Medical Surgical Bullets + Common Board Exam A patient who is receiving chemotherapy is placed in reverse

isolation because the white blood cell count may be depressed.

Questions Symptoms of mitral valve stenosis are caused by improper
Part II emptying of the left atrium.
By: Dani Lou Wilfred D. Hamoy, RN. MAN Persistent bleeding after open heart surgery may require the
administration of protamine sulfate to reverse the effects of heparin
After a corneal transplant, the patient should wear an eye shield sodium used during surgery.
when engaging in activities such as playing with children or pets. The nurse should teach a patient with heart failure to take digoxin
After a corneal transplant, the patient shouldn’t lie on the affected and other drugs as prescribed, to restrict sodium intake, to restrict
site, bend at the waist, or have sexual intercourse for 1 week. The fluids as prescribed, to get adequate rest, to increase walking and
patient must avoid getting soapsuds in the eye. other activities gradually, to avoid extremes of temperature
A Milwaukee brace is used for patients who have structural The nurse should check and maintain the patency of all connections
scoliosis. The brace helps to halt the progression of spinal curvature for a chest tube. If an air leak is detected, the nurse should place one
by providing longitudinal traction and lateral pressure. It should be Kelly clamp near the insertion site. If the bubbling stops, the leak is
worn 23 hours a day. in the thoracic cavity and the physician should be notified
Short-term measures used to treat stomal retraction include stool immediately. If the leak continues, the nurse should take a second
softeners, irrigation, and stomal dilatation. clamp, work down the tube until the leak is located, and stop the
A patient who has a colostomy should be advised to eat a low- leak.
residue diet for 4 to 6 weeks and then to add one food at a time to In two-person cardiopulmonary resuscitation, the rescuers
evaluate its effect. administer 60 chest compressions per minute and 1 breath for every
To relieve postoperative hiccups, the patient should breathe into a 5 compressions.
paper bag. Mitral valve stenosis can result from rheumatic fever.
If a patient with an ileostomy has a blocked lumen as a result of Atelectasis is incomplete expansion of lung segments or lobules
undigested high-fiber food, the patient should be placed in the knee- (clusters of alveoli). It may cause the lung or lobe to collapse.
chest position and the area below the stoma should be massaged. The nurse should instruct a patient who has an ileal conduit to
During the initial interview and treatment of a patient with syphilis, empty the collection device frequently because the weight of the
the patient’s sexual contacts should be identified. urine may cause the device to slip from the skin.
The nurse shouldn’t administer morphine to a patient whose A patient who is receiving cardiopulmonary resuscitation should be
respiratory rate is less than 12 breaths/minute. placed on a solid, flat surface.
To prevent drying of the mucous membranes, oxygen should be Brain damage occurs 4 to 6 minutes after cardiopulmonary function
administered with hydration. ceases.
Flavoxate (Urispas) is classified as a urinary tract spasmolytic. Climacteric is the transition period during which a woman’s
Hypotension is a sign of cardiogenic shock in a patient with a reproductive function diminishes and gradually disappears.
myocardial infarction. After infratentorial surgery, the patient should remain on his side,
The predominant signs of mechanical ileus are cramping pain, flat in bed.
vomiting, distention, and inability to pass feces or flatus. In a patient who has an ulcer, milk is contraindicated because its
For a patient with a myocardial infarction, the nurse should high calcium content stimulates secretion of gastric acid.
monitor fluid intake and output meticulously. Too little intake causes A patient who has a positive test result for human
dehydration, and too much may cause pulmonary edema. immunodeficiency virus has been exposed to the virus associated
Nitroglycerin relaxes smooth muscle, causing vasodilation and with acquired immunodeficiency syndrome (AIDS), but doesn’t
relieving the chest pain associated with myocardial infarction and necessarily have AIDS.
angina. A common complication after prostatectomy is circulatory failure
The diagnosis of an acute myocardial infarction is based on the caused by bleeding.
patient’s signs and symptoms, electrocardiogram tracings, and In right-sided heart failure, a major focus of nursing care is
serum enzyme studies. decreasing the workload of the heart.
Arrhythmias are the predominant problem during the first 48 hours Signs and symptoms of digoxin toxicity include nausea, vomiting,
after a myocardial infarction. confusion, and arrhythmias.
Clinical manifestations of malabsorption include weight loss, An asthma attack typically begins with wheezing, coughing, and
muscle wasting, bloating, and steatorrhea. increasing respiratory distress.
Asparaginase, an enzyme that inhibits the synthesis of In a patient who is recovering from a tonsillectomy, frequent
deoxyribonucleic acid and protein, is used to treat acute lymphocytic swallowing suggests hemorrhage.
leukemia. Ileostomies and Hartmann’s colostomies are permanent stomas.
To relieve a patient’s sore throat that’s caused by nasogastric tube Loop colostomies and double-barrel colostomies are temporary
irritation, the nurse should provide anesthetic lozenges, as ones.
prescribed. A patient who has an ileostomy should eat foods, such as spinach
For the first 12 to 24 hours after gastric surgery, the stomach and parsley, because they act as intestinal tract deodorizers.
contents (obtained by suctioning) are brown. An adrenalectomy can decrease steroid production, which can
After gastric suctioning is discontinued, a patient who is recovering cause extensive loss of sodium and water.
from a subtotal gastrectomy should receive a clear liquid diet. Before administering morphine (Duramorph) to a patient who is
The descending colon is the preferred site for a permanent suspected of having a myocardial infarction, the nurse should check
colostomy. the patient’s respiratory rate. If it’s less than 12 breaths/minute,
Valvular insufficiency in the veins commonly causes varicosity. emergency equipment should be readily available for intubation if
A patient with a colostomy should restrict fat and fibrous foods and respiratory depression occurs.
should avoid foods that can obstruct the stoma, such as corn, nuts, A patient who is recovering from supratentorial surgery is normally
and cabbage. allowed out of bed 14 to 48 hours after surgery. A patient who is
recovering from infratentorial surgery normally remains on bed rest In otitis media, the tympanic membrane is bright red and lacks its
for 3 to 5 days. characteristic light reflex (cone of light).
After a patient undergoes a femoral-popliteal bypass graft, the In patients who have pericardiocentesis, fluid is aspirated from the
nurse must closely monitor the peripheral pulses distal to the pericardial sac for analysis or to relieve cardiac tamponade.
operative site and circulation. Urticaria is an early sign of hemolytic transfusion reaction.
After a femoral-popliteal bypass graft, the patient should initially be During peritoneal dialysis, a return of brown dialysate suggests
maintained in a semi-Fowler position to avoid flexion of the graft bowel perforation. The physician should be notified immediately.
site. Before discharge, the nurse should instruct the patient to avoid An early sign of ketoacidosis is polyuria, which is caused by osmotic
positions that put pressure on the graft site until the next follow-up diuresis.
visit. Patients who have multiple sclerosis should visually inspect their
Of the five senses, hearing is the last to be lost in a patient who is extremities to ensure proper alignment and freedom from injury.
entering a coma. Aspirated red bone marrow usually appears rust-red, with visible
Cholelithiasis causes an enlarged, edematous gallbladder with fatty material and white bone fragments.
multiple stones and an elevated bilirubin level. The Dick test detects scarlet fever antigens and immunity or
The antiviral agent zidovudine (Retrovir) successfully slows susceptibility to scarlet fever. A positive result indicates no
replication of the human immunodeficiency virus, thereby slowing immunity; a negative result indicates immunity.
the development of acquired immunodeficiency syndrome. The Schick test detects diphtheria antigens and immunity or
Severe rheumatoid arthritis causes marked edema and congestion, susceptibility to diphtheria. A positive result indicates no immunity;
spindle-shaped joints, and severe flexion deformities. a negative result indicates immunity.
A patient with acquired immunodeficiency syndrome should advise The recommended adult dosage of sucralfate (Carafate) for
his sexual partners of his human immunodeficiency virus status and duodenal ulcer is 1 g (1 tablet) four times daily 1 hour before meals
observe sexual precautions, such as abstinence or condom use. and at bedtime.
If a radioactive implant becomes dislodged, the nurse should A patient with facial burns or smoke or heat inhalation should be
retrieve it with tongs, place it in a lead-shielded container, and admitted to the hospital for 24-hour observation for delayed
notify the radiology department. tracheal edema.
A patient who is undergoing radiation therapy should pat his skin In addition to patient teaching, preparation for a colostomy
dry to avoid abrasions that could easily become infected. includes withholding oral intake overnight, performing bowel
During radiation therapy, a patient should have frequent blood tests, preparation, and administering a cleansing enema.
especially white blood cell and platelet counts. The physiologic changes caused by burn injuries can be divided into
The nurse should administer an aluminum hydroxide antacid at two stages: the hypovolemic stage, during which intravascular fluid
least 1 hour after an enteric-coated drug because it can cause shifts into the interstitial space, and the diuretic stage, during which
premature release of the enteric-coated drug in the stomach. capillary integrity and intravascular volume are restored, usually 48
Acid-base balance is the body’s hydrogen ion concentration, a to 72 hours after the injury.
measure of the ratio of carbonic acid to bicarbonate ions (1 part The nurse should change total parenteral nutrition tubing every 24
carbonic acid to 20 parts bicarbonate is normal). hours and the peripheral I.V. access site dressing every 72 hours.
Amyotrophic lateral sclerosis causes progressive atrophy and A patient whose carbon monoxide level is 20% to 30% should be
wasting of muscle groups that eventually affects the respiratory treated with 100% humidified oxygen.
muscles. When in the room of a patient who is in isolation for tuberculosis,
Metabolic acidosis is caused by abnormal loss of bicarbonate ions or staff and visitors should wear ultrafilter masks.
excessive production or retention of acid ions. When providing skin care immediately after pin insertion, the
Hemianopsia is defective vision or blindness in one-half of the visual nurse’s primary concern is prevention of bone infection.
field of one or both eyes. After an amputation, moist skin may indicate venous stasis; dry skin
Systemic lupus erythematosus causes early-morning joint stiffness may indicate arterial obstruction.
and facial erythema in a butterfly pattern. In a patient who is receiving dialysis, an internal shunt is working if
After total knee replacement, the patient should remain in the the nurse feels a thrill on palpation or hears a bruit on auscultation.
semi-Fowler position, with the affected leg elevated. In a patient with viral hepatitis, the parenchymal, or Kupffer’s, cells
In a patient who is receiving transpyloric feedings, the nurse should of the liver become severely inflamed, enlarged, and necrotic.
watch for dumping syndrome and hypovolemic shock because the Early signs of acquired immunodeficiency syndrome include fatigue,
stomach is being bypassed. night sweats, enlarged lymph nodes, anorexia, weight loss, pallor,
If a total parenteral nutrition infusion must be interrupted, the and fever.
nurse should administer dextrose 5% in water at a similar rate. When caring for a patient who has a radioactive implant, health
Abrupt cessation can cause hypoglycemia. care workers should stay as far away from the radiation source as
Status epilepticus is treated with I.V. diazepam (Valium) and possible. They should remember the axiom, “If you double the
phenytoin (Dilantin). distance, you quarter the dose.”
Disequilibrium syndrome causes nausea, vomiting, restlessness, and A patient who has Parkinson’s disease should be instructed to walk
twitching in patients who are undergoing dialysis. It’s caused by a with a broad-based gait.
rapid fluid shift. The cardinal signs of Parkinson’s disease are muscle rigidity, a
An indication that spinal shock is resolving is the return of reflex tremor that begins in the fingers, and akinesia.
activity in the arms and legs below the level of injury. In a patient with Parkinson’s disease, levodopa (Dopar) is
Hypovolemia is the most common and fatal complication of severe prescribed to compensate for the dopamine deficiency.
acute pancreatitis. A patient who has multiple sclerosis is at increased risk for pressure
In a patient with stomatitis, oral care includes rinsing the mouth ulcers.
with a mixture of equal parts of hydrogen peroxide and water three Pill-rolling tremor is a classic sign of Parkinson’s disease.
times daily. For a patient with Parkinson’s disease, nursing
interventions are palliative.
Fat embolism, a serious complication of a long-bone fracture, causes During stage III of surgical anesthesia, unconsciousness occurs and
fever, tachycardia, tachypnea, and anxiety. surgery is permitted.
Metrorrhagia (bleeding between menstrual periods) may be the first Types of regional anesthesia include spinal, caudal, intercostal,
sign of cervical cancer. epidural, and brachial plexus.
Mannitol is a hypertonic solution and an osmotic diuretic that’s The first step in managing drug overdose or drug toxicity is to
used in the treatment of increased intracranial pressure. establish and maintain an airway.
The classic sign of an absence seizure is a vacant facial expression. Respiratory paralysis occurs in stage IV of anesthesia (toxic stage).
Migraine headaches cause persistent, severe pain that usually In stage I of anesthesia, the patient is conscious and tranquil.
occurs in the temporal region. Dyspnea and sharp, stabbing pain that increases with respiration
A patient who is in a bladder retraining program should be given an are symptoms of pleurisy, which can be a complication of
opportunity to void every 2 hours during the day and twice at night. pneumonia or tuberculosis.
In a patient with a head injury, a decrease in level of consciousness Vertigo is the major symptom of inner ear infection or disease.
is a cardinal sign of increased intracranial pressure. Loud talking is a sign of hearing impairment.
Ergotamine (Ergomar) is most effective when taken during the A patient who has an upper respiratory tract infection should blow
prodromal phase of a migraine or vascular headache. his nose with both nostrils open.
Treatment of acute pancreatitis includes nasogastric suctioning to A patient who has had a cataract removed can begin most normal
decompress the stomach and meperidine (Demerol) for pain. activities in 3 or 4 days; however, the patient shouldn’t bend and lift
Symptoms of hiatal hernia include a feeling of fullness in the upper until a physician approves these activities.
abdomen or chest, heartburn, and pain similar to that of angina Symptoms of corneal transplant rejection include eye irritation and
pectoris. decreasing visual field.
The incidence of cholelithiasis is higher in women who have had Graves’ disease (hyperthyroidism) is manifested by weight loss,
children than in any other group. nervousness, dyspnea, palpitations, heat intolerance, increased
Acetaminophen (Tylenol) overdose can severely damage the liver. thirst, exophthalmos (bulging eyes), and goiter.
The prominent clinical signs of advanced cirrhosis are ascites and The four types of lipoprotein are chylomicrons (the lowest-density
jaundice. lipoproteins), very-low-density lipoproteins, low-density
The first symptom of pancreatitis is steady epigastric pain or left lipoproteins, and high-density lipoproteins. Health care professionals
upper quadrant pain that radiates from the umbilical area or the use cholesterol level fractionation to assess a patient’s risk of
back. coronary artery disease.
Somnambulism is the medical term for sleepwalking. If a patient who is taking amphotericin B (Fungizone) bladder
Epinephrine (Adrenalin) is a vasoconstrictor. irrigations for a fungal infection has systemic candidiasis and must
An untreated liver laceration or rupture can progress rapidly to receive I.V. fluconazole (Diflucan), the irrigations can be
hypovolemic shock. discontinued because fluconazole treats the bladder infection as
Obstipation is extreme, intractable constipation caused by an well.
intestinal obstruction. Patients with adult respiratory distress syndrome can have high
The definitive test for diagnosing cancer is biopsy with cytologic peak inspiratory pressures. Therefore, the nurse should monitor
examination of the specimen. these patients closely for signs of spontaneous pneumothorax, such
Arthrography requires injection of a contrast medium and can as acute deterioration in oxygenation, absence of breath sounds on
identify joint abnormalities. the affected side, and crepitus beginning on the affected side.
Brompton’s cocktail is prescribed to help relieve pain in patients Adverse reactions to cyclosporine (Sandimmune) include renal and
who have terminal cancer. hepatic toxicity, central nervous system changes (confusion and
A sarcoma is a malignant tumor in connective tissue. delirium), GI bleeding, and hypertension.
Aluminum hydroxide (Amphojel) neutralizes gastric acid. Osteoporosis is a metabolic bone disorder in which the rate of bone
Subluxation is partial dislocation or separation, with spontaneous resorption exceeds the rate of bone formation.
reduction of a joint. The hallmark of ulcerative colitis is recurrent bloody diarrhea, which
Barbiturates can cause confusion and delirium in an elderly patient commonly contains pus and mucus and alternates with
who has an organic brain disorder. asymptomatic remissions.
In a patient with arthritis, physical therapy is indicated to promote Safer sexual practices include massaging, hugging, body rubbing,
optimal functioning. friendly kissing (dry), masturbating, hand-to-genital touching,
Some patients who have hepatitis A may be anicteric (without wearing a condom, and limiting the number of sexual partners.
jaundice) and lack symptoms, but some have headaches, jaundice, Immunosuppressed patients who contract cytomegalovirus (CMV)
anorexia, fatigue, fever, and respiratory tract infection. are at risk for CMV pneumonia and septicemia, which can be fatal.
Hepatitis A is usually mild and won’t advance to a carrier state. Urinary tract infections can cause urinary urgency and frequency,
In the preicteric phase of all forms of hepatitis, the patient is highly dysuria, abdominal cramps or bladder spasms, and urethral itching.
contagious. Mammography is a radiographic technique that’s used to detect
Enteric precautions are required for a patient who has hepatitis A. breast cysts or tumors, especially those that aren’t palpable on
Cholecystography is ineffective in a patient who has jaundice as a physical examination.
result of gallbladder disease. The liver cells can’t transport the To promote early detection of testicular cancer, the nurse should
contrast medium to the biliary tract. palpate the testes during routine physical examinations and
In a patient who has diabetes insipidus, dehydration is a concern encourage the patient to perform monthly self-examinations during
because diabetes causes polyuria. a warm shower.
In a patient who has a reducible hernia, the protruding mass Patients who have thalassemia minor require no treatment. Those
spontaneously retracts into the abdomen. with thalassemia major require frequent transfusions of red blood
To prevent purple glove syndrome, a nurse shouldn’t administer I.V. cells.
phenytoin (Dilantin) through a vein in the back of the hand, but
should use a larger vessel.
A high level of hepatitis B serum marker that persists for 3 months The universal sign for choking is clutching the hand to the throat.
or more after the onset of acute hepatitis B infection suggests For a patient who has heart failure or cardiogenic pulmonary
chronic hepatitis or carrier status. edema, nursing interventions focus on decreasing venous return to
Neurogenic bladder dysfunction is caused by disruption of nerve the heart and increasing left ventricular output. These interventions
transmission to the bladder. It may be caused by certain spinal cord include placing the patient in high Fowler’s position and
injuries, diabetes, or multiple sclerosis. administering oxygen, diuretics, and positive inotropic drugs as
Oxygen and carbon dioxide move between the lungs and the prescribed.
bloodstream by diffusion. A positive tuberculin skin test is an induration of 10 mm or greater
During cardiac arrest, if an I.V. route is unavailable, epinephrine can at the injection site.
be administered endotracheally. The signs and symptoms of histoplasmosis, a chronic systemic
Pernicious anemia results from the failure to absorb vitamin B12 in fungal infection, resemble those of tuberculosis.
the GI tract and causes primarily GI and neurologic signs and In burn victims, the leading cause of death is respiratory
symptoms. compromise. The second leading cause is infection.
A patient who has a pressure ulcer should consume a high-protein, The exocrine function of the pancreas is the secretion of enzymes
high-calorie diet, unless contraindicated. used to digest carbohydrates, fats, and proteins.
The CK-MB isoenzyme level is used to assess tissue damage in A patient who has hepatitis A (infectious hepatitis) should consume
myocardial infarction. a diet that’s moderately high in fat and high in carbohydrate and
After a 12-hour fast, the normal fasting blood glucose level is 80 to protein, and should eat the largest meal in the morning.
120 mg/dl. Esophageal balloon tamponade shouldn’t be inflated greater than
A patient who is experiencing digoxin toxicity may report nausea, 20 mm Hg.
vomiting, diplopia, blurred vision, light flashes, and yellow-green Overproduction of prolactin by the pituitary gland can cause
halos around images. galactorrhea (excessive or abnormal lactation) and amenorrhea
Anuria is daily urine output of less than 100 ml. (absence of menstruation).
In remittent fever, the body temperature varies over a 24-hour Intermittent claudication (pain during ambulation or other
period, but remains elevated. movement that’s relieved with rest) is a classic symptom of arterial
Risk of a fat embolism is greatest in the first 48 hours after the insufficiency in the leg.
fracture of a long bone. It’s manifested by respiratory distress. In bladder carcinoma, the most common finding is gross, painless
To help venous blood return in a patient who is in shock, the nurse hematuria.
should elevate the patient’s legs no more than 45 degrees. This Parenteral administration of heparin sodium is contraindicated in
procedure is contraindicated in a patient with a head injury. patients with renal or liver disease, GI bleeding, or recent surgery or
The pulse deficit is the difference between the apical and radial trauma; in pregnant patients; and in women older than age 60.
pulse rates, when taken simultaneously by two nurses. Drugs that potentiate the effects of anticoagulants include aspirin,
To reduce the patient’s risk of vomiting and aspiration, the nurse chloral hydrate, glucagon, anabolic steroids, and chloramphenicol.
should schedule postural drainage before meals or 2 to 4 hours after For a burn patient, care priorities include maintaining a patent
meals. airway, preventing or correcting fluid and electrolyte imbalances,
Blood pressure can be measured directly by intra-arterial insertion controlling pain, and preventing infection.
of a catheter connected to a pressure-monitoring device. Elastic stockings should be worn on both legs.
A positive Kernig’s sign, seen in meningitis, occurs when an attempt Active immunization is the formation of antibodies within the body
to flex the hip of a recumbent patient causes painful spasms of the in response to vaccination or exposure to disease.
hamstring muscle and resistance to further extension of the leg at Passive immunization is administration of antibodies that were
the knee. preformed outside the body.
In a patient with a fractured, dislocated femur, treatment begins A patient who is receiving digoxin (Lanoxin) shouldn’t receive a
with reduction and immobilization of the affected leg. calcium preparation because of the increased risk of digoxin toxicity.
Herniated nucleus pulposus (intervertebral disk) most commonly Concomitant use may affect cardiac contractility and lead to
occurs in the lumbar and lumbosacral regions. arrhythmias.
Laminectomy is surgical removal of the herniated portion of an Intermittent positive-pressure breathing is inflation of the lung
intervertebral disk. during inspiration with compressed air or oxygen. The goal of this
Surgical treatment of a gastric ulcer includes severing the vagus inflation is to keep the lung open.
nerve (vagotomy) to reduce the amount of gastric acid secreted by Wristdrop is caused by paralysis of the extensor muscles in the
the gastric cells. forearm and hand.
Valsalva’s maneuver is forced exhalation against a closed glottis, as Footdrop results from excessive plantar flexion and is usually a
when taking a deep breath, blowing air out, or bearing down. complication of prolonged bed rest.
When mean arterial pressure falls below 60 mm Hg and systolic A patient who has gonorrhea may be treated with penicillin and
blood pressure falls below 80 mm Hg, vital organ perfusion is probenecid (Benemid). Probenecid delays the excretion of penicillin
seriously compromised. and keeps this antibiotic in the body longer.
Lidocaine (Xylocaine) is the drug of choice for reducing premature In patients who have glucose-6-phosphate dehydrogenase (G6PD)
ventricular contractions. deficiency, the red blood cells can’t metabolize adequate amounts
A patient is at greatest risk of dying during the first 24 to 48 hours of glucose, and hemolysis occurs.
after a myocardial infarction. On-call medication is medication that should be ready for
During a myocardial infarction, the left ventricle usually sustains the immediate administration when the call to administer it’s received.
greatest damage. If gagging, nausea, or vomiting occurs when an airway is removed,
The pain of a myocardial infarction results from myocardial the nurse should place the patient in a lateral position with the
ischemia caused by anoxia. upper arm supported on a pillow.
For a patient in cardiac arrest, the first priority is to establish an
airway.
When a postoperative patient arrives in the recovery room, the pH PaCO2 HCO3– = metabolic acidosis compensated
nurse should position the patient on his side or with his head turned pH PaCO2 HCO3– = metabolic alkalosis compensated.
to the side and the chin extended. Polyuria is urine output of 2,500 ml or more within 24 hours.
In the immediate postoperative period, the nurse should report a The presenting sign of pleuritis is chest pain that is usually unilateral
respiratory rate greater than 30, temperature greater than 100° F and related to respiratory movement.
(37.8° C) or below 97° F (36.1° C), or a significant drop in blood If a patient has a gastric drainage tube in place, the nurse should
pressure or rise in pulse rate from the baseline. expect the physician to order potassium chloride.
Irreversible brain damage may occur if the central nervous system is An increased pulse rate is one of the first indications of respiratory
deprived of oxygen for more than 4 minutes. difficulty. It occurs because the heart attempts to compensate for a
Treatment for polycythemia vera includes administering oxygen, decreased oxygen supply to the tissues by pumping more blood.
radioisotope therapy, or chemotherapy agents, such as chlorambucil In an adult, a hemoglobin level below 11 mg/dl suggests iron
and nitrogen mustard, to suppress bone marrow growth. deficiency anemia and the need for further evaluation.
A patient with acute renal failure should receive a high-calorie diet The normal partial pressure of oxygen in arterial blood is 95 mm Hg
that’s low in protein as well as potassium and sodium. (plus or minus 5 mm Hg).
Addison’s disease is caused by hypofunction of the adrenal gland Vitamin C deficiency is characterized by brittle bones, pinpoint
and is characterized by fatigue, anemia, weight loss, and bronze skin peripheral hemorrhages, and friable gums with loosened teeth.
pigmentation. Without cortisol replacement therapy, it’s usually Clinical manifestations of pulmonary embolism are variable, but
fatal. increased respiratory rate, tachycardia, and hemoptysis are
Glaucoma is managed conservatively with beta-adrenergic blockers common.
such as timolol (Timoptic), which decrease sympathetic impulses to Normally, intraocular pressure is 12 to 20 mm Hg. It can be
the eye, and with miotic eyedrops such as pilocarpine (Isopto measured with a Schiøtz tonometer.
Carpine), which constrict the pupils. In early hemorrhagic shock, blood pressure may be normal, but
Miotics effectively treat glaucoma by reducing intraocular pressure. respiratory and pulse rates are rapid. The patient may report thirst
They do this by constricting the pupil, contracting the ciliary muscles, and may have clammy skin and piloerection (goose bumps).
opening the anterior chamber angle, and increasing the outflow of Cool, moist, pale skin, as occurs in shock, results from diversion of
aqueous humor. blood from the skin to the major organs.
While a patient is receiving heparin, the nurse should monitor the To assess capillary refill, the nurse applies pressure over the nail
partial thromboplastin time. bed until blanching occurs, quickly releases the pressure, and notes
Urinary frequency, incontinence, or both can occur after catheter the rate at which blanching fades. Capillary refill indicates perfusion,
removal. Incontinence may be manifested as dribbling. which decreases in shock, thereby lengthening refill time. Normal
When teaching a patient about colostomy care, the nurse should capillary refill is less than 3 seconds.
instruct the patient to hang the irrigation reservoir 18″ to 22″ (45 to Except for patients with renal failure, urine output of less than 30
55 cm) above the stoma, insert the catheter 2″ to 4″ (5 to 10 cm) ml/hour signifies dehydration and the potential for shock.
into the stoma, irrigate the stoma with 17 to 34 oz (503 to 1,005 ml) In elderly patients, the most common fracture is hip fracture.
of water at a temperature of 105° to 110° F (40° to 43° C) once a Osteoporosis weakens the bones, predisposing these patients to
day, clean the area around the stoma with soap and water before fracture, which usually results from a fall.
applying a new bag, and use a protective skin covering, such as a Before angiography, the nurse should ask the patient whether he’s
Stomahesive wafer, karaya paste, or karaya ring, around the stoma. allergic to the dye, shellfish, or iodine and advise him to take nothing
The first sign of Hodgkin’s disease is painless, superficial by mouth for 8 hours before the procedure.
lymphadenopathy, typically found under one arm or on one side of During myelography, approximately 10 to 15 ml of cerebrospinal
the neck in the cervical chain. fluid is removed for laboratory studies and an equal amount of
To differentiate true cyanosis from deposition of certain pigments, contrast media is injected.
the nurse should press the skin over the discolored area. Cyanotic After angiography, the puncture site is covered with a pressure
skin blanches, but pigmented skin doesn’t. dressing and the affected part is immobilized for 8 hours to decrease
A patient who has a gastric ulcer is most likely to report pain during the risk of bleeding.
or shortly after eating. If a water-based medium was used during myelography, the patient
Widening pulse pressure is a sign of increasing intracranial pressure. remains on bed rest for 6 to 8 hours, with the head of the bed
For example, the blood pressure may rise from 120/80 to 160/60 elevated 30 to 45 degrees. If an oil-based medium was used, the
mm Hg. patient remains flat in bed for 6 to 24 hours.
In a burn victim, a primary goal of wound care is to prevent The level of amputation is determined by estimating the maximum
contamination by microorganisms. viable tissue (tissue with adequate circulation) needed to develop a
To prevent external rotation in a patient who has had hip nailing, functional stump.
the nurse places trochanter rolls from the knee to the ankle of the Heparin sodium is included in the dialysate used for renal dialysis.
affected leg. Paroxysmal nocturnal dyspnea may indicate heart failure.
Severe hip pain after the insertion of a hip prosthesis indicates A patient who takes a cardiac glycoside, such as digoxin, should
dislodgment. If this occurs, before calling the physician, the nurse consume a diet that includes high-potassium foods.
should assess the patient for shortening of the leg, external rotation, The nurse should limit tracheobronchial suctioning to 10 to 15
and absence of reflexes. seconds and should make only two passes.
As much as 75% of renal function is lost before blood urea nitrogen Before performing tracheobronchial suctioning, the nurse should
and serum creatinine levels rise above normal. ventilate and oxygenate the patient five to six times with a
When compensatory efforts are present in acid-base balance, partial resuscitation bag and 100% oxygen. This procedure is called bagging.
pressure of arterial carbon dioxide (PaCO2) and bicarbonate Signs and symptoms of pneumothorax include tachypnea,
(HCO3–) always point in the same direction: restlessness, hypotension, and tracheal deviation.
pH PaCO2 HCO3– = respiratory acidosis compensated The cardinal sign of toxic shock syndrome is rapid onset of a high
pH PaCO2 HCO3– = respiratory alkalosis compensated fever.
A key sign of peptic ulcer is hematemesis, which can be bright red The level of alpha-fetoprotein, a tumor marker, is elevated in
or dark red, with the consistency of coffee grounds. patients who have testicular germ cell cancer.
Signs and symptoms of a perforated peptic ulcer include sudden, Clinical manifestations of orchitis caused by bacteria or mumps
severe upper abdominal pain; vomiting; and an extremely tender, include high temperature, chills, and sudden pain in the involved
rigid (boardlike) abdomen. testis.
Constipation is a common adverse reaction to aluminum hydroxide. The level of prostate-specific antigen is elevated in patients with
For the first 24 hours after a myocardial infarction, the patient benign prostatic hyperplasia or prostate cancer.
should use a bedside commode and then progress to walking to the The level of prostatic acid phosphatase is elevated in patients with
toilet, bathing, and taking short walks. advanced stages of prostate cancer.
After a myocardial infarction, the patient should avoid overexertion Phenylephrine (Neo-Synephrine), a mydriatic, is instilled in a
and add a new activity daily, as tolerated without dyspnea. patient’s eye to dilate the eye.
In a patient with a recent myocardial infarction, frothy, blood-tinged To promote fluid drainage and relieve edema in a patient with
sputum suggests pulmonary edema. epididymitis, the nurse should elevate the scrotum on a scrotal
In a patient who has acquired immunodeficiency syndrome, the bridge.
primary purpose of drugs is to prevent secondary infections. Fluorescein staining is commonly used to assess corneal abrasions
In a patient with acquired immunodeficiency syndrome, suppression because it outlines superficial epithelial defects.
of the immune system increases the risk of opportunistic infections, Presbyopia is loss of near vision as a result of the loss of elasticity of
such as cytomegalovirus, Pneumocystis carinii pneumonia, and the crystalline lens.
thrush. Transient ischemic attacks are considered precursors to strokes.
A patient with acquired immunodeficiency syndrome may have A sign of acute appendicitis, McBurney’s sign is tenderness at
rapid weight loss, a sign of wasting syndrome. McBurney’s point (about 2″ [5 cm] from the right anterior superior
If the body doesn’t use glucose for energy, it metabolizes fat and iliac spine on a line between the spine and the umbilicus).
produces ketones. When caring for a patient with Guillain-Barré syndrome, the nurse
Approximately 20% of patients with Guillain-Barré syndrome have should focus on respiratory interventions as the disease process
residual deficits, such as mild motor weakness or diminished lower advances.
extremity reflexes. Signs and symptoms of colon cancer include rectal bleeding, change
Hypertension and hypokalemia are the most significant clinical in bowel habits, intestinal obstruction, abdominal pain, weight loss,
manifestations of primary hyperaldosteronism. anorexia, nausea, and vomiting.
After percutaneous aspiration of the bladder, the patient’s first void Symptoms of prostatitis include frequent urination and dysuria.
is usually pink; however, urine with frank blood should be reported A chancre is a painless, ulcerative lesion that develops during the
to the physician. primary stage of syphilis.
A urine culture that grows more than 100,000 colonies of bacteria During the tertiary stage of syphilis, spirochetes invade the internal
per milliliter of urine indicates infection. organs and cause permanent damage.
A patient who is undergoing dialysis should take a vitamin In total parenteral nutrition, weight gain is the most reliable
supplement and eat foods that are high in calories, but low in indicator of a positive response to therapy.
protein, sodium, and potassium. The nurse may administer an I.V. fat emulsion through a central or
In a patient who has chronic obstructive pulmonary disease, the peripheral catheter, but shouldn’t use an in-line filter because the
most effective ways to reduce thick secretions are to increase fluid fat particles are too large to pass through the pores.
intake to 2,500 ml/day and encourage ambulation. If a patient who has a prostatectomy is using a Cunningham clamp,
The nurse should teach a patient with emphysema how to perform instruct him to wash and dry his penis before applying the clamp. He
pursed-lip breathing because this slows expiration, prevents alveolar should apply the clamp horizontally and remove it at least every 4
collapse, and helps to control the respiratory rate. hours to empty his bladder to prevent infection.
Clubbing of the digits and a barrel chest may develop in a patient If a woman has signs of urinary tract infection during menopause,
who has chronic obstructive pulmonary disease. she should be instructed to drink six to eight glasses of water per
A stroke (“brain attack”) disrupts the brain’s blood supply and may day, urinate before and after intercourse, and perform Kegel
be caused by hypertension. exercises.
In a patient who is undergoing dialysis, desired outcomes are If a menopausal patient experiences a “hot flash,” she should be
normal weight, normal serum albumin level (3.5 to 5.5 g/dl), and instructed to seek a cool, breezy location and sip a cool drink.
adequate protein intake (1.2 to 1.5 g/kg of body weight daily). Cheilosis causes fissures at the angles of the mouth and indicates a
Intermittent peritoneal dialysis involves performing three to seven vitamin B2, riboflavin, or iron deficiency.
treatments that total 40 hours per week. Tetany may result from hypocalcemia caused by
In a patient with chronic obstructive pulmonary disease, the best hypoparathyroidism.
way to administer oxygen is by nasal cannula. The normal flow rate A patient who has cervical cancer may experience vaginal bleeding
is 2 to 3 L/ minute. for 1 to 3 months after intracavitary radiation.
Isoetharine (Bronkosol) can be administered with a handheld Ascites is the accumulation of fluid, containing large amounts of
nebulizer or by intermittent positive-pressure breathing. protein and electrolytes, in the abdominal cavity. It’s commonly
Brain death is irreversible cessation of brain function. caused by cirrhosis.
Continuous ambulatory peritoneal dialysis requires four exchanges Normal pulmonary artery pressure is 10 to 25 mm Hg. Normal
per day, 7 days per week, for a total of 168 hours per week. pulmonary artery wedge pressure is 5 to 12 mm Hg.
The classic adverse reactions to antihistamines are dry mouth, After cardiac catheterization, the site is monitored for bleeding and
drowsiness, and blurred vision. hematoma formation, pulses distal to the site are palpated every 15
Because of the risk of paralytic ileus, a patient who has received a minutes for 1 hour, and the patient is maintained on bed rest with
general anesthetic can’t take anything by mouth until active bowel the extremity extended for 8 hours.
sounds are heard in all abdominal quadrants. Hemophilia is a bleeding disorder that’s transmitted genetically in a
sex-linked (X chromosome) recessive pattern. Although girls and
women may carry the defective gene, hemophilia usually occurs A rapid pulse rate in a postoperative patient may indicate pain,
only in boys and men. bleeding, dehydration, or shock.
Von Willebrand’s disease is an autosomal dominant bleeding Increased pulse rate and blood pressure may indicate that a patient
disorder that’s caused by platelet dysfunction and factor VIII is experiencing “silent pain” (pain that can’t be expressed verbally,
deficiency. such as when a patient is recovering from anesthesia).
Sickle cell anemia is a congenital hemolytic anemia that’s caused by Lidocaine (Xylocaine) exerts antiarrhythmic action by suppressing
defective hemoglobin S molecules. It primarily affects blacks. automaticity in the Purkinje fibers and elevating the electrical
Sickle cell anemia has a homozygous inheritance pattern. Sickle cell stimulation threshold in the ventricles.
trait has a heterozygous inheritance pattern. Cullen’s sign (a bluish discoloration around the umbilicus) is seen in
Pel-Ebstein fever is a characteristic sign of Hodgkin’s disease. Fever patients who have a perforated pancreas.
recurs every few days or weeks and alternates with afebrile periods. During the postoperative period, the patient should cough and
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an breathe deeply every 2 hours unless otherwise contraindicated (for
inherited metabolic disorder that’s characterized by red blood cells example, after craniotomy, cataract surgery, or throat surgery).
that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Before surgery, a patient’s respiratory volume may be measured by
Preferred sites for bone marrow aspiration are the posterior incentive spirometry. This measurement becomes the patient’s
superior iliac crest, anterior iliac crest, and sternum. postoperative goal for respiratory volume.
During bone marrow harvesting, the donor receives general The postoperative patient should use incentive spirometry 10 to 12
anesthesia and 400 to 800 ml of marrow is aspirated. times per hour and breathe deeply.
A butterfly rash across the bridge of the nose is a characteristic sign Before ambulating, a postoperative patient should dangle his legs
of systemic lupus erythematosus. over the side of the bed and perform deep-breathing exercises.
Rheumatoid arthritis is a chronic, destructive collagen disease During the patient’s first postoperative ambulation, the nurse
characterized by symmetric inflammation of the synovium that leads should monitor the patient closely and assist him as needed while he
to joint swelling. walks a few feet from the bed to a steady chair.
Screening for human immunodeficiency virus antibodies begins Hypovolemia occurs when 15% to 25% of the body’s total blood
with the enzyme-linked immunosorbent assay. Results are volume is lost.
confirmed by the Western blot test. Signs and symptoms of hypovolemia include rapid, weak pulse; low
The CK-MB isoenzyme level increases 4 to 8 hours after a blood pressure; cool, clammy skin; shallow respirations; oliguria or
myocardial infarction, peaks at 12 to 24 hours, and returns to anuria; and lethargy.
normal in 3 days. Acute pericarditis causes sudden severe, constant pain over the
Excessive intake of vitamin K may significantly antagonize the anterior chest. The pain is aggravated by inspiration.
anticoagulant effects of warfarin (Coumadin). The patient should be Signs and symptoms of septicemia include fever, chills, rash,
cautioned to avoid eating an excessive amount of leafy green abdominal distention, prostration, pain, headache, nausea, and
vegetables. diarrhea.
A lymph node biopsy that shows Reed-Sternberg cells provides a Rocky Mountain spotted fever causes a persistent high fever,
definitive diagnosis of Hodgkin’s disease. nonpitting edema, and rash.
Bell’s palsy is unilateral facial weakness or paralysis caused by a Patients who have undergone coronary artery bypass graft should
disturbance of the seventh cranial (facial) nerve. sleep 6 to 10 hours per day, take their temperature twice daily, and
During an initial tuberculin skin test, lack of a wheal after injection avoid lifting more than 10 lb (4.5 kg) for at least 6 weeks.
of tuberculin purified protein derivative indicates that the test dose Claudication pain (pain on ambulation) is caused by arterial
was injected too deeply. The nurse should inject another dose at insufficiency as a result of atheromatous plaque that obstructs
least 2″ (5 cm) from the initial site. arterial blood flow to the extremities.
A tuberculin skin test should be read 48 to 72 hours after Pacemakers can be powered by lithium batteries for up to 10 years.
administration. The patient shouldn’t void for 1 hour before percutaneous
In reading a tuberculin skin test, erythema without induration is suprapubic bladder aspiration to ensure that sufficient urine remains
usually not significant. in the bladder to make the procedure successful.
Death caused by botulism usually results from delayed diagnosis Left-sided heart failure causes pulmonary congestion, pink-tinged
and respiratory complications. sputum, and dyspnea. (Remember L for left and lung.)
In a patient who has rabies, saliva contains the virus and is a hazard The current recommended blood cholesterol level is less than 200
for nurses who provide care. mg/dl.
A febrile nonhemolytic reaction is the most common transfusion When caring for a patient who is having a seizure, the nurse should
reaction. follow these guidelines: (1) Avoid restraining the patient, but help a
Hypokalemia (abnormally low concentration of potassium in the standing patient to a lying position. (2) Loosen restrictive clothing.
blood) may cause muscle weakness or paralysis, (3) Place a pillow or another soft object under the patient’s head. (4)
electrocardiographic abnormalities, and GI disturbances. Clear the area of hard objects. (5) Don’t force anything into the
Beriberi, a serious vitamin B1 (thiamine) deficiency, affects patient’s mouth, but maintain a patent airway. (6) Reassure and
alcoholics who have poor dietary habits. It’s epidemic in Asian reorient the patient after the seizure subsides.
countries where people subsist on unenriched rice. It’s characterized Gingival hyperplasia, or overgrowth of gum tissue, is an adverse
by the phrase “I can’t,” indicating that the patient is too ill to do reaction to phenytoin (Dilantin).
anything. With aging, most marrow in long bones becomes yellow, but it
Excessive sedation may cause respiratory depression. retains the capacity to convert back to red.
The primary postoperative concern is maintenance of a patent Clinical manifestations of lymphedema include accumulation of
airway. fluid in the legs.
If cyanosis occurs circumorally, sublingually, or in the nail bed, the Afterload is ventricular wall tension during systolic ejection. It’s
oxygen saturation level (Sao 2) is less than 80%. increased in patients who have septal hypertrophy, increased blood
viscosity, and conditions that cause blockage of aortic or pulmonary Hemodialysis is the removal of certain elements from the blood by
outflow. passing heparinized blood through a semipermeable membrane to
Red blood cells can be stored frozen for up to 2 years; however, they the dialysate bath, which contains all of the important electrolytes in
must be used within 24 hours of thawing. their ideal concentrations.
For the first 24 hours after amputation, the nurse should elevate the Gangrene usually affects the digits first, and begins with skin color
stump to prevent edema. changes that progress from gray-blue to dark brown or black.
After hysterectomy, a woman should avoid sexual intercourse for 3 Kidney function is assessed by evaluating blood urea nitrogen
weeks if a vaginal approach was used and 6 weeks if the abdominal (normal range is 8 to 20 mg/dl) and serum creatinine (normal range
approach was used. is 0.6 to 1.3 mg/dl) levels.
Parkinson’s disease characteristically causes progressive muscle A weight-bearing transfer is appropriate only for a patient who has
rigidity, akinesia, and involuntary tremor. at least one leg that’s strong enough to bear weight, such as a
Tonic-clonic seizures are characterized by a loss of consciousness patient with hemiplegia or a single-leg amputation.
and alternating periods of muscle contraction and relaxation. Overflow incontinence (voiding of 30 to 60 ml of urine every 15 to
Status epilepticus, a life-threatening emergency, is a series of rapidly 30 minutes) is a sign of bladder distention.
repeating seizures that occur without intervening periods of The first sign of a pressure ulcer is reddened skin that blanches when
consciousness. pressure is applied.
The ideal donor for kidney transplantation is an identical twin. If an Late signs and symptoms of sickle cell anemia include tachycardia,
identical twin isn’t available, a biological sibling is the next best cardiomegaly, systolic and diastolic murmurs, chronic fatigue,
choice. hepatomegaly, and splenomegaly.
Breast cancer is the leading cancer among women; however, lung A mechanical ventilator, which can maintain ventilation
cancer accounts for more deaths. automatically for an extended period, is indicated when a patient
The stages of cervical cancer are as follows: stage 0, carcinoma in can’t maintain a safe PaO2 or PaCO2 level.
situ; stage I, cancer confined to the cervix; stage II, cancer extending Two types of mechanical ventilators exist: negative-pressure
beyond the cervix, but not to the pelvic wall; stage III, cancer ventilators, which apply negative pressure around the chest wall,
extending to the pelvic wall; and stage IV, cancer extending beyond and positive-pressure ventilators, which deliver air under pressure
the pelvis or within the bladder or rectum. to the patient.
One method used to estimate blood loss after a hysterectomy is Angina pectoris is characterized by substernal pain that lasts for 2 to
counting perineal pads. Saturating more than one pad in 1 hour or 3 minutes. The pain, which is caused by myocardial ischemia, may
eight pads in 24 hours is considered hemorrhaging. radiate to the neck, shoulders, or jaw; is described as viselike, or
Transurethral resection of the prostate is the most common constricting; and may be accompanied by severe apprehension or a
procedure for treating benign prostatic hyperplasia. feeling of impending doom.
In a chest drainage system, the water in the water-seal chamber The diagnosis of an acute myocardial infarction is based on the
normally rises when a patient breathes in and falls when he breathes patient’s signs and symptoms, electrocardiogram tracings, troponin
out. level, and cardiac enzyme studies.
Spinal fusion provides spinal stability through a bone graft, usually The goal of treatment for a patient with angina pectoris is to reduce
from the iliac crest, that fuses two or more vertebrae. the heart’s workload, thereby reducing the myocardial demand for
A patient who receives any type of transplant must take an oxygen and preventing myocardial infarction.
immunosuppressant drug for the rest of his life. Nitroglycerin decreases the amount of blood that returns to the
Incentive spirometry should be used 5 to 10 times an hour while the heart by increasing the capacity of the venous bed.
patient is awake. The patient should take no more than three nitroglycerin tablets in a
In women, pelvic inflammatory disease is a common complication of 15-minute period.
gonorrhea. Hemodialysis is usually performed 24 hours before kidney
Scoliosis is lateral S-shaped curvature of the spine. transplantation.
Signs and symptoms of the secondary stage of syphilis include a rash Signs and symptoms of acute kidney transplant rejection are
on the palms and soles, erosion of the oral mucosa, alopecia, and progressive enlargement and tenderness at the transplant site,
enlarged lymph nodes. increased blood pressure, decreased urine output, elevated serum
In a patient who is receiving total parenteral nutrition, the nurse creatinine level, and fever.
should monitor glucose and electrolyte levels. After a radical mastectomy, the patient’s arm should be elevated
Unless contraindicated, on admission to the postanesthesia care (with the hand above the elbow) on a pillow to enhance circulation
unit, a patient should be turned on his side and his vital signs should and prevent edema.
be taken. Postoperative mastectomy care includes teaching the patient arm
Edema is treated by limiting fluid intake and eliminating excess fluid. exercises to facilitate lymph drainage and prevent shortening of the
A patient who has had spinal anesthesia should remain flat for 12 to muscle and contracture of the shoulder joint (frozen shoulder).
24 hours. Vital signs and neuromuscular function should be After radical mastectomy, the patient should help prevent infection
monitored. by making sure that no blood pressure readings, injections, or
A patient who has maple syrup urine disease should avoid food venipunctures are performed on the affected arm.
containing the amino acids leucine, isoleucine, and lysine. For a patient who has undergone mastectomy and is susceptible to
A severe complication of a femur fracture is excessive blood loss lymphedema, a program of hand exercises can begin shortly after
that results in shock. surgery, if prescribed. The program consists of opening and closing
To prepare a patient for peritoneal dialysis, the nurse should ask the the hand tightly six to eight times per hour and performing such
patient to void, measure his vital signs, place him in a supine tasks as washing the face and combing the hair.
position, and using aseptic technique, insert a catheter through the Signs and symptoms of theophylline toxicity include vomiting,
abdominal wall and into the peritoneal space. restlessness, and an apical pulse rate of more than 200
If more than 3 L of dialysate solution return during peritoneal beats/minute.
dialysis, the nurse should notify the physician.
The nurse shouldn’t induce vomiting in a person who has ingested Answer: 1-2 liters per nasal cannula, too much O2 may eliminate the
poison and is having seizures or is semiconscious or comatose. COPD client’s stimulus to breathe, a COPD client has hypoxic drive to
Central venous pressure (CVP), which is the pressure in the right breathe.
atrium and the great veins of the thorax, is normally 2 to 8 mm Hg
CBQ no. 4 How does the nurse prevent hypoxia during suctioning?
(or 5 to 12 cm H2O). CVP is used to assess right-sided cardiac
function. Answer: Deliver 100% oxygen (hyperinflating) before and after each
CVP is monitored to assess the need for fluid replacement in endotracheal suctioning.
seriously ill patients, to estimate blood volume deficits, and to CBQ no. 5 During mechanical ventilation, what are three major
evaluate circulatory pressure in the right atrium. nursing intervention?
To prevent deep vein thrombosis after surgery, the nurse should Answer: Monitor client’s respiratory status and secure connections,
administer 5,000 units of heparin subcutaneously every 8 to 12 establish a communication mechanism with the client, keep airway
hours, as prescribed.
clear by coughing/suctioning.
Oral anticoagulants, such as warfarin (Coumadin) and dicumarol,
disrupt natural blood clotting mechanisms, prevent thrombus CBQ no. 6 When examining a client with emphysema, what physical
formation, and limit the extension of a formed thrombus. findings is the nurse likely to see?
Anticoagulants can’t dissolve a formed thrombus. Answer: Barrel chest, dry or productive cough, decreased breath
Anticoagulant therapy is contraindicated in a patient who has liver sounds, dyspnea, crackles in lung fields.
or kidney disease or GI ulcers or who isn’t likely to return for follow- CBQ no. 7 What is the most common risk factor associated with lung
up visits. cancer?
The nurse can assess a patient for thrombophlebitis by measuring
Answeer: Smoking
the affected and unaffected legs and comparing their sizes. The
nurse should mark the measurement locations with a pen so that CBQ no. 8 Describe the pre-op nursing care for a client undergoing a
the legs can be measured at the same place each day. laryngectomy.
Drainage of more than 3,000 ml of fluid daily from a nasogastric Answer: Involve family/client in manipulation of tracheostomy
tube may suggest intestinal obstruction. Yellow drainage that has a equipment before surgery, plan acceptable communication method,
foul odor may indicate small-bowel obstruction. refer to speech pathologist, discuss rehabilitation program.
Preparation for sigmoidoscopy includes administering an enema 1
CBQ no. 9 List 5 nursing interventions after chest tube insertion.
hour before the examination, warming the scope in warm water or a
sterilizer (if using a metal sigmoidoscope), and draping the patient to Answer: Maintain a dry occlusive dressing to chest tube site at all
expose the perineum. times. Check all connections every 4 hours. Make sure bottle III or
Treatment for a patient with bleeding esophageal varices includes end of chamber is bubbling. Measure chest tube drainage by
administering vasopressin (Pitressin), giving an ice water lavage, marking level on outside of drainage unit. Encourage use of
aspirating blood from the stomach, using esophageal balloon incentive spirometry every 2 hours.
tamponade, providing parenteral nutrition, and administering blood CBQ no. 10 What immediate action should the nurse take when a
transfusions, as needed.
chest tube becomes disconnected from a bottle or a suction
A trauma victim shouldn’t be moved until a patent airway is
established and the cervical spine is immobilized. apparatus? What should the nurse do if a chest tube is accidentally
After a mastectomy, lymphedema may cause a feeling of heaviness removed from the client?
in the affected arm. Answer: Place end in container of sterile water. Apply an occlusive
A dying patient shouldn’t be told exactly how long he’s expected to dressing and notify physician STAT.
live, but should be told something more general such as “Some CBQ no. 11 What instructions should be given to a client following
people live 3 to 6 months, but others live longer.” radiation therapy?
After eye surgery, a patient should avoid using makeup until
Answer: Do NOT wash off lines; wear soft cotton garments, avoid
otherwise instructed.
use of powders/creams on radiation site.
CBQ no. 12 What precautions are required for clients with TB when
Common Board Questions (CBQ) in Nurse Licensure Examination placed on respiratory isolation?
(RESPIRATORY SYSTEM) Answer: Mask for anyone entering room; private room; client must
wear mask if leaving room.
CBQ n0. 1 List 4 common symptoms of pneumonia the nurse might CBQ no. 13 List 4 components of teaching for the client with
note on a physical exam. tuberculosis.
Answer: Tachypnea, fever with chills, productive cough, bronchial Answer: Cough into tissues and dispose immediately into special
breath sounds. bags. Long-term need for daily medication. Good handwashing
CBQ no. 2 State 4 nursing interventions for assisting the client to technique. Report symptoms of deterioration, i.e., blood in
cough productively. secretions.
Answer: Deep breathing, fluid intake increased to 3 liters/day, use Common Board Questions (CBQ) in Nurse Licensure Examination
humidity to loosen secretions, suction airway to stimulate coughing. (CARDIOVASCULAR SYSTEM)
CBQ no. 3 What symptoms of pneumonia might the nurse expect to
see in an older client? CBQ no. 1 How do clients experiencing angina? Describe that pain.
Answer: Confusion, lethargy, anorexia, rapid respiratory rate. Answers: Described as squeezing, heavy, burning, radiates to left
CBQ no. 4 What should the O2 flow rate be for the client with arm or shoulder, transient or prolonged.
COPD? CBQ no. 2 Develop a teaching plan for the client taking nitroglycerin.
Answers: Take at first sign of anginal pain. Take no more than 3, five L/min., take measures to alleviate pain and anxiety (administer prn
minutes apart. Call for emergency attention if no relief in 10 pain medications and anti-anxiety medications).
minutes. CBQ no. 16 What symptoms should the nurse expect to find in the
CBQ no. 3 List the parameters of blood pressure for diagnosing client with hypokalemia?
hypertension. Answers: Dry mouth and thirst, drowsiness and lethargy, muscle
Answers: >140/90 weakness and aches, and tachycardia.
CBQ no. 4 Differentiate between essential and secondary CBQ no. 17 Bradycardia is defined as a heart rate below ___ BPM.
hypertension. Tachycardia is defined as a heart rate above ___ BPM.
Answers: Essential has no known cause while secondary Answers: bradycardia 60 bpm; tachycardia 100 bpm
hypertension develops in response to an identifiable mechanism. CBQ no. 18 What precautions should clients with valve disease take
CBQ no. 5 Develop a teaching plan for the client taking prior to invasive procedures or dental work?
antihypertensive medications. Answers: Take prophylactic antibiotics.
Answers: Explain how and when to take med, reason for med, Common Board Questions (CBQ) in Nurse Licensure Examination
necessary of compliance, need for follow-up visits while on med, (RENAL SYSTEM)
need for certain lab tests, vital sign parameters while initiating
therapy. CBQ no. 1 Differentiate between acute renal failure and chronic
CBQ no. 6 Describe intermittent claudication. renal failure.
Answers: Pain related to peripheral vascular disease occurring with Answers: Acute renal failure: often reversible, abrupt deterioration
exercise and disappearing with rest. of kidney function. – Chronic renal failure: irreversible, slow
CBQ no. 7 Describe the nurse’s discharge instructions to a client with deterioration of kidney function characterized by increasing BUN
venous peripheral vascular disease. and creatinine. Eventually dialysis is required.
Answers: Keep extremities elevated when sitting, rest at first sign of CBQ no. 2 During the oliguric phase of renal failure, protein should
pain, keep extremities warm (but do NOT use heating pad), change be severely restricted. What is the rationale for this restriction?
position often, avoid crossing legs, wear unrestrictive clothing. Answer: Toxic metabolites that accumulate in the blood (urea,
CBQ no. 8 What is often the underlying cause of abdominal aortic creatinine) are derived mainly from protein catabolism.
aneurysm? CBQ no. 3 Identify 2 nursing interventions for the client on
Answers: Atherosclerosis. hemodialysis.
CBQ no. 9 What lab values should be monitored daily for the client Answer: Do NOT take BP or perform venipunctures on the arm with
with thrombophlebitis who is undergoing anticoagulant therapy? the A-V shunt, fistula, or graft. Assess access site for thrill or bruit.
Answers: PTT, PT, Hgb, and Hct, platelets. CBQ no. 4 What is the highest priority nursing diagnosis for clients in
CBQ no. 10 When do PVCs (premature ventricular contractions) any type of renal failure?
present a grave danger? Answer: Alteration in fluid and electrolyte balance.
Answers: When they begin to occur more often than once in 10 CBQ no. 5 A client in renal failure asks why he is being given
beats, occur in 2s or 3s, land near the T wave, or take on multiple antacids. How should the nurse reply?
configurations. Answer: Calcium and aluminum antacids bind phosphates and help
CBQ no. 11 Differentiate between the symptoms of left-sided cardiac to keep phosphates from being absorbed into blood stream thereby
failure and right-sided cardiac failure. preventing rising phosphate levels, and must be taken with meals.
Answers: Left-sided failure results in pulmonary congestion due to CBQ no. 6 List 4 essential elements of a teaching plan for clients with
back-up of circulation in the left ventricle. Right-sided failure results frequent urinary tract infections.
in peripheral congestion due to back-up of circulation in the right Answer: Fluid intake 3 liters/day; good handwashing; void every 2-3
ventricle. hours during waking hours; take all prescribed medications; wear
CBQ no. 12 List 3 symptoms of digitalis toxicity. cotton undergarments.
Answers: Dysrhythmias, headache, nausea and vomiting CBQ no. 7 What are the most important nursing interventions for
CBQ no. 13 What condition increases the likelihood of digitalis clients with possible renal calculi?
toxicity occurring? Answer: Strain all urine is the MOST IMPORTANT intervention. Other
Answers: When the client is hypokalemic (which is more common interventions include accurate intake and output documentation
when diuretics and digitalis preparations are given together). and administer analgesics as needed.
CBQ no. 14 What life style changes can the client who is at risk for CBQ no. 8 What discharge instructions should be given to a client
hypertension initiate to reduce the likelihood of becoming who has had urinary calculi?
hypertensive? Answer: Maintain high fluid intake 3-4 liters per day. Follow-up care
Answers: Cease cigarette smoking if applicable, control weight, (stones tend to recur). Follow prescribed diet based in calculi
exercise regularly, and maintain a low-fat/low-cholesterol diet. content. Avoid supine position.
CBQ no. 15 What immediate actions should the nurse implement CBQ no. 9 Following transurethral resection of the prostate gland
when a client is having a myocardial infarction? (TURP), hematuria should subside by what post-op day?
Answers: Place the client on immediate strict bedrest to lower Answer: Fourth day
oxygen demands of heart, administer oxygen by nasal cannula at 2-5 CBQ no. 10 After the urinary catheter is removed in the TURP client,
what are 3 priority nursing actions?
Answer: Continued strict I&O; continued observations for
hematuria; inform client burning and frequency may last for a week.
CBQ no. 11 After kidney surgery, what are the primary assessments
the nurse should make?
Answer: Respiratory status (breathing is guarded because of pain);
circulatory status (the kidney is very vascular and excess bleeding
can occur); pain assessment; urinary assessment most importantly,
assessment of urinary output.