet
d. Limit fluids with meals
36.A client with increasing difficulty swallowing , weight loss
and fatigue just received a diagnosis of esophageal cancer. Because
this client has difficulty swallowing, the nurse should give the
highest priority to which action.
a. Helping the client cope with body image disturbance
b. Ensuring adequate nutrition
c. Maintaining a patent airway
d. Preventing injury
37.The nurse is caring for a client with cirrhosis. Which
manifestations indicate deficient Vit. K absorption caused by this
liver disease?
a. Dyspnea and fatigue
b. Ascites and orthopnea
c. Purpura nd petechaie
d. Gynecosmastia and testicular hypertrophy
38.Two days ago, the client underwent an autograft for secof and
third degree
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burns on the arms. Now the nurse finds the client doing arm
ecxercise. Te nurse knows that exercise should be avoided because
it may.
a. Dislodge the autograft
b. Increase the edema in the arms
c. Increase the amount of scarring
d. Decrease circulation of the fingers
39.A client with UTI receives a prescription for cotrimoxazole
(Septra) 2 tablets P.O daily for 10 days. Which observation best
demonstrates that the client followed the prescribed regimen?
a. Increase urine output to 2L in 24 hrs
b. Decreased flank and abdominal discomfort
c. Absence of bacteria on urine culture
d. Normal RBC count
40.A client has undergone laryngectomy and tracheostomy
formation. Which instruction should the nurse give to the client
and family about the operation?
a. The tracheostomy tube should be cleaned with alcohol and
water.
b. Family members should conitinue to converse with the
client
c. Oral intake should be limited to 1 week only
d. The amount of protein in the diet should be limited
41.When caring for a client who has just had a total
laryngectomy,the nurse should plan to
a. Encourage oral feedings as soon as possible
b. Develop an alternative communication method
c. Keep the tracheostomy cuff fully inflated
d. Keep the client flat in bed
42.After a left pneumonectomy, a client has a chest tube for
drainage. For this client, the nurse must
a. Monitor fluctuations in the water seal chamber
b. Clamp the chest tube once every shift
c. Encourage coughing and deep breathing
d. Milk the chest tube every 2 hrs
43.A client reports sharp chest pain in the right side of the
chest and difficulty of breathing and has respiratory rate of 40
bpm. Which goal should the nurse consider as the top priority?
a. Maintainance of adequate circulatory volume
b. Maintainance of effective respiration
c. Anxiety reduction
d. Pain reduction
44.A client develops brigh red urine while receiveing heparin
for pulmonary embolus. What should the nurse do first?
a. Decrease the heparin infusion rate
b. Prepare to administer protamine sulfate
c. Monitor the paritial thromboplastin time(PTT)
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d. Stop the infusion for 2 hrs and start it at a lower dose as
prescribed
45.In a client is chronic bronchitis, which sign should lead the
nurse to suspect right heart failure (cor pulmonale)
a. Circumoral cyanosis
b. Bilateral crackels
c. Productive cough
d. Leg edema
46.When caring for a client with endotracheal tube, the nurse
should consider which action to be the most important?
a. Auscultate the lungs for bilateral breath sounds
b. Turning the client from side to side every 2 hrs
c. Monitor serial blood gas every 4 hrs
d. Provide frequent oral hygiene
47.The nurse administer albuterol (Proventil) as prescribed to a
client with emphysema. Which findings indicate that the drug is
producing a therapeutic effect?
a. RR of 22 bpm
b. Dialted and reactive pupils
c. Urine output of 40 ml/hr
d. PR of 100 bpm
48.After transurethral resection of the prostate for benign
prostatic hypertrophy, a client returns to the room with continous
bladder irrigation. On the first day after surgery, the client
reports bladder pain, what should the nurse do first?
a. Increase the IV flow rate
b. Notify the physician immediately
c. Assess the irrigation catheter for patency and drainage
d. Asminsiter meperidine 50 mg IM as prescribe
49.A client with arterial insuffieciency has just undergone
below knee amputation of the right leg. Which action should the
nurse include in the post op[ care plan?
a. Elevate the stump fot the first 24 hrs
b. Maintain the client on complete bed rest
c. Appy heat to the stump as the client desires
d. Remove the pressure dressing after the first 8 hrs
50.Which of these laboratory test is the most accurate indicator
of renal function
a. BUN
b. Creatinine clearance
c. Serum creatinine
d. Urinalysis
51.Which nursing intervention is the most important when caring
for a client with acute pyelonphritis?
a. Administer sitz bath twice a day
b. Increase fluid intake to 3 L a day
c. Use an indwelling (folley) catheter to measure urine output
accurately
d. Encourage the client to drink cranberry juice to acidify the
urine
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52.Which nursing intervention is the most important during the
acute oliguric phase of acuter renal failure?
a. Encouraging coughing and deep breathing exercise
b. Promoting carbohydrate intake
c. Limiting fluid intake
d. Controlling pain
53.A client with renal failure is undergoing continous
ambulatory peritoneal dialysis (CAPD). Which nursing diagnosis is
most apporopriate for this client?
a. Altered urinary elimination
b. Toileting self care deficit
c. Sensory or perceptual alterations
d. Dressing or grooming self care deficit
54.A client is admitted with a cervical spine injury caused by a
diving accident. When planning this clients care,the nurse should
give which nursing diagnosis the highest priority?
a. Impaired physical mobility
b. Ineffective breathing pattern
c. Sensory or perceptual alteration
d. Activity intolerance
55.The nurse is developing a plan of care for a patient who has
undergone a laminectomy to repair a herniated intervertebral disk.
Which action should the nurse include?
a. Keep the pillow under the knees at all time
b. Place the client in a semi fowlers position
c. Maintain bed rest for 72 hrs postop
d. Turn the patient from side to side using the log rolling
technique
56.The nurse must total parenteral nutrition(TPN) through a
triple lumen catheter line. What can the nurse do to prevent
complications?
a. Cover the catheter insertion site with an occlusive
dressing
b. Use clean technique when changing the dressing
c. Insert an indwelling urinary catheter
d. Keep the client on complete bed rest.
57.The nurse assesses a client shortly after kidney transplant
surgery. Which postoperative finding should the nurse report to the
physician immediately?
a. Serum potassium of 4.9 mEq/L
b. Serum sodium of 135 mEq/L
c. Temperature of 99.2 F (37.3)
d. Urine output of 400 ml in 24 hrs
58.A cient is admitted with a gunshot wound to the abdomen.
After an exploratory laparatomy, the client , the client is
transferred to the ICU. Which assessment finding suggests that the
client now is developing acute renal failure?
a. BUN level of 22 mg/dl
b. Serum creatinine level of 1.2 mg/dl
c. Temperature of 1.2 F
d. Urine output of 400 ml in 24 hrs
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59.A client seeks care for severe pain in the right upper
quadrant of the abdomen, which is accompanied by nausea and
vomiting. The physician makes a diagnosis of acute cholecystitis
and cholelithiasis. For this client, which nursing diagnosis should
receive the highest priority?
a. Pain r/t biliary spasm
b. Knowledge deficit r/t prevention of recurrence
c. Anxiety r/t unknown outcome of hospitalization
d. Altered nutrition: less than body requirements r/t to biliary
inflammatioin
60.For a client with advanced liver cirrhosis, which assessment
finding best indicates deterioration of liver function?
a. Fatigue and muscke weakness
b. difficulty in arousal
c. Nausea and anorexia
d. Weight gain
61.A client is admitted with increased ascites associated with
cirrhosis. Which nursing diagnosis should receive the highest
priority?
a. Fatigue
b. Fluid volume excess
c. Ineffective breathing pattern
d. Altered nutrition: less than body requirements
62.A client with advanced cirrhosis has a prothrombin time of 15
seconds compared to a control time of 11 sec. which drug should the
nurse expect to administer?
a. Spironolactone (alsdactone)
b. Phytonadione( mephyton)
c. Furosimide (Lasix)
d. Warfarin (Coumadin)
63.The physician prescribes spironolactone(Aldactone) 50 mg P.O
four times daily for a client with fluid retention due to liver
cirrhosis, which finding indicates that the drug is producing a
therapeutic effect?
a. Serum K level of 3.5 mEq/L
b. Weight loss of 2 lb in 24 hrs
c. Serum Na level of 135 mEq/L
d. Blood pH of 7.25
64.While preparing a client with for cholecystectomy, the nurse
explains that incentive spirometry will be used after surgery. The
nurse also should tell the client the primary purplose of incentive
spirometry is:
a. Increases respiratory effectiveness
b. Preclude the need for nasogastric intubation
c. Improve nutritional status during the recovery period
d. Decrease the amount of respiratory anesthesia
65.A client is transferred to ICU after evacuation of a subdural
hematoma. To reduce the risk of increasing intracranial pressure ,
the nurse should:
a. Encourage oral fluid intake
b. Suction the client once per shift
c. Elevate the head of the bed to high fowlers
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d. Administer a stool softener as prescribed
66.Two days after repairing a clients ruptured cerebral
aneurysm, the physician orders mannitol (osmitro) 1.5 g/kg, to be
infused over 60 minutes. If the client weighs 175 lbs, how many
grams of mannitol should be administered?
a. 263 g
b. 119 g
c. 75g
d. 60 g
67.A client is receiving a n I.V infusion of mannitol after
undergoing intracranial pressure surgery for removal of a brain
tumor. To determine if this drug is producing its therapeutic
effect, the nurse should consider which as the most significant
a. Decrease level of consciousness
b. Elevated BP
c. Increased urine output
d. Decreased heart rate
68.A client is hospitalized for open reducrion of a fractured
femur. During postoperative assessments, the nurse monitors for
signs of fat embolism, which include:
a. Pallor and coolness of the affected leg
b. Nausea and vomiting after eating
c. Hypothermia and bradycardia
d. Restlessness and petechiae
69.A client is in Bucks skin traction for right hip fracture.
The nurse should include which action in this clients plan of
care.
a. Remove the weight once every shift
b. Maintain the bed in knee gatch position
c. Keep the client is a semi fowlers position
d. Maintain traction in correct body allignment
70.A client who has just received a diagnosis of early glaucoma
is being prepared for discharge. Which information should the nurse
provide during this clients discharge teaching session?
a. Instructions for eye patching
b. Discharge assessment of visual acuity
c. Demonstration of eye drop instillation
d. Instructions on intraocular lens cleaning
71.A client was admitted to a coronary care unit with acute
myocardial infarction (MI). Now the client report midsternal pain
radiating down the left arm, appears restless and is slightly
diaphoretic. The nurse obtains the following assessment findings:
T= 00. 6 F (37.5 C); PR = 102 bpm, regular;slightly labored
respiration of 26 bpm, and BP of 150/90 mmHg. When planning the
clients care, the nurse should give the highest priority to which
nursing diagnosis?
a. Risk for altered body temperature
b. Decreased cardiac output
c. Anxiety
d. Pain
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72.A client with cirrhosis of the liver is increaslingly
confused and combative. Which of the following diets would the
nurse expect to be ordered for this client?
a. Low fat, low sodium
b. High carbohydrate, low protein
c. Low potassium ,low phosphorus
d. Gluten and wheat free.
73.Which of the following should the nurse teach a client using
recombinant epoetin alpha (Epogen) for chronic renal failure?
a. This drug will help with the bleeding problems associated
with kidney damage
b. Epoetin alpha should reduce fatigue and improve energy
level
c. Taking this medication may reduce the need for dialysis
d. Once a good blood level is established, the injectable form
will be changed to an oral form
74.An appropriate plan of care for a client admitted with renal
colic would include which of the following?
a. Inserting an indwelling urinary catheter
b. Straining all urine
c. Maintaining T tube patency
d. Limiting fluid intake
75.Which statement would not be included in discharge teaching
for a client with a history of rheumatoid arthritis who was treated
with severe anemia secondary to GI hemorrhage?
a. Take your iron supplement with orange juice
b. Use aspirin for joint pain
c. Plan to take iron for 6 months
d. Avoid taking iron with tea or calcium supplements
76.A client with exacerbation of COPD and pneumonia has the
following ABG results: pH 7.30, PaC02 60 mmHg, PaO2 75 mmHg and
HCO3 is 24 Meq/L. The nurse anticipates wich intervention?
a. Increase oxygen via face mask
b. Encourage coughing and deep breathing
c. Admister sodium bicarbonate
d. No intervention is neede. ABG values are normal
77.A client with cerebrovascular accident has a nursing
diagnosis of ineffective airway clearance. The goal for this client
is to mobilize pulmonary secretions. Which action should the nurse
plan to take to meet this goal?
a. Reposition the client every 2 hrs
b. Restrict fluids to 1000 ml in 24 hrs
c. Asminister O2 by nasal canula as ordered
d. Keep the head of the bed at a 30 degrees angle
78.A client is admitted to the hospital with a productive cough,
night sweats and fever. Which of these actions is most important in
the clients initial plan of care?
a. assess the clients temperature every 8 hrs
b. place the client in respiratory isolation
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c. monitor the clientf fluidintake and output
d. wear gloves during all client contact
79.a client with heart failure has been receiving an IV infusion
at 125 ml/hr. Now the client is short of breath and the nurse notes
of bilateral crackles, neck vein distention and tachycardia. What
should the nurse do first?
a. Notify the physician
b. Discontinue the IV access device
c. Administer the prescribed diuretic
d. Slow the infusion and notify the physician
80.After bronchoscopy, the client must receive NPO until the gag
reflex returns. What is the best way to assess the gag reflex?
a. Instruct the client to cough
b. Ask the client to extend the tongue
c. Tickle the uvula with a tongue blade
d. Observe while the client swallows sips of water.
81.A client with shock due to hemorrhage has these V/S: T= 97.6
F(36.4C), PR= 140 bpm, BP of 60/30 mmHG. For this client, the nurse
should question which physicians order?
a. Monitor urine output every hr
b. Infuse IV fluids at 83 ml/hr
c. Admister oxygen by nasal canula at 3 L/min
d. Draw specimens for hemoglobin and hematocrit every 6 hrs
82.A client with history of atrial fibrillation presents to the
outpatient clinic with nausea, vomiting, HR of 55 bpm, and visual
disturbances. The nurse would further assess the client for which
of the following conditions?
a. Digitalis glycoside toxicity
b. Angina
c. Heart failure
d. Depression
83.A clients ABG values are pH of 7.29, PaO2 48 mmHg, PaCO2 76
mmHg, HCO3 of 36 mEq/l. the plan of care for this client with these
values would include close monitoring for which of the following
s/sx?
a. Cyanosis and restlessness
b. Flushed skin and lethargy
c. Weakness and irritability
d. Anxiety and fever
84.During postural drainage, movement of secretions from the
lower respiratory tract to the upper respiratory tract occurs due
to:
a. Friction between the cilia
b. Force of gravity
c. Increased insulin use
d. Increased red blood cell production
85.Clients with COPD may be bedridden at home and get little
exercise. Which of the following is a normal physiologic reaction
to prolonged period of bed rest and inactivity?
a. Increased sodium retention
b. Increased calcium excretion
c. Increased insulin use
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d. Increased red blood cell production
86.For a client with COPD who has trouble raising respiratory
secretions, which of the following nursing measures would help
reduce the tenacity of secretions?
a. Ensuring that the clients diet is low in Na
b. Ensuring that the clients oxygen therapy is continous
c. Helping the client maintain a high fluid intake
d. Keeping the client in sitting position as much as
possible
87.The nurse teaches the client with COPD to assess for signs
and symptoms of right sided heart failure which include:
a. Clubbing of nail beds
b. Hypertension
c. Ankle edema
d. Increased appetite
88.While caring for a client who has sustained an MI, the nurse
notes eight premature ventricular contractions in 1 minute on the
cardiac monitor. The client is receiving an IV infusion of 5%
dextrose in water and 2 L/minte of oxygen. The nurses first course
of action would be to:
a. Increase the IV infusion rate
b. Notify the physician promptly
c. Increase the oxygen concentration
d. Administer a prescribed analgesic
89.Whichof the following findings is an indicative of MI?
a. Elevated serum cholesterol level
b. Elevated creatinine phosphokinase (CPK) value
c. Agrees to participating in cardiac rehabilitation program
d. Can perform personal self care activities without pain.
90.Which of the following is expected for a client on the day of
hospitalization after an MI? the client:
a. Has minimal chest pain
b. Can identify risk factors for MI
c. Agrees to participating in cardiac rehabilitation program
d. Can perform personal self care activities without pain
91.Nursing measures for the client who has had an MI include
helping the client to avoid activity that results in valsalva
maneuver. Which of the following actions would help prevent
valsalva maneuver? Have the client:
a. Take fewer deep breaths
b. Clench teeth while moving in bed
c. Drinks fluids through a straw
d. Avoid holding breath during activity
92.A basic principle of any rehabilitation program , including
cardiac rehabilitation begins:
a. On discharge from hospital
b. On discharge from cardiac care unit
c. On admission to the hospital
d. Four weeks after the onset of disease
93.The client has a history of heart failure and the nurse is
preparing the client to
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go home. The nurse should instruct the client to:
a. Monitor urine output daily
b. Maintain bed rest for at least one week
c. Monitor daily potassium intake
d. Weigh daily
94.Digoxin is administred IV to clients with CHF primarily
because the drugs acts to :
a. Dilate coronary artery
b. Increase myocardial contractility
c. Decrease cardiac dysrhytmias
d. Decrease electrical conductivity in the heart
95.The client ask the nurse about the reason for taking
enalapril maleate. The nurse based her response on the fact that
enalapril is prescribed for people with heart failure to:
a. Lower blood pressure by increasing peripheral resistance
b. Lower the heart rate by slowing the conduction sytem
c. Block the conversion of angiotensin 1 to angiotesin 11
d. Increase cardiac contractility thereby improving cardiac
output
96.Metoprolol tartrate a Beta adrenergic antagonsist may be
administered to a client with heart failure because it acts to:
a. Reduce peripheral vascular resistance
b. Increase peripheral vascular reistance
c. Reduce fluid volume
d. Improve myocardial contractility
97.The most effective measure the nurse can use to prevent the
wound infection when changing a clients dressing after coronary
artery bypass surgery is to:
a. Observe careful handwashing procedures
b. Cleanse the incisional area with antiseptic
c. Use prepacked sterile dressing to cover the wound
d. Place soiled dressings in a waterproof bag before disposing
them
98.Which information obtained by the nurse when assessing a
patient admitted with mitral valve stenosis should be communicated
to the health care provider immediately?
a. The pt has a loud diastolic murmur all across the
precordium
b. The pt has crackles audible to the lung apices
99.When caring for a pt with infective endocarditis of the
tricuspid valve, the nurse will plan to monitor the pt for:
a. Flank pain
b. Hemiparesis
c. Dyspnea
d. splenomegaly
100. the nurse is taking a history from a 24 y/o pt with
hypertrophic cardiomyopathy. Which information obtained by the
nurse is the most important?
a. the pt reports using cocaine once at 16 y/o
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b. the patient has a history of upper respiratory infection
c. the pts 29 year old brother has had a sudden cardiac
arrest
d. the pt has a family history of CAD
Answers to part 1
1. D. precipitating factors of angina include exertion during
physical activities,colds, after heavy meals , emotional stress
wherein theres an increase oxygen demand but less supply d/t of
obstruction of blood flow. It may also occur during rest as a
result of coronary spasm. Pain usually last for 3-5 minutes or
15-20 min especially after a heavy meal or anger.
2. D. TIA is caused by temporary decreased in blood flow , could
be caused by atherosclerosis,emboli or thrombi. Anticoagulants such
as aspirin is given to dissolve the clot or prevent platelet
aggregation that could lead to emboli or thrombi.
3. A. hemorrhagic stroke can lead to seizures. Thus antiseizures
such as phentoin is prescribed. One often cause is hypertension
causing small vessels in the brain to rupture and bleed thus
antihypertensive such as methyldopa is included. The bleeding also
cause edema or inflammation to the surrounding tissues so
anti-inflammatory such as dexamethason is given to reduce the
edema. Heparin is an anticoagulant that may cause further bleeding
and should be questioned.
4. C. teaching should include small frequent feeding to avoid
too much HCl acid secretion, completing the prescribed medications
even the patient seems to feel better, avoiding gastric irritants
such as caffeine,
highly flavored foods, aspirin may cause ulcer and bleeding and
should be avoided.
5. C. cushings disease is an excessive production of
mineralocorticoids( aldosterone- for sodium and water
reabsorption), glucocorticoids( cortisol- breakdown of fats and
protein and gluconeogenesis) and androgens (masculine hormone.
Although a pitting edema is a characteristic symptom of cushing
disease because of excessive water and sodium reabsorption, it is
not an emergency condition. Irregular apical pulse is the primary
concern and should be reported immediately.
6. B. the ventilator will alarm to let the caregiver know there
is a problem. Some of the most common alarms are high pressure, low
pressure and battery. If the high pressure alarm sounds, it means
that air is having a hard time getting into the lungs, it usually
means suctioning is needed to get extra secretions out of the
airway. Low pressure means that there might be an airleak or a
disconnected tube.
7. B. Parkinsons crisis is also referred as acute akinesia
present in advanced state of the disease. The rigidity of the
intercoastal muscle makes the patient unable to cough out
accumulated sputum/secretions .thus, patients with parkinsons
disease are prone to repiratory infections.
8. A. Addisons disease is also known as Adrenal insufficiency.
Theres insufficient adrenocorticotropic hormone (ACTH) production
which includes epinephrine and norepinephrine that are helpful in
the flight and fight response. If the body is unable to fight off
stressors, this will lead to body exhaustion and increase
susceptibility to illnesses and
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infections. Another adrenal hormone is aldosterone which is
responsible for water and sodium reabsorption. Insufficient amount
of this leads to increased loss of sodium and water, not urine
retention and fluid excess. Excessive loss of sodium and water can
lead to dehydration and increase temperature.
9. B. antidiuretic hormone(ADH) prevents diuresis or urination.
Excessive ADH leads to excess Na and H2O retention thereby gaining
weight. Increased amount of fluid in the blood vessels causes
increased venous return and fluid overload. Chronic condition may
lead to congestive heart failure in which distended neck vein is
one of the sign
10.A. osteoarthritis is not an inflammatory disease thereby
doesnt produce inflammatory and systemic sign and symptoms. It s a
wear and tear degenerative disease. Pain can occur after repetitive
use of the joint . pain and stiffness can also occur after a long
period of inactivity such as when you go to bed at night and suffer
a pain and stiffness when you wake up in the morning.
11.Receptive aphasia is characterized by fluent but meaningless
speech with severe impairment of the ability understanding spoken
and written words. Short and simple sentences should be used.
12.A. DI is characterized by inadequate antidiuretic hormone
leading to excessive loss of Na and H20 followed by hypotension and
tachycardia. Tachycardia is a compensatory mechanism in an effort
to pump more blood d/t the decreasing circulating fluid. It is
important to increase the fluid intake to prevent hypovolemic
shock.
13.D. It is unnecessary to keep the cast warm, it should be
exposed to cool air. Fiberglass is dried up within 10-15 minutes,
theres no need to assess the pedal and tibial pulses since its not
the one casted. The casted part is the right arm so it is important
to check distal circulation and sensation. Assess brachial and
ulnar pulse.
14.A. hyperglycemia could lead to osmotic dieresis leading to
fluid volume deficit as manifested by dry skin. Decreased cardiac
output cant be related to increasese HR, it is d/t dehydration and
increased heart rate is a compensatory mechanism . theres no data
for insulin deficiency , there might be enough insulin but the
cells are resistant to use it.
15.Ewan ko pa
16.D. Insulin is usually administered before meal to anticipate
the increase of blood sugar after eating. Never administer a
subcutaneous insulin deltoid because you might give it IM. Deltoid
is muscular so it is only used for IM insulin route. Dont shake the
bottle to mix, just roll gently between hands or by turning the
bottle up and down slowly.
17.B. thyroid hormones are responsible for many metabolic
processes. Options A,C,D are result of hyperthyroidism d/t
increased metabolism and neuromuscular hyperactivity. One function
of thyroid hormone is protein synthesis which maintain osmotic
pressure in the blood vessels . if protein concentration in the
vessels is decreased,theres a fluid shift into the extracellular
space leading to edema.
18.C. synthroid adverse effects typically resulted from overdose
and include the signs and symptoms of
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hyperthyroidism which includes tachycardia.
19.D. pH is below normal which suggest an acidosis. PaCO2 is for
respiratory index while HCO3 is for metabolic. The pH follows HCO3,
thereby it is metabolic acidosis
20.A. always follow the principle of ABC prioritization, Airway,
breathing, circulation. Respiratory acidosis is typically the
result of accumulation of CO2 in the body tissues due to
hypoventilation. First priority is to assist with the prescribed
therapy which includes means to improve ventilation.
21.B. Bleeding / hematoma is a life threatening complication
that obstructs airway postthyroidectomy. Tracheostomy set should be
at the bedside to establish airway immediately if respiratory
distress occurs.
22.A. In an early stage of cancer, it usually starts as a tumor
, as tumor invades vascularized tumor, it may cause bleeding.
23.B. Nitroglycerin is an unstable substance and easily
denatured when exposed to heat and light. The dark bottle protect
the drug from the light. If the drug doesnt tingle under the
tongue, it could be that its not working anymore, it could be
expired or denatured. You should not take more than 3 tablets , if
the pain is not relieve in 15 minutes, you should consult the
doctor because this is not an angina pain anymore, it could be a
myocardial infarction.
24.A. mantoux test or tuberculin test is a screening test for
pulmonary tuberculosis. It is done by introducing a protein
derivative of the causative bacteria in the dermis of the skin.
After 48-72 hours, an induration of 10 mm or more is a positive
test and indicates that you might be positive for PTB, a further
evaluation and testing is needed to confirm the presence of
PTB.
25.C. Streptomycin is an antibiotic belonging to the
aminoglycosides family. Aminoglycosides work by inhibiting the
bacterial protein synthesis. Streptomycin frequently affects the
vestibular branch of the auditory nerve causing nausea, vomiting,
vertigo. Symptoms subside and recovery occur following
discontinuation of the drug. In long term therapy however, ototoxic
effect causes hearing loss when extensive is usually permanent.
26.A. the main problem mention is dementia. People with dementia
may not be able to think well enough to do normal activities of
daily living such as getting dressed and eating.
27.A. Probenecid works by decreasing uric acid in the blood by
promoting its kidney exctetion.
In overdosage and intoxication, it causes various hematologic
side effects.
28.A. DM type 1 is a decreased in insulin production leading to
increasing amount of glucose in the blood. Hyperglycemia causes
osmotic diuresis that leads to frequent urination and leads to
dehydration.
29.D. A,B,C are normal findings. S/E iof chemotherapy includes
nausea and vomiting, prolonged N/V caused dehydration.
30.C. it is more logical and appropriate to administer
prescribed antiemtic first before feeding the patient. This is to
avoid vomiting after a meal.
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31.A. the most serious S/E of zidovudine is anemia, myopathy and
neutripenia
32.A.The protruded or herniated disk irritates or compressed the
surrounding nerve endings which causes severe back pain radiating
to the thighs.
33.D. all options are clinical manifestation of hepatitis B. I
think the most correct answer is D, because it needs closer
monitoring and care.
34.A. ileostomy is bringing out the ileum which is the end of
the small intestine into an opening on the abdomen. One important
function of the colon is water absroption, since water is not
anymore pass through the colon , most fluid is lost into the pouch
rather than being absorb making the client more prone to
dehydration. Pouch should be worn all the time. Low fiber diet
should be advised postoperatively because surgery causes the bowel
to swell making digestion of fiber difficult. Once the swelling has
subsided(usually after 8 wks) the patient can resume a normal
diet.
35.B. instruction to the patient should include avoiding acid
stimulant such as coffee, alcohol, fatty foods,aspirin, tobacco,
chocolate, peppermint,etc. you should also instruct patient to
remain in upright position for atleat 30 min after eating and
sleeping with the bed slightly elevated, small frequent feeding is
better tolerated than 3 big meals.
36.B. Esophageal CA presents many signs and symptoms. However
the question is asking specifically on the problem r/t to
difficulty swallowing. You should look for a problem that is most
related to difficulty swallowing, that is insufficient food intake
and nutrition. The nurse should then ensure
adequate nutrition in relation to this problem.
37.C. Vit K is important in the clotting mechanism of the body.
Lack of this can lead to bleeding. Purpura and petechiae are forms
of bleeding
38.A. avoid exercise for 3-4 wks because this may stretch and
injure the graft.
39.C. Antibacterial should work for what its designed for and
that is to eliminate the causing bacteria of a disease. Even though
the symptoms subside, still a number of the causative bacteria is
present in the urinary tract, if the medication is stopped without
completing the prescribed duration of antimicrobial therapy, they
will again multiply and cause the exacerbation of the disease.
Therefore, it is important to complete the whole duration of the
drug therapy to ensure elimination of all the bacteria.
40.B. inner cannula is cleaned with Hydrogen Peroxide and
rainsed with water. The stoma is also cleaned using a soapy wash
cloth then rinsing it. Inner surrounding of the stoma with driep up
sputum crust can be cleaned with a cotton tipped swab soaked in
hydrogen peroxide. Alcohol promotes dryness. Theres no indication
why you have to limit fluid intake. Protein intake should be
increased to promote healing. Patient can still communicate with
proper speech therapy and learning other means of
communication.
41.B. keep the bed elevated to promote ventilation of the lungs
and reduces edema and swelling of the neck. The patient is on NGT
feeding temporarily , no food is allowed by mouth until the
pharyngeal suture line is healed. The tracheostomy cuff
-
should not be fully inflated to avoid pressure trauma to the
windpipe. Usually 10 ml of air is used and the cuff should be
deflated once in a while to relieve the pressure. In total
laryngectomy, speech rehabilitation training is necessary(
esophageal voice, electrolarynx) or using sign language.
42.A. clamp is only necessary when there is a leak along the
tubing and is used to locate the leak. Clamp should only be used in
a limited time to prevent tension pneumothorax and mediastinal
shift. Milking is only per MD order. To ensure that the drainage
system is intact, the nurse should monitor for gently fluctuations
in the water seal chamber with each inspiration and expirarion.This
is called tidaling. Though coughing and deep breathing is also an
important teaching, making sure the drainage system is intact is
more important to serves its purpose.
43.B. Follow the ABC prioritization( 1.Airway, 2.breathing,
3.circulation)
44.C. Assess first before you intervene. PTT is used to test how
long it takes your blood to clot and check for bleeding problems
especially when the patient is on blood thinning therapy such as
heparin .
45.D. the question is asking specifically about sign of righ
heart failure. Cor pulmonale is a right ventricular hypertrophy due
to chronic lung disease. Right side heart failure is usually
associated with signs of the venous system. Due to the hyperthropy
of the right ventricle, there is insufficient filling, thus blood
backs up to the venous system causing peripheral edema.
46.A. the most priority is to ensure a patent airway,
auscultating the presence of breathsound is an indication that the
air way is patent.
47.A. albuterol is a bronchodilator that relaxes muscle of the
airway and increases airflow into the lungs
48.C. always assess first before you intervene. Clots along the
drainage can cause urine stasis and aggravate pain.
49.A. this is to prevent edema.
50.B. Creatinine clearance. Creatine is a byproduct of
metabolism and excreted by the kidney.
51.B. increase fluid intake is very important to flushes out
bacteria
52.C. in oliguric phase , it doesnt mean that there is an
insufficient fluid intake, its because theres a decrease glomerular
filtration leading to fluid accumulation in the body and fluid
overload. Emphasize Na and fluid restriction at this point.
53.C. peritonitis is the most major risk in peritoneal dialysis
d/t to introduction of microorganism through the catheter.
54.B. airway and breathing is always the priority.
55.D. Pillows under knees can be used but should not be kept at
all time to promote venous return and prevent blood clot formation.
Ambulation is encouraged within hours after surgery to promote lung
aeration. Pt can be positioned supine with a pillow under neck or
at the sides. The patient should also change position at least
every 2 hrs , when turning the body should be moved as a unit.
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56.A. patients with central line catheter are ambulatory and
urinary catheter is not needed unless theres some kidney pathology
that requires the use of it. Sterile technique is used when
changing the dressing , occlusive dressing is used to prevent air
from entering the line.
57.D. Normal serum potassium level is 3.5-5 mEq/L, normal serum
sodium is 135-145 mEq/L. normal urine output is at least 30 ml/hr
.
58.D. The first phase of acute renal failure is oliguric phase
with urine output of 400ml or less in 24 hrs. Normal urine ourput
in 24 hrs is 1500 ml. normal serum creatinine is .7-1.4 mg/dl. BUN
is not significantly increased normal bun is 10-20 mg/dl.
59.A. one principle of prioritization is to look on the clients
needs on the clients perspective . pain is considered as the 5th
vital sign. The pain is severe that needs to be addressed first
among the other options.
60.B. All options except D are signs and symptoms of liver
cirrhosis but option B poses the most serious complication.
Advanced liver cirrhosis can lead to hepatic encephalopathy which
is the accumulation of toxins in thebrain leading to decreased
mental function and coma.
61.C. airway and breathing is always the priority. The patient
has difficulty of breathing because of the pressure exerted by the
enlarged abdomen to the diaphragm.
62.B. The patient has prolonged clotting time which predisposes
the patient to bleeding . Coaugulant such as phytonadion (Vit.
K)should be given to counteract effect .warfarin is an
ancticoagulant which place the patient in increased risk of
bleeding.
Furosemide and Spironolactone are diuretics.
63.B. Sprironolactone is a K sparing diuretic . It is used to
excrete extra fluid from the body , therby, lose of body weight
means tha most fluid are being excreted out.
64.A. incentive spirometry is a breathing device that promote
maximal lung aeration and respiratory effectiveness
65.D. Elevate only to 15-30 degrees to promote venous return and
reduce cerebral edema. Enforce any fluid restriction and monitor
carefully input and output. Avoid activities that increase
intrathoracic or intraabdominal pressure such as straining during
bowel movement, this impedes blood flow from the cranium.
Suctioning can stimulate the vagal reflex and further increase ICP,
suctioning is only done if its extremely necessary.
66.1 kg= 2. 2 lbs
175 lb X 1 kg = 79.55 lbs
2.2 lbs
79.55 lbs X 1.5 g= 119 g
67.C. mannitol is a diuretic that excretes extra fluid out from
the body. Increased UO is an indication that mannitols desired
effect is achieved
68.A. bone marrow is also composed of fat globules that may
escapes out during bone fracture and causes fat embolism. The fat
globules can impede blood flow making the affected leg pale and
cool.
69.D. traction should be continuous , the weight is never
removed nor interrupted. The patient is in supine
-
with neck supported by a pillow. The leg with a traction should
be held straight and never flexed.
70.C. Glaucoma occurs due to the pressure build up in the eye by
increased amount of aqueous vitrous humor. Eye drops could either
work by promoting the flow of the aqueous fluid or decrease the
production of it.
71.D. One priority in acute MI is pain control drugs such as
morphine to reduce catecholamine induced oxygen demand to injured
heart muscle.
72.A. cirrhosis may lead to malnutrition. It is essential to
maintain a healthy , nutritious diet such as increasing
carbohydrate and protein intake. Low fat diet should be observed
because bile is needed for digestion and bile is not sufficiently
produced in cirrhotic liver. Salt and Na intake should also be
minimal because patients with cirrhosis tends to retain extra
fluid. When liver cirrhosis is complicated by hepatic
encephalopathy, then this is the time that protein intake should be
limited.
73.B. kidney produced erythropoietin necessary for blood cell
formation, kidney damage leads to anemia. Signs and symptoms of
anemia include easy fatigability and body weakness. Epogen is given
SQ or IV to aids in erythropoeisis and reduces symptoms of
anemia
74.B. renal colic is a very excruciating pain caused by the
passage of stone along the ureter. Indwelling catheter will not
ease the pain. It may in fact add more to the pain experience. T
tube is used to drain bile . Increased fluid intake should be
encourage to help flush the stone. It is appropriate to collect all
urine and strain for stone passage to assess effectiveness of
therapy and or to study the stone composition.
75.B. Vit C such as orange juice enhances absorption, tea,
coffee and calcium reduces iron absorption. Aspirin is avoided
because it is a blood thinner and aggravates bleeding
76.B. Doctors always prescribed a low oxygen delivery to
patients with COPD usually at 2 L/min because high concentration of
oygen can depress the respiratory drive. Besides high oxygen
concentration is of no use if the airway is obstructed with
secretions. It is very important to encourage the pt to cough out
secretions to help clear the airway and encourage deep breathing.
All ABG values are abnoramal.
77.A. Fluid may be increased to liquefy secretions. Oxygen
administration and putting the pt in semi fowlers do not help in
mobilizing secretions. stroke patients who are on bed rest are
prone to respiratory complications because of retention of
secretions. Therefore assisted ambulation and frequent positioning
may help to mobilize secretions .
78.B. the signs and symptoms presented are indications of PTB.
Its a safe precautionary practice to place the pt in respiratory
isolation to prevent cross infection while further assessment and
evaluation is carried out.
79.B. the nurse should suspect a circulatory overload because of
the assessment findings. Initial action is to stop the IV to stop
further introduction of fluid.
80.C. contraction of the back of the throat when the uvula is
tickled means that gag reflex has returned.
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81.B. Iv rate should be a fast drip to immediately restore the
fluid volume
82.A.Digitalis are given to patients with cardiac problems to
strengthen heart contraction. Initial s/sx of Digitalis toxicity is
GI manifestation such as N/V, loss of appetite, diarrhea. Other
symptoms include visual changes, slow pulse , confusion etc.
83.B. With the ABG values presented, the pt is suffering from
respiratory acidosis.
84.B. In postural drainage, the patient is placed on a
trendelenberg position so gravity aids in the movement of mucus to
the upper respiratory tract.
85.B. Immobilization causes calcium lose from the bones into the
bloodstream and cause hypercalcemia. The kidney in response of
hypercalcemia increases its excretion.
86.C. increased fluid intake loosen up secretions thus easy to
expectorate
87.C. one classical sign of right side heart failure is edema
due to decreased venous return.
88.B . Because PVC s may signal an impending life threatening
rhythm , notify the physician if the pt has more than six PVCs per
minute.
89.B. creatine phospholinase is an enzyme normally found in
muscle fibers. It is released in the bloodstream when there is
muscle damage. MI is the interruption of blood supply causing heart
muscle cells to die.
90.Im not sure of the correct answer, but I guess the best
option is B. Pain in MI doesnt last until the following day. Most
patients after a heart attack are hesitant to resume activities,
bed rest
is advised at least for the first couple of days at least 1-2
days. Patients are strongly advised to participate in cardiac
rehabilitation program to help patients to recover quickly and
improve their overall physical, mental and social functioning.
91.D. straining against a closed epiglottis which includes
holding breath or forceful expiration stimulates valsalva maneuver.
Pts should be advised to avoid holding breaths while moving .
92.C. rehabilitation begins upon admission
93.D. weight gain can be a sign that you the pt is retaining
fluid and his heart condition is worsening.
94.B. Digitalis is given to increase cardiac contractility
followed by decreased in HR
95.C. Enalapril is an ACE inhibitor (Angiotension Converting
Enzyme inhibitor) that decreases BP. Angiotensin II is a potent
vasoconstrictor.
96.A. beta adrenergic antagonist antagonizes the action of
sympathetic response. It works by reducing the force of contraction
of heart muscles thereby reducing peripheral resistance and blood
pressure .
97.A. Proper handwashing has always been the single most
effective measure to prevent cross contamination and infection.
98.B. Mitral valve stenosis is the narrowing and stiffening of
the mitral valve caused oftenly caused by rheumatic fever in
adults. Due to the narrowed valve, blood is not efficiently pumped
into the left ventricle, over time, pressure in the atrium
increases and blood is backed up to the lungs
-
and cause pulmonary hypertension and pulmonary edema which is
manifested by presence of lung crackles.
99.C. Infective endocarditis is due to bacterial or fungal
infection that affects the endocardium of the heart especially the
heart valves. Over time, materials called vegetations developed
along the valves. These contain bacteria, blood clots, debri from
the infection. This vegetations prevent the valve from working
properly and will lead to cardiac failure.
100. C. although the specific causes of hypertrophic
cardiomyopahty are not yet fully known. The primary cause seems to
be genetic.