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A. Administering antacids for gastroenteritis

B. Advising the client to assume a high Fowler·s position for
a peptic ulcer
C. Calling the surgeon in anticipation of an appendectomy
D. Suggesting a course of antibiotics to treat peritonitis
 m- 
_
 
þ he client is exhibiting classic findings associated
with appendicitis, which requires surgery as soon as possible;
notifying the surgeon should be the nurse·s first action.
_ §ebound tenderness is not associated with gastroenteritis,
which is characterized by generalized abdominal cramping,
diarrhea, fever, and malaise.
_ A high Fowler·s position would not alleviate pain produced by a
peptic ulcer, which includes burning, aching, and gnawing pain.
_ Nausea and vomiting are not generally associated with
peritonitis, which is indicated by diffuse abdominal pain,
rebound tenderness, fever, and an elevated WBC count.
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A. Decreased intermittent claudication

B. Increased ability to walk to the bathroom without fatigue
C. Increased heart rate by 10 beats per minute
D. Weight gain of 3 pounds in one day
 m- *
_
 
þ Fatigue may be associated with decreased cardiac
output; an increase in the client·s ability to ambulate to the
bathroom without fatigue indicates improvement in cardiac
output.
_ A decrease in intermittent claudication indicates improved
peripheral perfusion, but it does not demonstrate increased
cardiac output.
_ he body normally responds to a decrease in cardiac output by
increasing the heart rate.
_ Weight gain indicates fluid retention and a worsening of the
client·s heart failure.
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A. Administration of sodium bicarbonate

B. Elevation of the body part
C. Gentle massage of the affected area
D. Administration of warmed, humidified oxygen
 m- *
_
 
þ Elevation of the body part helps to reduce the
edema associated with frostbite.
_ Sodium bicarbonate is indicated for the treatment of
hypothermia.
_ Massaging the affected area may result in further tissue damage.

_ Warm, humidified oxygen is used as treatment for

hypothermia.
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A. ´ he physician removes the precancerous mass to prevent

cancer from occurring.µ
B. ´ his is diagnostic surgery done to confirm or rule out
malignancy.µ
C. ´ his will provide a more realistic look to the body part.µ
D. ´ his will relieve your distress and help you to be more
comfortable.µ
 m- *
_
 
þA biopsy is performed to aid in diagnosing whether
a mass is benign or malignant.
_ Mreventative surgery is done to remove tissue prior to its
becoming cancerous; whether or not the mass is precancerous
has yet to be determined.
_ §econstructive surgery provides a more realistic look to a body
part.
_ Malliative surgery is used to relieve the client·s distress and help
make him more comfortable.
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A. Acute arterial occlusion

B. Dissecting aneurysm
C. Mostphlebitic syndrome
D. §aynaud·s phenomenon
 m-
_
 
þ he change in color, temperature, sensation, and
pulse accompanied by the sudden onset of pain (the classic ´M·sµ
of assessment) all suggest an acute arterial occlusion.
_ A dissecting aneurysm usually occurs in the chest, not the legs;
a tearing or ripping sensation of pain in the anterior chest,
back, epigastric region, or abdomen is common.
_ Mostphlebitic syndrome is characterized by a brownish
discoloration of the skin, the hallmark sign.
_ §aynaud·s phenomenon involves the episodic constriction of
the small arteries or arterioles of the extremities, resulting in
intermittent pallor and cyanosis of the skin, fingers, toes and,
possibly, the ears or nose, followed by hyperemia, which may
produce rubor.
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A. Dental surgery in the recent past

B. History of coronary artery disease (CAD)
C. History of marijuana use
D. Mrolonged use of steroid therapy
 m-
_
 
þ Dental surgery is one of the predisposing factors
for the development of endocarditis because it may create a
portal of entry for microorganisms.
_ A history of valvular heart disease (not CAD), I.V. drug use
(not marijuana use), and prolonged I.V. antibiotic therapy (not
steroid therapy) are predisposing factors for endocarditis.
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A. Intermittent episodes of high fever with chills

B. Maresthesias and loss of position sense
C. Mositive Homans· sign and calf pain
D. Mulsatile mass and systolic bruit
 m- 
_
 
þA pulsatile mass and systolic bruit are classic signs
of an abdominal aortic aneurysm.
_ Intermittent episodes of high fever with chills are associated
with secondary lymphedema or other infections.
_ Maresthesias and loss of position sense are associated with
peripheral arterial occlusive disease as well as neurovascular
and neurologic conditions.
_ A positive Homans· sign and calf pain are symptoms of deep
vein thrombosis.
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A. A facemask is necessary for delivery of adequate

B. Oxygen is reserved for use when the client is short of breath.
C. he client is encouraged to remove the oxygen as often as
possible.
D. he oxygen must be administered at a low rate.
 m- 
_
 
þ he primary stimulus to breathe for the client with
COMD is hypoxia.
_ If oxygen were administered at too high a rate, the client·s
respiratory drive would be depressed.
_ he increased effectiveness of using a facemask as opposed to a
nasal cannula has not been proven.
_ Due to loss of supporting structures and narrowing of airways,
the condition is irreversible; intermittent oxygen is not
effective.
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A. A woman who has taken hormonal contraceptives for the past 2

years
B. A client who has had laparoscopic gallbladder surgery
C. A client with arterial vascular disease and difficulty walking
D. A client who has experienced multiple trauma and fractures
 m- 
_
 
þ A client with massive trauma and multiple orthopedic injuries is
at increased risk for developing a ME. he injury may predispose the client to
fat emboli and bony fragments that can become emboli, and the prolonged
period of immobility that results from the injuries and their treatment further
compounds the client·s risk. Women on hormonal contraceptives have a
slightly higher risk for ME, but this risk is not as great as that for the client
experiencing multiple trauma and fractures. he risk for cardiovascular
complications increases after age 35 in women who smoke and after age 40 in
women who do not smoke.
_ ëaparoscopic cholecystectomy is now considered a relatively minor procedure
requiring a short hospitalization, usually in an outclient department.
_ A client with arterial vascular disease may be at increased risk for pulmonary
emboli but ME usually develops in the venous system.
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A. Effective coughing and deep-breathing

B. Oxygen saturation level of 98%
C. §eport of breathing without difficulty
D. §eport of pain relief
 m- *
_
 
þ Following a thoracotomy, the goal is to promote
adequate gas exchange, evidenced by objective parameters
including oxygen saturation, normal blood gases, and breath
sounds.
_ Effective coughing and deep breathing help to maintain a patent
airway and promote lung expansion, but they do not ensure
adequate gas exchange.
_ Although client reports of breathing without difficulty are an
important assessment, adequacy of gas exchange is best
evaluated by objective findings.
_ Assessment and pain relief is important, but pain relief is not a
reliable indicator of adequate gas exchange.
› ##(!#$ (!
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A. Adventitious breath sounds with crackles and wheezes

B. Bronchial breath sounds over consolidated lung fields
C. Decreased breath sounds with crackles and a pleural
friction rub
D. Wheezing with expiration more prolonged than inspiration
 m- *
_
 
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A. Barrel chest
B. Flail chest
C. Funnel chest
D. Migeon chest
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