GCC 726 - 750

A suitable diet for a client with cirrhosis and abdominal ascites is one that is:

• High in sodium, low in calories
• Low in potassium, high in calories
• High in protein, high in calories
• Low in calcium, low in calories
• -

Answer explanation

Option A: High in sodium, low in calories

Option B: Low in potassium, high in calories

Option C: High in protein, high in calories

Option D: Low in calcium, low in calories

Option E: -

Correct Option: Option C

Explanation: Causes of postoperative fever include abscess formation, atelectasis, wound infection, fat emboli after bone trauma, drug reactions, malignancy, silent aspiration, dehydration, central nervous system damage, urinary tract infections, phlebitis/deep vein thrombosis, and pulmonary emboli. Causes of elevated core temperature include blood transfusion, drug-induced fever, overuse of techniques to prevent hypothermia, hypothalamic injury, malignant hyperthermia, warm environment, use of anticholinergics, endocrine disorders, and neurogenic hyperthermia.

The nurse cares for a client who returns from gastric resection surgery. Which nursing intervention is a priority?

• Assessing for flatus
• Monitoring for symptoms of hemorrhage
• Monitoring patency of the nasogastric tube
• Encouraging ambulation
• -

Answer explanation

Option A: Assessing for flatus

Option B: Monitoring for symptoms of hemorrhage

Option C: Monitoring patency of the nasogastric tube

Option D: Encouraging ambulation

Option E: -

Correct Option: Option B

Explanation: Hyperplasia of the gums is associated with Dilantin therapy. Answer A is not related to the therapy; answer B is a side effect, and answer D is not related to the question.

A client with tuberculosis who has been receiving combined therapy with INH and Rifampin asks the nurse how long he will have to take medication. The nurse should tell the client that:

• Medication is rarely needed after 2 weeks
• He will need to take medication the rest of his life
• The course of combined therapy is usually 6 months
• He will be re-evaluated in 1 month to see if further medication is needed
• -

Answer explanation

Option A: Medication is rarely needed after 2 weeks

Option B: He will need to take medication the rest of his life

Option C: The course of combined therapy is usually 6 months

Option D: He will be re-evaluated in 1 month to see if further medication is needed

Option E: -

Correct Option: Option C

Explanation: Epistaxis is the medical term for nosebleed. Epistaxis may be caused by nasal trauma, nose picking, dry environmental conditions, warfarin or platelet-inhibiting drug use, renal failure, or other bleeding disorders. Miosis is pinpoint pupils, hematoma is a bruise, and myalgia is muscle pain.

The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby's reflux. The nurse should tell the mother to:

• Feed the baby only when he is hungry
• Burp the baby after the feeding is completed
• Place the baby supine with head elevated
• Burp the baby frequently throughout the feeding
• -

Answer explanation

Option A: Feed the baby only when he is hungry

Option B: Burp the baby after the feeding is completed

Option C: Place the baby supine with head elevated

Option D: Burp the baby frequently throughout the feeding

Option E: -

Correct Option: Option D

Explanation: Most of the blood flow to coronary arteries is supplied during diastole. Breathing patterns (Options A and C) don't affect blood flow. Coronary arteries receive only a minute portion of blood during systole (Option D).

The nurse knows that case management is:

• The process of managing the outcomes of client care by quality improvement measures and involvement of the interdisciplinary team
• The process of client assessment and direct client care by the primary nurse, utilizing the nursing process and nursing diagnoses to guide delivery of care
• The process used by the health care facility's legal or risk management department to evaluate legal claims filed against the facility or employees of the facility
• The process of overseeing and organizing client care in collaboration with the client's primary health care provider and consulting physicians
• -

Answer explanation

Option A: The process of managing the outcomes of client care by quality improvement measures and involvement of the interdisciplinary team

Option B: The process of client assessment and direct client care by the primary nurse, utilizing the nursing process and nursing diagnoses to guide delivery of care

Option C: The process used by the health care facility's legal or risk management department to evaluate legal claims filed against the facility or employees of the facility

Option D: The process of overseeing and organizing client care in collaboration with the client's primary health care provider and consulting physicians

Option E: -

Correct Option: Option D

Explanation: Normal CVP ranges from 2 to 5 mm Hg. The CVP is a measure of blood volume status in the body. A higher value indicates fluid overload. Pulmonary artery pressure is a measure of pressure within the lungs, and cardiac output is a measure of the amount of blood the heart pumps. Heart rate is measured by palpation, auscultation, or through a machine.

The nurse is palpating the fontanels of a 2-month-old. The fontanels should feel:

• Tense and bulging
• Soft and sunken
• Flat and firm
• Flat and tense
• -

Answer explanation

Option A: Tense and bulging

Option B: Soft and sunken

Option C: Flat and firm

Option D: Flat and tense

Option E: -

Correct Option: Option C

Explanation: Iodine reduces thyroid vascularity and prevents release of thyroid hormone into the circulation. Propylthiouracil, which blocks thyroid hormone synthesis, is the drug most commonly used to treat hyperthyroidism; methimazole has similar effects and can be used in patients allergic to propylthiouracil. Propranolol, a beta-adrenergic blocker, is used to decrease patient anxiety and the cardiac effects of hyperthyroidism. Option A is incorrect because levothyroxine is used to treat hypothyroidism, not hyperthyroidism. The adrenergic agents listed in Option C are inappropriate for the hyperthyroid patient because they would further stimulate the cardiovascular system, which is already under stress from hypermetabolism. The drugs listed in Option D are used primarily to treat asthma and may lead to increased excitability and tachycardia in a patient with hyperthyroidism.

The nurse performs an admission assessment on a client who is directly admitted to the hospital from the physician's office. The client is worried and distracted, and explains to the nurse that because of the direct admission from the physician's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client?

• An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here beside your bed so that you can contact your family and friends. Is there anything that I can do for you right now to help you?
• I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight.
• An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? You also have a telephone here at your bedside so that you can contact your family and friends.
• I can call your physician for you and ask if you could go home today, then schedule another date for your hospital admission.
• -

Answer explanation

Option A: An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here beside your bed so that you can contact your family and friends. Is there anything that I can do for you right now to help you?

Option B: I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight.

Option C: An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? You also have a telephone here at your bedside so that you can contact your family and friends.

Option D: I can call your physician for you and ask if you could go home today, then schedule another date for your hospital admission.

Option E: -

Correct Option: Option A

Explanation: The vital signs should be taken before any chemotherapy agent. If it is an IV infusion of chemotherapy, the nurse should check the IV site as well. Answers B and C are incorrect because it is not necessary to check the electrolytes or blood gases.

Which post-operative assessment finding on a client with a femoral popliteal graft of the right leg would require immediate charge nurse notification?

• Edema of the right extremity and pain at the incision site
• A temperature of 99.6ºF and redness of the incision
• Serous drainage noted at the surgical area
• A loss of posterior tibial and dorsalis pedis pulses on the right leg
• -

Answer explanation

Option A: Edema of the right extremity and pain at the incision site

Option B: A temperature of 99.6ºF and redness of the incision

Option C: Serous drainage noted at the surgical area

Option D: A loss of posterior tibial and dorsalis pedis pulses on the right leg

Option E: -

Correct Option: Option D

Explanation: A bruit is distinctly heard over an abdominal aortic aneurysm. It suggests a partial arterial occlusion. A thrill is palpated over an aneurysm. Crackles are heard in the lungs. A friction rub indicates inflammation of the peritoneum, pleura, and mediastinum.

During client care rounds with the multidisciplinary team, the nurse reports that a client coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the client, in which the physician participating in rounds writes the order. This is an example of:

• Collaboration of client care with the ancillary care providers.
• Collaboration of client care between the physician and the dietary department.
• Collaboration of care with the risk management team because of the client's risk for aspiration.
• Collaboration of care among members of the multidisciplinary team.
• -

Answer explanation

Option A: Collaboration of client care with the ancillary care providers.

Option B: Collaboration of client care between the physician and the dietary department.

Option C: Collaboration of care with the risk management team because of the client's risk for aspiration.

Option D: Collaboration of care among members of the multidisciplinary team.

Option E: -

Correct Option: Option D

Explanation: I assisted the client to a standing position at the side of the bed. The client complained of dizziness and “almost passing out.” I assisted the client back to a supine position and obtained a set of orthostatic blood pressures. The blood pressures were: 122/75 supine and 89/60 standing. The client appears to have orthostatic hypotension. The client has orthostatic hypotension. The nurse reports the action being taken; assisting the client to stand; the client’s complaints; the nurse’s action; assisting the client back to bed; taking a set of orthostatic blood pressures, both supine and standing; and the nurse’s analysis of the situation.

A patient develops a small-bowel obstruction 5 days after undergoing surgery. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?

• Imbalanced nutrition: Less than body requirements
• Acute pain
• Deficient fluid volume
• Excess fluid volume
• -

Answer explanation

Option A: Imbalanced nutrition: Less than body requirements

Option B: Acute pain

Option C: Deficient fluid volume

Option D: Excess fluid volume

Option E: -

Correct Option: Option C

Explanation: After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect.