51. After which surgical procedure would the nurse plan to monitor the client' sankle-brachial index (ABI)?a. Off pump coronary artery bypassb. Dynamic cardiomyoplastyc. Carotid endarterectomyd. Femoral-popliteal bypass52. The evening nurse goes in to care for a client who had a modified mastectomythat morning. Which fact is essential for the nurse to know to provide safe care?a. The involved arm should be wearing an elastic sleeve.b. The involved arm should not be used for BP measurement.c. The involved arm should be not be exercised for 10 days.d. The involved arm should be maintained at the level of the heart.注释：ankle-brachial index (ABI)裸臂血压指数bypass搭桥术；旁路cardiomyoplasty心肌成形术carotid endarterectomy颈动脉内膜切除术mastectomy乳房切除术Rationale 51. Correct answer: d.Ankle-brachial index is a test of arterial status in the lower extremity. Normal arteriesin the foot (dorsalis pedis and posterior tibial) have an index of 1.0-1.2. An indexbelow 1.0 indicates arterial obstruction. After a bypass graft procedure in the leg, ABIis measured every 8 hours for the first 24 hours and then once a day. Peripheral pulses,color, and sensation in the extremity are also monitored. Arterial status of the foot isnot a major concern after off pump coronary artery bypass, dynamic cardiomyoplasty,or carotid endarterectomy.52. Correct answer: b.BP should not be measured on the arm on the operative side because the procedureinterferes with circulation and can cause venous congestion in the affected extremity.Elastic sleeves are used in the management of lymphedema after a mastectomy.Limited exercises of the affected arm are started on the evening of surgery. Theinvolved arm should not be kept in a dependent position for an extended length oftime and if edema is present, it should be elevated as much time as possible.53. Which assessment finding(s) on a client who had a transurethral resection of theprostate for BPH 4 hours ago would indicate the need to notify the physician?a. Red bloody urine with small clotsb. BP of 110/50 mmHg, pulse 130 bpmc. Urinary output of 200 ml greater than intake d. Pain related to bladder spasms54. The nurse should interpret a complaint of joint pain from a client with amechanical heart valve as potentially indicative of which problem?a. Streptococcal infectionb. Vegetative embolusc. Bleedingd. Hypoxemia注释：transurethral 经尿道的prostate前列腺BPH(being prostatic hyperplas⑶良性前列腺增生症clot血块streptococcal infection 链球菌感染hypoxemia低氧血症Rationale53. Correct answer: b.A rapid pulse with a low BP is a potential sign of excessive blood loss and physicianshould be notified based on this finding. Some hematuria is usual for several days after surgery. A urinary output of 200 ml or greater than intake is adequate. Bladderspasms are expected to occur following surgery.54. Correct answer: c.Mechanical valves require that a client be on anticoagulant therapy for life because ofthe risk of thromboemboli. Therefore, the client is at risk for bleeding associated withanticoagulation, signs of which are joint pain, black or tarry stools, blood in the urine,and bleeding gums. Streptococcal infection occurs anywhere in the body andsymptoms depend in part on location of the infection.Osteomyelitis may bestreptococcal in origin and bone pain occurs but not necessarily joint pain. Avegetative embolus is a complication of infective endocarditis in which a piece of theplatelet fibrin bacteria mass called vegetation which forms on the heart valves breaksoff and travels in the blood stream. Symptoms of an embolus depend on where itlodges in the body and to what extent blood flow to the tissues are disrupted.Hypoxemia refers to decreased oxygen in the blood defined as a below normal PaO2;hypoxia is oxygen lack at the tissue level. Joint pain due to hypoxia is seen invasoocclusive crisis in sickle cell disease.55. A client with atrial fibrillation suddenly complains of acute, severe pain in the leftarm. On assessment the nurse finds the arm to be cold, pale, and without palpablepulses. Which problem should the nurse suspect? a. Myocardial infarctionb. Compartment syndromec. Arterial embolusd. Hypovolemic shock56. When caring for a postoperative client who has had a thyroidectomy, whichmedication should the nurse ensure is immediately available at the bedside?a. Calcium gluconateb. Propylthiouracilc. SSKId. Synthroid注释：fibrillation纤维性颤动palpable可触知的, 明显的myocardial infarction 心肌梗塞hypovolemic shock低血容性休克thyroidectomy甲状腺切除术calcium gluconate 葡萄糖酸钙propylthiouracil丙基硫氧喀咤SSKI饱和碘化钾溶液synthroid左旋甲状腺素钠 Rationale55 . Correct answer: c.Arterial emboli are often associated with atrial fibrillation and often cause acutearterial occlusion the S&S of which are pain in the affected area, paralysis, absence ofpulses, pallor, paresthesias, numbness and coolness. MI can cause an arterial embolusbut an MI itself does not cause these symptoms. Compartment syndrome occurswhen pressure, usually from edema, bleeding, or restrictive dressing, increases in alimited anatomic space and compromises circulation and function of tissues withinthe space. It is not caused by atrial fibrillation and symptoms are unrelenting pain,pallor, pulselessness, and paresthesias. Symptoms of hypovolemic shock are systemic,not limited to one extremity.56 .Correct answer: a.Calcium gluconate should be immediately available at the bedside of a client who hashad a thyroidectomy because of the risk of hypocalcemic tetany. Propylthiouracil, anantithyroid drug, blocks synthesis of thyroid hormone and is used in the treatment ofhyperthyroidism. SSKI decreases blood flow to the thyroid gland. Synthroid is athyroid hormone replacement drug and is used in the treatment of hypothyroidism. 57. A client having surgery for glaucoma asks the nurse how the doctor will know ifthe surgery is successful. Which would be an appropriate response for the nurse tomake?a. IOP will decreaseb. Ability to read small print will improvec. Pupil will remain permanently dilatedd. Peripheral vision will increase58. Which advice would be appropriate for the nurse to give to a client with dumpingsyndrome?a. Take a drink after every four to five bites of food at a mealb. Eat several small meals per day of wet foodsc. Remain in an upright position for 30-60 minutes after eatingd. Avoid foods that are concentrated carbohydrates注释：glaucoma青光眼IOP (intra-ocular pressure)眼内压peripheral vision 外周视觉dumping syndrome胃切除后综合征carbohydrates碳水化合物 Rationale57. Correct answer: a.The reason surgery is done for glaucoma is to lower IOP because increased IOP causesprogressive loss of vision. Surgery is done when medication is ineffective. Damagedone by increased IOP is permanent; therefore, ability to read is not improved. Thepupil is not affected by the surgery so contraction and dilation occur normally.Glaucoma causes loss of peripheral vision before loss of central vision and this loss isirreversible.58. Correct answer: d.Foods that are concentrated carbohydrates should be avoided. Dumping syndromehas vasomotor (tachycardia, diaphoresis, flushing, weakness, palpitations, and anxiety)and GI symptoms (distention, nausea, vomiting, and diarrhea) and occurs when thereis a rapid entry of boluses of hyperosmolar food directly into the small intestine. Todecrease the symptoms of dumping syndrome, a client also should eat six small mealsper day of dry foods and should not drink fluids with meals; avoid very hot or coldfoods; and lie down for 30-60 minutes after eating.59. When caring for a client who has had a kidney transplant, the nurse assesses forsigns of rejection. For which S&S would the nurse observe? Mark all that apply.a. Change in urinary outputb. Flank painc. Edema d. Sudden weight gain60. After which procedure would the nurse be expected to titrate IV fluids to replaceoutput during the first 24 hours?a. Liver transplantb. Heart transplantc. Kidney transplantd. Lung transplant注释：Transplant 移植Rejection 排斥S&S (signs and symptoms)体征和症状Edema水肿Titrate v.滴定测量I&O (intake/ input and output)摄入量与排出量Rationale59. Correct answers: a, b, c, and d.Change in urinary output, flank pain, edema, and sudden weight gain that is reflectiveof edema because water has weight are all symptoms of rejection of a kidneytransplant. 60. Correct answer: c.Maintenance of fluid and electrolyte status is a key aspect of care following liver, heart,kidney, and lung transplants. However, it is only following a kidney transplant thatI&O is checked hourly and IV fluids are titrated to replace output for the first 12-24hours.61. Which action should the nurse take when during assessment; he/she finds theclient who is 2 days post a liver transplant has a temperature persistent of 101.5°F,pulse 95, and respiratory rate of 18?a. Reposition the clientb. Administer oxygenc. Administer pain medicationd. Call the physician62. When conducting discharge teaching for a transplant client, the nurse must makesure the client and family understand the importance of which self care activities?Mark all that apply.a. Medication complianceb. Reporting of S&S etc.c. Keeping follow-up appointmentsd. Establishing a set sleep/wake routine 注释：Persistent 持续的Administer oxygen 输氧S&S (signs and symptoms)体征和症状Immunosuppressed免疫功能不全的Tachypnea呼吸急促Rationale61. Correct answer: d.Because immunosuppressed clients do not have as robust an immune response toinfection and symptoms will be more subtle such as a temperature of 101.5°F,tachycardia, and tachypnea. Infection and its treatment are the critical concerns in thissituation for this client and none of the other options address these.62. Correct answers: a, b, and c.Establishing a set sleep/wake routine is not essential for the transplant client and isnot a part of routine discharge teaching for these clients.63. Which directions would the nurse give to a client who is being prepared fordischarge following a pneumonectomy? Mark all that apply.a. Continue breathing exercises at home.b. Exercise arm and shoulder five times per day.c. Practice standing straight with shoulders even in front of the mirror. d. Do not lift more than 20 lb for at least a month.e. Stop any activity that causes dyspnea, chest pain, or excessive fatigue.f. Obtain influenza and pneumonia vaccines.g. Expect an intermittent cough with increased sputum.64. A client with which problem needs careful assessment for the development ofARDS?a. Pericarditisb. Anemiac. Acute pancreatitisd. Pyelonephritis注释：Pneumonectomy 肺切除术Dyspnea呼吸困难Vaccines 疫苗Intermittent 间歇的ARDS急性呼吸窘迫综合症Pericarditis 心包炎Pancreatitis 胰腺炎Rationale 63. Correct answers: a, b, c, e, and f.Breathing exercises need to be continued usually for about 3 weeks. Arm andshoulder exercises need to be continued five times a day with 10-20 repetitions eachtime. Clients need to practice standing straight with shoulders even because theshoulder on the affected side will tend to be lower due to the transection of musclesand natural tendency to guard sore areas. Looking in the mirror is the best way to seehow the shoulder needs to be held for posture to be correct. Any activity that causesdyspnea, chest pain, or excessive fatigue should be stopped; these are signs ofexceeding the ability of the remaining lung to meet the demand for oxygen. Chestpain may indicate inadequate oxygen reaching the myocardium. Obtaining thepneumonia and influenza vaccines is important because with only one remaining lungthere is almost no respiratory reserve and so the ability to cope with a respiratoryinfection is severely compromised. It is incorrect to tell the client not to lift more than20 lb for at least a month because heavy lifting must be avoided for 3-6 months. Anintermittent cough with increased sputum is not expected. In fact if this occurs, itshould be reported immediately.64. Correct answer: c.ARDS is a complication of acute pancreatitis usually developing 3-7 days after theonset of the pancreatitis. It is most common in clients with severe volume depletion.The complication associated with pericarditis is pericardial effusion, with anemia the risk is for congestive heart failure. With pyelonephritis, intractable infection that mayrequire surgery, even nephrectomy, to eradicate it.65. A client having cryosurgery for removal of a squamous cell carcinoma asks if theprocedure will hurt. Which is the correct answer for the nurse to give?a. ”You will not feel anything."b. "There will be a brief tingling pain.”c. "There will be no pain but you may experience aslight odd smell.”d. "There will be a momentary, stabbing pain."66. When planning for the postoperative care of clients having a thyroidectomy,which piece of equipment is most essential for the nurse to have available at thebedside?a. Suction machineb. Tracheostomy setc. Cardiac monitord. Humidifier注释：Cryosurgery冷冻手术squamous cell carcinoma 鳞状细胞癌thyroidectomy甲状腺切除术Tracheostomy set气管切开器 Rationale65. Correct answer: b.A brief tingling pain is felt with cryosurgery. An unpleasant odor can occur whenelectrocautery is used to burn abnormal tissue as in cases of cervical dysplasia orgenital warts.66. Correct answer: b.A tracheostomy set is needed at the bedside because of the risk of respiratory distressfrom compression of the trachea from bleeding or edema, laryngeal spasm fromhypocalcemic tetany, or vocal cord spasm secondary to laryngeal nerve damage.67. Which S&S occurring in a client 48 hours post-adrenalectomy indicate thatglucocorticoid dosage needs to be increased?a. Marked weakness, anorexia, nausea, or vomiting.b. Severe dyspnea, tachycardia, apprehensionc. Paresthesias, numbness and tingling in the extremities, muscle spasmsd. Orthostatic hypotension, depressed reflexes, slow mentation.68. A visitor with an obvious upper respiratory infection arrives to see a client 24 hourspostoperative from an adrenalectomy. The nurse explains that it is very important thatthe client not be exposed to anyone with a contagious illness. The visitor asks why.Which fact should be the basis of the nurse' s answer?a. The client is unable to fight infection because of loss of stress hormones. b. Fluid and electrolyte fluctuations create an environment in which infectiveorganisms can thrive.c. Risk of infection is greatly increased because of excess cortisol.d. The immune system is suppressed as part of the preparation for surgery and ittakes 3-4 weeks for it to regain normal function.注释：S&S [=signs and symptoms]体征和症状Adrenalectomy肾上腺切除术Glucocorticoid肾上腺糖皮质激素Dosage 齐ij量Anorexia厌食症Dyspnea呼吸困难Paresthesias感觉异常Cortisol皮质醇Rationale67. Correct answer: a.Marked weakness, anorexia, nausea, or vomiting are S&S indicating that the dose ofglucocorticoids needs to be increased. Severe dyspnea, tachycardia, andapprehension are S&S of respiratory/cardiovascular problems such as pulmonaryedema. Paresthesias, numbness, tingling in the extremities, and muscle spasms are symptoms of hypocalcemic tetany. Orthostatic hypotension occurspostadrenalectomy but does not indicate a need for increased glucocorticoids nor dodepressed reflexes and slow mentation.68. Correct answer: c.Excess cortisol increases the risk of infection because it decreases the inflammatoryresponse. Loss of epinephrine and norepinephrine are not the important factors in theincreased risk of infection. Fluid and electrolyte fluctuations do not create anenvironment in which infective organisms can thrive. The immune system is notsuppressed in preparation for surgery.69. When teaching self-care to a client who has had abdominal liposuction, whichinformation should the nurse include?a. Wear the compression garment when up for 2 weeksb. Take aspirin as needed for discomfortc. Expect asymmetry in the first few weeks after which it will taper off.d. Avoid weight gain so effect of surgery is not negated.70. Which statement made by a client who has had a blepharoplasty indicates theneed for further teaching?a. "I will avoid reading for 2-3 days."b. ”I will not be able to wear my contact lenses for at least 2 weeks."c. "I will apply warm compresses to control swelling/1 d. "I need to avoid alcohol for 3 weeks.”注释：Liposuction 抽脂术Asymmetry不对称（ 现象）Blepharoplasty眼睑成形术Rationale69. Correct answer: d.Weight gain will negate the effect of the surgery. The compression garment must beworn for 7-10 days. Aspirin, as well as all anticoagulants, must be avoided because ofthe risk of bleeding. Asymmetry is a complication of the liposuction, it is not expected.70. Correct answer: c.Iced compresses are used to control swelling and discoloration. All other statementscorrectly apply to the client who has had a blepharoplasty.71. A client scheduled for a nephrectomy asks during the preoperative teachingsession when the drain in the wound will be removed. Which is the best reply for thenurse to give?a. At the same time the sutures are removed.b. Not until urinary output is clear and at least 600 ml/24 hr.c. After narcotics are no longer required for pain relief.d. When drainage has decreased to less than 30 ml/d 72. Which problem places a client scheduled for a nephrostomy at the greatest risk forpostoperative hemorrhage?a. Diabetes mellitusb. History of urinary tract infectionsc. Uncontrolled hypertensiond. Pernicious anemia注释：Nephrectomy肾切除术Suture缝合线Narcotic麻醉剂Nephrostomy肾造瘦术Hemorrhage 出血Rationale71. Correct answer: d.The Jackson-Pratt drain is removed when there is less than 30 ml of drainage in 24hours. Sutures are removed in 7-10 days when the incision has healed. Urinary outputis via the remaining kidney and has no relationship to the need for a drain in theoperative area. Incisional pain is managed with opioid analgesics but pain is unrelatedto drainage and the need for a drain. 72. Correct answer: c.BP needs to be tightly controlled in clients undergoing a nephrostomy because of therisk of hemorrhage. Diabetes mellitus, prior urinary tract infections, or perniciousanemias do not increase the risk of hemorrhage from the procedure.73. For the client in sickle cell crisis, the nurse should frequently assess fora. amount of fluid intakeb. level of painc. prolonged erection in malesd. lower leg ulcers74. Which information should be included in the teaching plan for a client who hashad an ureterosigmoidostomy?a. Lifelong prophylactic antibiotics will be needed.b. Annual sigmoidoscopy should be obtained starting 10 years after surgery.c. Fluid intake should not exceed 1200 ml/d.d. Diet should be high in fiber and low in fat.注释：sickle cell镰状细胞ulcer溃疡ureterosigmoidostomy输尿管乙状结肠吻合术 prophylactic预防疾病的sigmoidoscopy乙状结肠镜检查Rationale73. Correct answer: b.Pain is the primary symptom of sickle cell crisis. Prolonged erection and lower legulcers are chronic problems associated with sickle cell disease.74. Correct answer: b.An annual sigmoidoscopy is recommended starting 10 years after surgery because ofthe increased risk of neoplasia developing in the sigmoid colon at the site ofanastomosis of the ureters. Prophylactic antibiotics are not given, however, becausethere is the risk of kidney infection from reflux of feces, any temperature of lO lrormore, costovertebral angle pain, or significant changes in color, consistency, oramount of output should be reported to the health care provider. There is nolimitation on fluid intake and no dietary restrictions.75. The nurse goes in to meet and assess her client who had a vulvectomy 2 days ago.The client is dozing in bed in Fowler' s position but states she is uncomfortable, whenasked. Which action should the nurse take first?a. Call the physicianb. Reposition the client in semi-Fowler' sc. Administer pain medicationd. Explain it is normal to be uncomfortable after the surgery 76. The nurse should interpret a weight gain of 5.5 lb over 24 hours in a client with abiologic cardiac valve replacement as a sign of the development of which problem?a. Graft rejectionb. Pericarditisc. Congestive heart failured. Pyelonephritis注释：Vulvectomy外阴切除术semi-Fowler半坐卧位Pericarditis 心包炎Rationale75. Correct answer: b.Change client s position to semi-Fowler' s to alleviate discomfort and tension onsuture line; sitting in a Fowler' s position puts direct pressure on suture line(s) andcauses discomfort. Pain medication cannot be administered without first checking foran order and determining when it was last given. In addition, change in position thatmay relieve the discomfort can be done immediately while the nurse is at the bedside,so it is the first action the nurse should take. Explaining discomfort is normal mayrelieve anxiety but clients have a right to pain relief whether pain is expected or not.76. Correct answer: c. Weight gain, dyspnea, and tachycardia are symptoms of CHF, which can occur withgraft failure. Hyperacute graft rejection is almost exclusively limited to transplantedkidneys and is a rare event because of careful cross matching before transplant.Symptoms of pericarditis include severe precordial pain, which is worse when lyingsupine and reduced when sitting up, fever, tachycardia, and myalgia. Symptoms ofpyelonephritis include fever, chills, flank pain, costovertebral angle tenderness, andsigns of lower UTI.77. After which surgical procedure would the nurse plan to monitor the client' sankle-brachial index (ABI)?a. Off pump coronary artery bypassb. Dynamic cardiomyoplastyc. Carotid endarterectomyd. Femoral-popliteal bypass78. The evening nurse goes in to care for a client who had a modified mastectomythat morning. Which fact is essential for the nurse to know to provide safe care?a. The involved arm should be wearing an elastic sleeve.b. The involved arm should not be used for BP measurement.c. The involved arm should be not be exercised for 10 days.d. The involved arm should be maintained at the level of the heart.注释: ankle-brachial index 踝臂指数cardiomyoplasty心肌成形术Carotid endarterectomy颈动脉内膜切除术Mastectomy乳房切除Rationale77. Correct answer: d.Ankle-brachial index is a test of arterial status in the lower extremity. Normal arteriesin the foot (dorsalis pedis and posterior tibial) have an index of 1.0-1.2. An indexbelow 1.0 indicates arterial obstruction. After a bypass graft procedure in the leg, ABIis measured every 8 hours for the first 24 hours and then once a day. Peripheral pulses,color, and sensation in the extremity are also monitored. Arterial status of the foot isnot a major concern after off pump coronary artery bypass, dynamic cardiomyoplasty,or carotid endarterectomy.78. Correct answer: b.BP should not be measured on the arm on the operative side because the procedureinterferes with circulation and can cause venous congestion in the affected extremity.Elastic sleeves are used in the management of lymphedema after a mastectomy.Limited exercises of the affected arm are started on the evening of surgery. Theinvolved arm should not be kept in a dependent position for an extended length oftime and if edema is present, it should be elevated as much time as possible. 79. Which assessment finding(s) on a client who had a transurethral resection of theprostate for BPH 4 hours ago would indicate the need to notify the physician?a. Red bloody urine with small clotsb. BP of 110/50 mmHg, pulse 130 bpmc. Urinary output of 200 ml greater than intaked. Pain related to bladder spasms80. The nurse should interpret a complaint of joint pain from a client with amechanical heart valve as potentially indicative of which problem?a. Streptococcal infectionb. Vegetative embolusc. Bleedingd. Hypoxemia注释：Transurethral 经尿道的Prostate前列腺Streptococcal infection 链球菌感染Hypoxemia低氧血症Embolus栓子，栓塞Rationale79. Correct answer: b. A rapid pulse with a low BP is a potential sign of excessive blood loss and physicianshould be notified based on this finding. Some hematuria is usual for several daysafter surgery. A urinary output of 200 ml or greater than intake is adequate. Bladderspasms are expected to occur following surgery.80. Correct answer: c.Mechanical valves require that a client be on anticoagulant therapy for life because ofthe risk of thromboemboli. Therefore, the client is at risk for bleeding associated withanticoagulation, signs of which are joint pain, black or tarry stools, blood in the urine,and bleeding gums. Streptococcal infection occurs anywhere in the body andsymptoms depend in part on location of the infection.Osteomyelitis may be streptococcal in origin and bone pain occurs but not necessarilyjoint pain. A vegetative embolus is a complication of infective endocarditis in which apiece of the platelet fibrin bacteria mass called vegetation which forms on the heartvalves breaks off and travels in the blood stream. Symptoms of an embolus dependon where it lodges in the body and to what extent blood flow to the tissues aredisrupted. Hypoxemia refers to decreased oxygen in the blood defined as a belownormal PaO2; hypoxia is oxygen lack at the tissue level. Joint pain due to hypoxia isseen in vasoocclusive crisis in sickle cell disease.81. A client with atrial fibrillation suddenly complains of acute, severe pain in the leftarm. On assessment the nurse finds the arm to be cold, pale, and without palpablepulses. Which problem should the nurse suspect? a. Myocardial infarctionb. Compartment syndromec. Arterial embolusd. Hypovolemic shock82. When caring for a postoperative client who has had a thyroidectomy, whichmedication should the nurse ensure is immediately available at the bedside?a. Calcium gluconateb. Propylthiouracilc. SSKId. Synthroid注释：Fibrillation纤维性颤动Palpable明显的，可触知的Myocardial infarction 心肌梗塞Compartment syndrome 腔室症候群Hypovolemic shock低血溶性休克Thyroidectomy甲状腺切除Propylthiouracil丙基硫氧喀咤SSKI饱和碘化钾溶液Synthroid左甲状腺素 Rationale81. Correct answer: c.Arterial emboli are often associated with atrial fibrillation and often cause acutearterial occlusion the S&S of which are pain in the affected area, paralysis, absence ofpulses, pallor, paresthesias, numbness and coolness. MI can cause an arterial embolusbut an MI itself does not cause these symptoms. Compartment syndrome occurswhen pressure, usually from edema, bleeding, or restrictive dressing, increases in alimited anatomic space and compromises circulation and function of tissues withinthe space. It is not caused by atrial fibrillation and symptoms are unrelenting pain,pallor, pulselessness, and paresthesias. Symptoms of hypovolemic shock are systemic,not limited to one extremity.82. Correct answer: a.Calcium gluconate should be immediately available at the bedside of a client who hashad a thyroidectomy because of the risk of hypocalcemic tetany. Propylthiouracil, anantithyroid drug, blocks synthesis of thyroid hormone and is used in the treatment ofhyperthyroidism. SSKI decreases blood flow to the thyroid gland. Synthroid is athyroid hormone replacement drug and is used in the treatment of hypothyroidism.83. A client having surgery for glaucoma asks the nurse how the doctor will know ifthe surgery is successful. Which would be an appropriate response for the nurse tomake? a. IOP will decreaseb. Ability to read small print will improvec. Pupil will remain permanently dilatedd. Peripheral vision will increase84. Which advice would be appropriate for the nurse to give to a client with dumpingsyndrome?a. Take a drink after every four to five bites of food at a mealb. Eat several small meals per day of wet foodsc. Remain in an upright position for 30-60 minutes after eatingd. Avoid foods that are concentrated carbohydrates注释：Glaucoma青光眼IOP= (intra-ocular pressure)眼内压Peripheral vision外围视觉，周边视觉Rationale83. Correct answer: a.The reason surgery is done for glaucoma is to lower IOP because increased IOP causesprogressive loss of vision. Surgery is done when medication is ineffective. Damagedone by increased IOP is permanent; therefore, ability to read is not improved. Thepupil is not affected by the surgery so contraction and dilation occur normally. Glaucoma causes loss of peripheral vision before loss of central vision and this loss isirreversible.84. Correct answer: d.Foods that are concentrated carbohydrates should be avoided. Dumping syndromehas vasomotor (tachycardia, diaphoresis, flushing, weakness, palpitations, and anxiety)and GI symptoms (distention, nausea, vomiting, and diarrhea) and occurs when thereis a rapid entry of Boluses of hyperosmolar food directly into the small intestine. Todecrease the symptoms of dumping syndrome, a client also should eat six small mealsper day of dry foods and should not drink fluids with meals; avoid very hot or coldfoods; and lie down for 30-60 minutes after eating.85. When caring for a client who has had a kidney transplant, the nurse assesses forsigns of rejection. For which S&S would the nurse observe? Mark all that apply.a. Change in urinary outputb. Flank painc. Edemad. Sudden weight gain86. After which procedure would the nurse be expected to titrate IV fluids to replaceoutput during the first 24 hours?a. Liver transplant b. Heart transplantc. Kidney transplantd. Lung transplant注释：S&S = signs and symptoms 体征和症, 犬Edem a水肿Titrate滴定测量Rationale85. Correct answers: a, b, c, and d.Change in urinary output, flank pain, edema, and sudden weight gain that is reflectiveof edema because water has weight are all symptoms of rejection of a kidneytransplant.86. Correct answer: c.Maintenance of fluid and electrolyte status is a key aspect of care following liver, heart,kidney, and lung transplants. However, it is only following a kidney transplant thatI&O is checked hourly and IV fluids are titrated to replace output for the first 12-24hours. 87. Which action should the nurse take when during assessment, he/she finds theclient who is 2 days post a liver transplant has a temperature persistent of 101.5°F,pulse 95, and respiratory rate of 18?a. Reposition the clientb. Administer oxygenc. Administer pain medicationd. Call the physician88. When conducting discharge teaching for a transplant client, the nurse must makesure the client and family understand the importance of which self care activities?Mark all that apply.a. Medication complianceb. Reporting of S&S etc.c. Keeping follow-up appointmentsd. Establishing a set sleep/wake routineRationale87. Correct answer: d.Because immunosuppressed clients do not have as robust an immune response toinfection and symptoms will be more subtle such as a temperature of 101.5°F, tachycardia, and tachypnea. Infection and its treatment are the critical concerns in thissituation for this client and none of the other options address these.88. Correct answers: a, b, and c.Establishing a set sleep/wake routine is not essential for the transplant client and isnot a part of routine discharge teaching for these clients.89. Which directions would the nurse give to a client who is being prepared fordischarge following a pneumonectomy? Mark all that apply.a. Continue breathing exercises at home.b. Exercise arm and shoulder five times per day.c. Practice standing straight with shoulders even in front of the mirror.d. Do not lift more than 20 lb for at least a month.e. Stop any activity that causes dyspnea, chest pain, or excessive fatigue.f. Obtain influenza and pneumonia vaccines.g. Expect an intermittent cough with increased sputum.90. A client with which problem needs careful assessment for the development ofARDS?a. Pericarditisb. Anemiac. Acute Ipancreatitis d. Pyelonephritis注释：Pneumonectomy 肺切除术Dyspnea呼吸困难Pneumonia 肺炎Pericarditis 心包炎Pancreatitis 胰腺炎Rationale89. Correct answers: a, b, c, e, and f.Breathing exercises need to be continued usually for about 3 weeks. Arm andshoulder exercises need to be continued five times a day with 10-20 repetitions eachtime. Clients need to practice standing straight with shoulders even because theshoulder on the affected side will tend to be lower due to the transection of musclesand natural tendency to guard sore areas. Looking in the mirror is the best way to seehow the shoulder needs to be held for posture to be correct. Any activity that causesdyspnea, chest pain, or excessive fatigue should be stopped; these are signs ofexceeding the ability of the remaining lung to meet the demand for oxygen. Chestpain may indicate inadequate oxygen reaching the myocardium. Obtaining thepneumonia and influenza vaccines is important because with only one remaining lungthere is almost no respiratory reserve and so the ability to cope with a respiratoryinfection is severely compromised. It is incorrect to tell the client not to lift more than20 lb for at least a month because heavy lifting must be avoided for 3-6 months. An intermittent cough with increased sputum is not expected. In fact if this occurs, itshould be reported immediately.90. Correct answer: c.ARDS is a complication of acute pancreatitis usually developing 3-7 days after theonset of the pancreatitis. It is most common in clients with severe volume depletion.The complication associated with pericarditis is pericardial effusion, with anemia therisk is for congestive heart failure. With pyelonephritis, intractable infection that mayrequire surgery, even nephrectomy, to eradicate it.91. A client having cryosurgery for removal of a squamous cell carcinoma asks if theprocedure will hurt. Which is the correct answer for the nurse to give?a. "You will not feel anything."b. "There will be a brief tingling pain."c. "There will be no pain but you may experience a slight odd smell.Hd. "There will be a momentary, stabbing pain.”92. When planning for the postoperative care of clients having a thyroidectomy,which piece of equipment is most essential for the nurse to have available at thebedside?a. Suction machineb. Tracheostomy setc. Cardiac monitor d. Humidifier注释：squamous cell carcinoma 嶙状细胞癌cryosurgery冷冻治疗tingling pain 刺痛Rationale91. Correct answer: b.A brief tingling pain is felt with cryosurgery. An unpleasant odor can occur whenelectrocautery is used to burn abnormal tissue as in cases of cervical dysplasia orgenital warts.92. Correct answer: b.A tracheostomy set is needed at the bedside because of the risk of respiratory distressfrom compression of the trachea from bleeding or edema, laryngeal spasm fromhypocalcemic tetany, or vocal cord spasm secondary to laryngeal nerve damage.93. Which S&S occurring in a client 48 hours postadrenalectomy indicate thatglucocorticoid dosage needs to be increased?a. Marked weakness, anorexia, nausea, or vomiting.b. Severe dyspnea, tachycardia, apprehensionc. Paresthesias, numbness and tingling in the extremities, muscle spasmsd. Orthostatic hypotension, depressed reflexes, slow mentation.94. A visitor with an obvious upper respiratory infection arrives to see a client 24hours postoperative from an adrenalectomy. The nurse explains that it is very important that the client not be exposed to anyone with a contagious illness. Thevisitor asks why. Which fact should be the basis of the nurse' s answer?a. The client is unable to fight infection because of loss of stress hormones.b. Fluid and electrolyte fluctuations create an environment in which infectiveorganisms can thrive.c. Risk of infection is greatly increased because of excess cortisol.d. The immune system is suppressed as part of the preparation for surgery and ittakes 3-4 weeks for it to regain normal function.注释：Postadrenalectomy肾上腺切除术术后Glucocorticoid肾上腺糖皮质激素Anorexia食欲不振，厌食症Apprehension 忧虑，恐惧Paresthesias n.感觉异常（ 皮肤的反常感觉如痒、刺痛等）Orthostatic hypotension直立性低血压；体位性低血压Cortisol皮质醇Rationale93. Correct answer: a.Marked weakness, anorexia, nausea, or vomiting are S&S indicating that the dose ofglucocorticoids needs to be increased. Severe dyspnea, tachycardia, andapprehension are S&S of respiratory/cardiovascular problems such as pulmonaryedema. Paresthesias, numbness, tingling in the extremities, and muscle spasms are symptoms of hypocalcemic tetany. Orthostatic hypotension occurspostadrenalectomy but does not indicate a need for increased glucocorticoids nor dodepressed reflexes and slow mentation.94. Correct answer: c.Excess cortisol increases the risk of infection because it decreases the inflammatoryresponse. Loss of epinephrine and norepinephrine are not the important factors in theincreased risk of infection. Fluid and electrolyte fluctuations do not create anenvironment in which infective organisms can thrive. The immune system is notsuppressed in preparation for surgery.95. When teaching self-care to a client who has had abdominal liposuction, whichinformation should the nurse include?a. Wear the compression garment when up for 2 weeks.b. Take aspirin as needed for discomfort.c. Expect asymmetry in the first few weeks after which it will taper off.d. Avoid weight gain so effect of surgery is not negated.96. Which statement made by a client who has had a blepharoplasty indicates theneed for further teaching?a. "I will avoid reading for 2-3 days."b. "I will not be able to wear my contact lenses for at least 2 weeks."c. ”I will apply warm compresses to control swelling.Hd. ”I need to avoid alcohol for 3 weeks.”注释: Liposuction 抽脂术Asymmetry不对称Blepharoplasty睑成形术/ 整形术compression garment压缩式紧身衣Rationale95. Correct answer: d.Weight gain will negate the effect of the surgery. The compression garment must beworn for 7-10 days. Aspirin, as well as all anticoagulants, must be avoided because ofthe risk of bleeding. Asymmetry is a complication of the liposuction, it is not expected.96. Correct answer: c.Iced compresses are used to control swelling and discoloration. All other statementscorrectly apply to the client who has had a blepharoplasty.97. A client scheduled for a nephrectomy asks during the preoperative teachingsession when the drain in the wound will be removed. Which is the best reply for thenurse to give?a. At the same time the sutures are removed.b. Not until urinary output is clear and at least 600 ml/24 hr.c. After narcotics are no longer required for pain relief.d. When drainage has decreased to less than 30 ml/d98. Which problem places a client scheduled for a nephrostomy at the greatest riskfor postoperative hemorrhage?a. Diabetes mellitus b. History of urinary tract infectionsc. Uncontrolled hypertensiond. Pernicious anemia注释：Suture （ 尤指手术后伤口的）缝合，缝线Narcotic麻醉药Nephrostomy肾造屡术；肾造口术Hemorrhage 出血Rationale97. Correct answer: d.The Jackson-Pratt drain is removed when there is less than 30 ml of drainage in 24hours. Sutures are removed in 7-10 days when the incision has healed. Urinary outputis via the remaining kidney and has no relationship to the need for a drain in theoperative area. Incisional pain is managed with opioid analgesics but pain is unrelatedto drainage and the need for a drain.98. Correct answer: c.BP needs to be tightly controlled in clients undergoing a nephrostomy because of therisk of hemorrhage. Diabetes mellitus, prior urinary tract infections, or perniciousanemias do not increase the risk of hemorrhage from the procedure.99. Which information should be included in the teaching plan for a client who hashad an ureterosigmoidostomy?a. Lifelong prophylactic antibiotics will be needed. b. Annual sigmoidoscopy should be obtained starting 10 years after surgery.c. Fluid intake should not exceed 1200 ml/d.d. Diet should be high in fiber and low in fat.100. The nurse realizes that more teaching is needed when the client on a cardiaclow-cholesterol diet makes which choice from the menu?a. Stewed chicken, green beans, and noodlesb. Liver and onions, salad with ranch dressing, and milkc. Ham and bean soup, salad with vinaigrette dressing, and cornbreadd. Pork roast, brown rice, and beets注释：Ureterosigmoidostomy输尿管乙状结肠吻合术Prophylactic 预防的Sigmoidoscopy乙状结肠镜检查Vinaigrette色拉调味汁（ 用油、醋和各种香草等混合而成）Rationale99. Correct answer: b.An annual sigmoidoscopy is recommended starting 10 years after surgery because ofthe increased risk of neoplasia developing in the sigmoid colon at the site ofanastomosis of the ureters. Prophylactic antibiotics are not given, however, becausethere is the risk of kidney infection from reflux of feces, any temperature of 101°F ormore, costovertebral angle pain, or significant changes in color, consistency, or amount of output should be reported to the health care provider. There is nolimitation on fluid intake and no dietary restrictions.100. Correct answer: b.The client should avoid liver because organ meat is high in cholesterol91. A client having cryosurgery for removal of a squamous cell carcinoma asks if theprocedure will hurt. Which is the correct answer for the nurse to give?a. ”You will not feel anything."b. "There will be a brief tingling pain.”c. "There will be no pain but you may experience a slight odd smell.Hd. "There will be a momentary, stabbing pain."92. When planning for the postoperative care of clients having a thyroidectomy,which piece of equipment is most essential for the nurse to have available at thebedside?a. Suction machineb. Tracheostomy setc. Cardiac monitord. Humidifier注释：squamous cell carcinoma 鳞状细胞癌 cryosurgery冷冻治疗tingling pain 刺痛Rationale91. Correct answer: b.A brief tingling pain is felt with cryosurgery. An unpleasant odor can occur whenelectrocautery is used to burn abnormal tissue as in cases of cervical dysplasia orgenital warts.92. Correct answer: b.A tracheostomy set is needed at the bedside because of the risk of respiratory distressfrom compression of the trachea from bleeding or edema, laryngeal spasm fromhypocalcemic tetany, or vocal cord spasm secondary to laryngeal nerve damage.93. Which S&S occurring in a client 48 hours postadrenalectomy indicate thatglucocorticoid dosage needs to be increased?a. Marked weakness, anorexia, nausea, or vomiting.b. Severe dyspnea, tachycardia, apprehensionc. Paresthesias, numbness and tingling in the extremities, muscle spasmsd. Orthostatic hypotension, depressed reflexes, slow mentation.94. A visitor with an obvious upper respiratory infection arrives to see a client 24hours postoperative from an adrenalectomy. The nurse explains that it is veryimportant that the client not be exposed to anyone with a contagious illness. Thevisitor asks why. Which fact should be the basis of the nurse' s answer?a. The client is unable to fight infection because of loss of stress hormones. b. Fluid and electrolyte fluctuations create an environment in which infectiveorganisms can thrive.c. Risk of infection is greatly increased because of excess cortisol.d. The immune system is suppressed as part of the preparation for surgery and ittakes 3-4 weeks for it to regain normal function.注释：Postadrenalectomy肾上腺切除术术后Glucocorticoid肾上腺糖皮质激素Anorexia食欲不振，厌食症Apprehension 忧虑，恐惧Paresthesias n.感觉异常（ 皮肤的反常感觉如痒、刺痛等）Orthostatic hypotension直立性低血压；体位性低血压Cortisol皮质醇Rationale93. Correct answer: a.Marked weakness, anorexia, nausea, or vomiting are S&S indicating that the dose ofglucocorticoids needs to be increased. Severe dyspnea, tachycardia, andapprehension are S&S of respiratory/cardiovascular problems such as pulmonaryedema. Paresthesias, numbness, tingling in the extremities, and muscle spasms aresymptoms of hypocalcemic tetany. Orthostatic hypotension occurspostadrenalectomy but does not indicate a need for increased glucocorticoids nor dodepressed reflexes and slow mentation. 94. Correct answer: c.Excess cortisol increases the risk of infection because it decreases the inflammatoryresponse. Loss of epinephrine and norepinephrine are not the important factors in theincreased risk of infection. Fluid and electrolyte fluctuations do not create anenvironment in which infective organisms can thrive. The immune system is notsuppressed in preparation for surgery.95. When teaching self-care to a client who has had abdominal liposuction, whichinformation should the nurse include?a. Wear the compression garment when up for 2 weeks.b. Take aspirin as needed for discomfort.c. Expect asymmetry in the first few weeks after which it will taper off.d. Avoid weight gain so effect of surgery is not negated.96. Which statement made by a client who has had a blepharoplasty indicates theneed for further teaching?a. "I will avoid reading for 2-3 days.”b. "I will not be able to wear my contact lenses for at least 2 weeks."c. will apply warm compresses to control swelling.Hd. "I need to avoid alcohol for 3 weeks/'注释：Liposuction 抽脂术Asymmetry不对称Blepharoplasty睑成形术/ 整形术 compression garment压缩式紧身衣Rationale95. Correct answer: d.Weight gain will negate the effect of the surgery. The compression garment must beworn for 7-10 days. Aspirin, as well as all anticoagulants, must be avoided because ofthe risk of bleeding. Asymmetry is a complication of the liposuction, it is not expected.96. Correct answer: c.Iced compresses are used to control swelling and discoloration. All other statementscorrectly apply to the client who has had a blepharoplasty.97. A client scheduled for a nephrectomy asks during the preoperative teachingsession when the drain in the wound will be removed. Which is the best reply for thenurse to give?a. At the same time the sutures are removed.b. Not until urinary output is clear and at least 600 ml/24 hr.c. After narcotics are no longer required for pain relief.d. When drainage has decreased to less than 30 ml/d98. Which problem places a client scheduled for a nephrostomy at the greatest riskfor postoperative hemorrhage?a. Diabetes mellitusb. History of urinary tract infectionsc. Uncontrolled hypertensiond. Pernicious anemia 注释:Suture （ 尤指手术后伤口的）缝合，缝线Narcotic麻醉药Nephrostomy肾造屡术；肾造口术Hemorrhage 出血Rationale97. Correct answer: d.The Jackson-Pratt drain is removed when there is less than 30 ml of drainage in 24hours. Sutures are removed in 7-10 days when the incision has healed. Urinary outputis via the remaining kidney and has no relationship to the need for a drain in theoperative area. Incisional pain is managed with opioid analgesics but pain is unrelatedto drainage and the need for a drain.98. Correct answer: c.BP needs to be tightly controlled in clients undergoing a nephrostomy because of therisk of hemorrhage. Diabetes mellitus, prior urinary tract infections, or perniciousanemias do not increase the risk of hemorrhage from the procedure.99. Which information should be included in the teaching plan for a client who hashad an ureterosigmoidostomy?a. Lifelong prophylactic antibiotics will be needed.b. Annual sigmoidoscopy should be obtained starting 10 years after surgery.c. Fluid intake should not exceed 1200 ml/d.d. Diet should be high in fiber and low in fat. 100. The nurse realizes that more teaching is needed when the client on a cardiaclow-cholesterol diet makes which choice from the menu?a. Stewed chicken, green beans, and noodlesb. Liver and onions, salad with ranch dressing, and milkc. Ham and bean soup, salad with vinaigrette dressing, and cornbreadd. Pork roast, brown rice, and beets注释：Ureterosigmoidostomy输尿管乙状结肠吻合术Prophylactic 预防的Sigmoidoscopy乙状结肠镜检查Vinaigrette色拉调味汁（ 用油、醋和各种香草等混合而成）Rationale99. Correct answer: b.An annual sigmoidoscopy is recommended starting 10 years after surgery because ofthe increased risk of neoplasia developing in the sigmoid colon at the site ofanastomosis of the ureters. Prophylactic antibiotics are not given, however, becausethere is the risk of kidney infection from reflux of feces, any temperature of 101°F ormore, costovertebral angle pain, or significant changes in color, consistency, oramount of output should be reported to the health care provider. There is nolimitation on fluid intake and no dietary restrictions.100. Correct answer: b.The client should avoid liver because organ meat is high in cholesterol 101. When taking a client s medical history, which are the precipitating factors formyocardial infarction? (Select all that apply.)a. Hypothyroidismb. Cigarette smokingc. Hyperlipidemiad. Rheumatic Fevere. Elevated serum iron levelf. High density lipids < 40 mgg. Using oral contraceptives102. When the nurse performs an admission assessment on a client, the nurse notesthat the client has xanthomas present on both eyelids. The laboratory value the nursewould want to check based on this assessment finding isa. triglyceride levelb. homocystine levelc. cardiac enzymes—CPK-MB, troponin, and myoglobind. cholesterol panel注释：myocardial infarction 心肌梗塞Hyperlipidemia 高脂血Rheumatic Fever 风湿热Xanthomas黄色瘤Triglyceride甘油三酸酯 Homocystine同型半胱氨酸Cardiac enzymes 心肌酶Troponin肌钙蛋白Myoglobin肌红蛋白Rationale101. Correct answers: b, c, e, f, and g.Hypothyroidism is not a risk factor for ML Rheumatic fever is a risk factor for valvedisease.102. Correct answer: d.Cholesterol accumulates in tumor nodules on the skin. Triglyceride level is a measureof fats in the blood stream. Elevated homocystine levels are considered anindependent risk factor for atherosclerosis. Cardiac enzymes elevate with MI.103. A client presents to the clinic with the following symptoms: a burning sensationin the lower extremities, thickened toe nails, and pain in legs when walking. The nursewould assess the client for which additional factor consistent with Burger' s disease(thromboangitis obliterans)?a. Bounding peripheral pulsesb. Rubor when the extremities are elevatedc. Intolerance to heatd. Symptoms triggered by stress 104. A goal for a client with arteriosclerosis obliterans is to increase arterial bloodsupply to the extremities. Which of the following nursing interventions would beappropriate for this goal?a. Elevate the extremities above the level of the heart for 15 minutes four times a day.b. Have client perform Buerger-Allen exercises four times a day.c. Maintain client on bed rest with legs in a neutral position.d. Position client in high-Fowler' s position with legs straight.注释：thromboangitis obliterans血栓闭塞性脉管炎rubor发红，泛红arteriosclerosis obliterans动脉硬化闭塞症，闭塞性动脉硬化Rationale103. Correct Answer: d.Symptoms are triggered by stress.104. Correct answer: b.These exercises help drain static blood from the legs when elevated and then increasethe amount of blood going to the legs when in a dependent position and when thelegs are flat, the person exercises their ankles and feet increasing circulation. Answer"a" drains static blood from the legs and is used with varicose veins. Answers "c"and "d" do not drain stagnant blood from the legs and thus will not increase arterialblood flow to them. 105. Which of the following assessment findings are consistent with the diagnosis ofvenous stasis?a. Absent or diminished peripheral pulsesb. Hair loss on the extremityc. Moist ulcers around the malleolusd. Edema of the extremitye. Coolness of the extremityf. Leathery quality of the extremityg. Pallor of the extremity106. A client is returned to the unit after having a repair of an abdominal aorticaneurysm. The nurse should place the client in which of the following positions?a. High-Fowler' sb. Simsc. Semi-Fowler, sd. Flat注释：venous stasis静脉淤血malleolus踝关节；踝部abdominal aortic aneurysm 腹主动脉瘤Rationale105. Correct answers: c, d, and f. Moist ulcers around the malleolus, leathery quality to the skin of the extremity, andedema of the extremity are signs of venous stasis. Absent pulses, coolness, pallor andhair loss are all signs of arterial insufficiency.106. Correct answer: d.The client should be placed in a flat position so that flexion of the graft isprevented.107. The nurse is giving a client low molecular weight heparin, enoxaparin. The correctnursing interventions when administering this medication include all of the followingexcepta. using a TB syringeb. injecting the medicine using Z-track methodc. not rubbing the site postinjectiond. administering the medicine in the anterolateral abdominal wall108. In order to prevent the postoperative complication of thrombophlebitis in aclient who has had mitral valve replacement, the nurse would have the client engagein which of the following activities?a. Perform dorsiflexion of the feet several times every hour while awakeb. Cough and take deep breaths every hour while awakec. Sit up in a chair for several hours during the afternoond. Eat a high-fiber, high-calorie diet注释：Heparin 肝素 Enoxaparin依诺肝素Anterolateral 前外侧的Thrombophlebitis血栓性静脉炎Dorsiflexion 背屈Rationale107. Correct answer: b.Z-track method is used for IM injections in order to trap medicine in the muscle.108. Correct answer: a.Performing dorsiflexion of the feet several times every hour while awake preventsvenous stasis. Answers "b" and ac" help prevent pneumonia and answer "d" aidshealing.109. The nurse is caring for a client who hasjust arrived on the unit following a cardiaccatheterization. Which of the following assessments would be most immediate?a. Heart and lung soundsb. Pain at the catheter insertion sitec. Pulses distal to the insertion sited. Urine output110. A client comes into the ER complaining of "his heart racing.Cardiac monitorshows atrial tachycardia with a ventricular rate of 190 bpm. The nurse anticipates thatthe physician will order adenosine (Adenocard) to be given. Prior to giving themedication the nurse should do which of the following?a. Determine when the client last ate b. Ask the laboratory to draw serum BUN and creatinine levelsc. Ask the client if he/she has a history of asthmae. Have the client sign a consent注释：cardiac catheterization 心导管插入术adenosine 腺背serum BUN血清尿素氮creatinine 肌肝Rationale109. Correct answer: c.All assessments would need to be done but the risk of a clot-decreasing circulation ismost important.110. Correct answer: c.Adenosine (Adenocard) can cause bronchospasms in asthmatic clients.111. Metoprolol tartrate (Lopressor) is ordered for a client who has had a myocardialinfarction. The nurse would expect which therapeutic result from administration ofthis drug?a. Increased urinary outputb. Decreased coronary artery spasmsc. Increased cardiac outputd. Decreased resting heart rate 112. A clienf s cardiac monitor strip shows the following: HR 42/min, rhythm regular,PRI 0.16 seconds, QRS 0.06 seconds. The client is experiencing dizziness, nausea, andchest pain rated as 3 on a scale of 1-10 with 10 being the worst pain. The drug ofchoice to treat this dysrhythmia isa. Lidocaine (Xylocaine)b. Adenosine (Adenocard)c. Atropine Sulfated. Epinephrine (Adrenalin)注释：Metoprolol tartrate酒石酸美托洛尔myocardial infarction 心肌梗塞dysrhythmia心律失常Atropine Sulfate硫酸阿托品Rationale111. Correct answer: d.It is a beta-adrenergic blocking agent, which slows the heart rate.112. Correct answer: c.Atropine sulfate blocks vagal impulses to the heart and increases heart rate. Lidocaineis used for control of ventricular dysrhythmias. Adenosine is used to restore NSR inclients with supraventricular tachycardia. Epinephrine is a catecholamine which actson alpha and beta receptors and is used for anaphylactic reactions and relief ofbronchospasms. 113. A client is admitted to the ER with new onset atrial fibrillation with a ventricularresponse of 110/min. The nurse would anticipate which of the following treatmentoptions to be ordered. (Select all that apply.)a. Defibrillationb. Start oxygen at 2-4 Ipmc. Anticoagulant therapyd. Medicate with beta blockere. Start Lidocaine dripf. Atrial pacing114. The nurse is assessing a newborn infant who is exhibiting the following signsand symptoms: elevated blood pressure, bounding brachial pulses, diminished pedalpulses, elevated Jugular venous distention (JVD), and cardiac murmur. Based on theassessment, the nurse would suspect that the client may have which of the followingconditions?a. Congestive heart failureb. Coarctation of the aortac. Mitral valve prolapsed. Transposition of the great vessels注释：Defibrillation 除颤Anticoagulant therapy 抗凝治疗Jugular venous distention 颈静脉扩张 cardiac murmur 心脏杂音Mitral valve prolapse 二尖瓣脱垂Rationale113. Correct answers: b, c, d, and f.Elective cardioversion and not defibrillation may be used. Lidocaine is used to treatventricular dysrhythmias.114. Correct answer: b.There is narrowing of the aorta restricting outflow so that there is elevated pressure inthe upper extremities and diminished outflow to the lower extremities.115. The nurse has assessed a client and has determined that the client is exhibitingsigns and symptoms of left heart failure. Identify which of the signs and symptoms areindicative of left heart failure.a. Tachypnea, loss of appetite, ST elevation on the ECGb. Hemoptysis, cogwheel murmur, midsternal chest painc. Ascites, oliguria, fatigued. Orthopnea, bibasilar crackles, gallop rhythm116. The nurse is providing nutritional counseling for a client who is receiving a loopdiuretic. Which meal plan would be most appropriate for this client?a. Raisin bran cereal, tomato juice, whole grain toastb. Boiled chicken, green beans, tossed saladc. Vegetable soup, low-salt crackers, skim milkd. Poached fish, beets, macaroni and cheese 注释：Tachypnea呼吸急促Hemoptysis 喀血Ascites 腹水Orthopnea端坐性呼吸困难Diuretic利尿的Rationale115. Correct answer: d.Blood backs into the lungs causing congestion and respiratory symptoms and agallop rhythm develop from increased blood flow across the valves. Answer "b"consists of signs and symptoms of pulmonary air embolism. Answer "c" consists ofsigns and symptoms of right heart failure.116. Correct answer: a.Tomato juice and raisins contain potassium, which is lost through loop diuretics.117. The nurse is reading a 6-second cardiac rhythm strip and notes 9 QRS complexesin it. The clienf s heart rate isa. 54b. 63c. 81d. 90118. A client has been diagnosed with pericardial effusion. The nurse would preparethe client for which of the following procedures? a. Myotomyb. Pericardiectomyc. Pericardiostomyd. Dynamic cardiomyoplasty注释：pericardial effusion 心包积液Myotomy肌切开术Pericardiostomy心包造口术，心包穿刺引流Rationale117. Correct answer: d.9*10=90118. Correct answer: c.Pericardiostomy is the creation of an opening into the pericardium. It is usually doneto drain a pericardial effusion. Myotomy is the cutting into a muscle. Precardiectomyis the excision of a part of the pericardium. Dynamic cardiomyoplasty is a proceduredone to improve the pumping action of the myocardium.119. Which instruction would be inappropriate to give a client following coronaryartery bypass graft surgery?a. No driving for 6-8 weeksb. Avoid smoking or tobacco use for 4-6 weeksc. No heavy lifting for 6-8 weeksd. Can resume sexual intercourse in 3-4 weeks 120. A nurse checks the client s arterial blood gas results which are as follows: pH,7.38; PO2, 88 mmHg; PCO2, 33 mmHg; HCO3, 24 mEq/l; and O2 saturation 96%. Whichis the correct interpretation of these results?a. Metabolic acidosisb. Metabolic alkalosisc. Normal valuesd. Respiratory alkalosis注释：coronary artery bypass graft surgery 冠脉旁路搭桥术saturation 饱和度alkalosis碱中毒Rationale119. Correct answer: b.Smoking and use of tobacco should be stopped entirely not just for 4-6 weeks. Allother instructions are appropriate for the client following coronary artery bypass graftsurgery.120. Correct answer: c.The blood gas results listed are all in normal range so no acid-base imbalance ispresent.121. Which of the following instructions regarding a cardiac nuclear scan should anurse give the client?a. Avoid coffee, tea, and cocoa the morning of the test b. Take a clear liquid diet for 24 hours before the testc. Dress in comfortable clothing and walking shoesd. Take all medications as prescribed prior to the test122. Which assessment finding in a neonate should the nurse interpret as a sign ofpossible coarctation of the aorta?a. Triphasic color changes in the upper extremitiesb. Pulsating abdominal mass with a systolic bruit and cool lower extremities.c. Decreased distal pulses, thick, malformed nails, cyanotic upper extremity digitsd. Bounding pulses in the arms and absent pulses in the groin and legs注释：Neonate （ 尤指出生不足四周的）新生儿Coarctation 狭窄systolic bruit收缩期杂音malformed畸形的cyanotic发绡的， 青紫的Rationale121. Correct answer: c.122. Correct answer: d.Bounding pulses in the upper extremities and decreased or absent pulses in the groinand legs occurring several hours to days after birth and the closure of the ductusarteriosus are signs of severe coarctation of the aorta. Triphasic skin changes in theaffected parts are characteristic of Raynaud, s disease. A pulsating abdominal mass with a systolic bruit and cool lower extremities are signs of an abdominal aorticaneurysm. Decreased distal pulses, thick, malformed nails, cyanotic upper extremitydigits are symptoms of thromboangitis obliterans (Buerger' s disease).123. The nurse is administering a beta blocker to a client admitted with an MI. Theclienf s wife asks what the medication will do. Which fact should be the foundation ofthe nurse' s reply? The medication will:a. reduce the amount of oxygen needed by the heart muscleb. decrease the risk of a blood clotc. enhance the affinity of oxygen for hemoglobind. increase the volume of blood in the coronary arteries124. The nurse would expect to administer morphine sulfate, oxygen, nitroglycerineand aspirin to a client with which problem?a. Raynaud' s diseaseb. Myocardial infarctc. Valvular heart diseased. Kawasaki disease注 释 ：Hemoglobin血红蛋白morphine sulfate 硫酸吗啡nitroglycerine 硝化甘油Rationale( 英 [■ raejs • na:l] 美[■ raeja , nael] n.理 论 的 说 明 ；基 本 原 理 ， 基 础 理 论 ；根据;) 123. Correct answer: a.Drugs that reduce oxygen demand or increase the oxygen supply to the myocardiumare part of the immediate care of clients with an MI. These drugs include nitrates, betablockers, calcium channel blockers, antihypertensives, and antiplatelet agents. Betablockers reduce oxygen demand by the myocardium.124. Correct answer: b.MONA (morphine sulfate, oxygen, nitroglycerine and aspirin are administered in theemergency rook to clients with myocardial infarcts. The treatment of Raynaud' sconsist of elimination of precipitating factors, medications such as analgesics,vasodilators, and calcium channel blockers, or sympathectomy. Treatment of valvularheart disease includes digitalis, diuretics, ACE inhibitors, antibiotics prior to dentalwork or invasive procedures to prevent endocarditis, and surgical repair orreplacement. Salicyclate therapy and intravenous gamma globulin administration isthe treatment for Kawasaki disease.125. For the client in sickle cell crisis, the nurse should frequently assess fora. amount of fluid intakeb. level of painc. prolonged erection in malesd. lower leg ulcers 126. How should the nurse interpret laboratory results consisting of a positiveCoombs' test, decreased Het, increased reticulocyte count, and increased bilirubin?These results are consistent witha. Hereditary spherocytosisb. Autoimmune hemolytic anemiac. Sickle cell diseased. Acute lymphocytic leukemia注释：sickle cell镰状细胞reticulocyte网织红细胞bilirubin胆红素spherocytosis球形红细胞增多症Rationale125. Correct answer: b.Pain is the primary symptom of sickle cell crisis. Prolonged erection and lower legulcers are chronic problems associated with sickle cell disease.126. Correct answer: b.A positive Coombs' test, decreased Het, increased reticulocyte count, and increasedbilirubin are indicative of autoimmune hemolytic anemia. Hereditary spherocytosis isassociated with increased fragility of red blood cells, an elevated reticulocyte count and an elevated serum bilirubin along with the presence of spherocytes on aperipheral blood smear. The major laboratory findings related to sickle cell anemia arethe large percentage of hemoglobin S present on electrophoresis and the percentageof irreversibly sickled red blood cells. In addition the hematocrit is decreased and thereticulocyte count and white blood cell count are usually increased. Laboratoryfindings associated with acute lymphocytic leukemia are decreased hemoglobin,hematocrit and platelet count and a white cell count that may be normal, low orelevated. 。