Question 1

Larry is a 56-year-old fisherman who is admitted at the intensive care unit. It is noted that intubation is contraindicated and is not possible for this patient and an esophageal obturator airway (EOA) was considered as an option. Which of the following is true about esophageal obturator airway?

Accepted Answer

The statement that's true about esophageal obturator airway is that it should not be used with a conscious and pediatric patient. This is also contraindicated in patients who swallowed caustic substances. Insertion should only be attempted by people highly proficient in their use. Moreover, since visualization is not required, the EOA may be very useful in patients when intubation is contraindicated or not possible. Vomiting and aspiration are possible complications of insertion and removal of an EOA.

Question 2

Naomi, a 40-year-old cook, returns to the recovery unit after a cholecystectomy. During the assessment, the nurse notices that Naomi's blood pressure is gradually dropping and her apical pulse is increasing. What will be the initial nursing action at this time?

Accepted Answer

The initial nursing action is to immediately notify the physician and report the vital signs obtained. These are signs of impending shock or possibly a reaction to anesthesia.

Question 3

Viva, a 25-year-old call center representative, was brought to the emergency room with chief complaint of visual disturbance that was described as double vision and flashing lights. At the time of assessment, Viva said that visual disturbances are gone, but she now has a severe pounding headache over her left eye. The nurse suspects a case of:

Accepted Answer

The nurse suspects a case of an aura and migraine. The warning sign, or aura, is associated with migraines, although not everyone with migraine has an aura. Migraine is usually unilateral and described as pounding. Viva's symptoms are most compatible with migraine.

Question 4

Antonio is an adult patient who is admitted due to lung cancer. The nurse learns that the patient is a cigarette smoker and has been for nearly 35 years. The nurse is aware that smoking is always associated with which type of lung cancer?

Accepted Answer

The nurse is aware that smoking is always associated with squamous cell carcinoma. Many agree that squamous cell carcinoma is always associated with cigarette smoking, although some textbooks of Medicine and Nursing classify primary pulmonary carcinoma somewhat differently.

Question 5

The nurse is caring for a patient with a prolapsed mitral valve. The nurse is aware that it is a benign cardiac condition that can be associated with atypical chest pain. The nurse is also aware that the chest pain is possibly due to:

Accepted Answer

The nurse is aware that the chest pain is possibly due to papillary muscle ischemia and dysfunction. Ventricular ischemia does not occur with prolapsed mitral valve. Options A and B are not painful conditions in themselves.

Question 6

A nurse caring for an adult male patient who sustained a high-voltage electrical injury analyzes the patient's test results. Which finding would the nurse interpret as increasing the patient's risk of developing acute tubular necrosis?

Accepted Answer

A finding that would increase the risk of developing acute tubular necrosis is the presence of myoglobin in the urine. Myoglobin can be released from damaged muscles and precipitate out in the renal tubules, causing acute tubular necrosis.

Question 7

Corrine is a 48-year-old mother who is admitted to the hospital with a diagnosis of ruled out mitral stenosis. She signed the consent for surgery to correct her stenosed valve because of unbearable signs and symptoms. She is complaining of difficulty breathing, coughing up blood, orthopnea, and paroxysmal dyspnea. The nurse is aware that these symptoms are the result of:

Accepted Answer

The nurse is aware that the symptoms are due to pulmonary hypertension. Pulmonary congestion secondary to left atrial hypertrophy causes these symptoms. The left ventricle does not hypertrophy in mitral stenosis; right heart failure would cause abdominal discomfort and peripheral edema; pericardial thickening does not occur.

Question 8

A nurse is caring for Mrs. Holiday, who was diagnosed with chronic renal failure. During the end of shift endorsement, the nurse said that she was able to observe which of the following?

Accepted Answer

The nurse should have observed anorexia, weakness, and pruritus. Anorexia and weakness are caused by progressive renal damage; pruritus is caused by presence of urea in sweat.

Question 9

Erick is a 50-year-old patient who had an abdominal surgery. An hour after the surgery, Erick develops internal hemorrhage. During further assessments, the nurse would expect that the patient will exhibit:

Accepted Answer

Upon further assessment, the nurse would expect to observe tachycardia. The patient, who is in shock, will have an accelerated heart rate to increase the blood flow and oxygen to the body tissues. There will also be a decreased urinary output, increased and shallow respirations, and hypotension.

Question 10

A clinical nurse specialist notes that a patient is demonstrating signs and symptoms of blood transfusion reaction. The nurse immediately stops the blood transfusion and then does what??

Accepted Answer

After stopping the transfusion, the nurse should hang a bag of normal saline utilizing new tubing. The tubing must be replaced to avoid infusing the blood left in the original tubing. The normal saline infusion will maintain an open line for any further intravenous treatment.

Question 11

Tamica is a female adult patient who is admitted due to esophageal varices, with chief complaint of hematemesis. The physician ordered 3 "u" of blood to be transfused after proper typing and crossmatching. The nurse administers the first unit of blood and after 30 minutes, the patient complains of severe flank pain. What would be the initial nursing action?

Accepted Answer

The initial nursing action is to stop the blood transfusion. It is an adaptation associated with a hemolytic transfusion reaction; flank pain is due to agglutination of red cells in the kidneys and renal vasoconstriction, therefore the transfusion should be stopped to avoid further instillation of blood that is being viewed as foreign by the body.

Question 12

A patient is scheduled for kidney transplant surgery. The physician ordered preoperative medications of azathioprine, cyclosporine, and prednisone. The nurse is aware that these medications will:

Accepted Answer

The nurse is aware that these medications will reduce antibody production. These drugs suppress the immune system, decreasing the body's production of antibodies in response to the new organ, which acts as an antigen. These medications decrease the risk of rejection.

Question 13

A patient with diabetic ketoacidosis has a potassium level of 5.5mEq/L. When monitoring the electrocardiogram tracing, the clinical nurse specialist would expect to observe:

Accepted Answer

The clinical nurse specialist would expect to observe a widened QRS complex and peaked T wave. Potassium is the principal intracellular cation and in case of ketoacidosis, it moves out of cells into the extracellular compartment to replace potassium lost as a result of glucose-induced osmotic dieresis; overstimulation of cardiac muscles is the result.

Question 14

Hypoinsulinism is a long term complication of pancreatoduodenectomy. An adult patient is already aware of it since the physician discussed it with him during the doctor's morning rounds. To validate the understanding of the teaching, the nurse asks the patient when to seek medical supervision and treatment. The patient must state that he should call if he experiences:

Accepted Answer

The patient must state that he should call once he experiences an abnormal increase in thirst. One of the characteristic of hypoinsulinism is polydipsia, which is brought by an impaired carbohydrate metabolism. Polyuria, weight loss, and increased appetite are also indicative of hypoinsulism or diabetes mellitus.

Question 15

A nurse is assessing a patient who is on his 24-hours post-surgery for correction of an abdominal hernia. The nurse would like to determine if the patient's peristalsis has returned in order to start the diet because the patient's husband reported that the patient is asking for glass of water. What would be the first indicator that the nurse should expect?

Accepted Answer

The first indicator that the peristalsis has returned is when the patient has bowel sounds. Bowel sounds are the result of peristaltic movements that propel intestinal contents through the alimentary tract and cause characteristic sounds.

Question 16

Rudy is a 55-year-old patient who was diagnosed with Hepatitis A. After three weeks, the patient developed hepatic cirrhosis and ascites with an elevated serum ammonia level. What would be the priority nursing intervention, considering that the patient has high ammonia levels?

Accepted Answer

The priority nursing intervention considering that the patient has a high ammonia level is to observe for any signs of increasing confusion. The patient's safety will be the priority since the patient has altered level of consciousness caused by an increased serum ammonia level that impairs the cranial nerve system.

Question 17

Michelle is a 27-year-old model who has just undergone a subtotal gastrectomy. Immediately after the procedure, she was brought to the post-anesthesia care unit. A clinical specialist nurse who is assigned to Michelle noticed that there are small blood clots in the gastric drainage. What would be the nurse's initial action?

Accepted Answer

The nurse's initial action is to do nothing since it is just a normal event. The small blood clots or some bleeding is expected as a result of trauma of surgery. It is expected with a duration of 4-5 hours after the surgery.

Question 18

Michelle is a post-operative patient who had a subtotal gastrectomy. After 72 hours, she complained of abdominal pain that she described as severe with a pain scale of 8 to 9. The assigned nurse did an abdominal palpation and noted that it is rigid. The nurse should initially:

Accepted Answer

The nurse should initially obtain the patient's vital signs. Severe pain and abdominal rigidity are signs that the patient is bleeding from the suture line or they can be signs of peritonitis. Obtaining the vital signs will provide supporting data. If there's no rigidity, then the patient can be instructed to ambulate with care. Giving an analgesic can hide the symptoms, leading to a delayed diagnosis.

Question 19

Nurse Gwen is caring for a patient who had an infratentorial craniotomy. The patient is already at the intensive care unit after a discharge from the post-anesthesia care unit. After careful periodic assessments, Gwen noticed that the patient has an increasing intracranial pressure. Nurse Gwen should initially:

Accepted Answer

Nurse Gwen should initially notify the physician regarding the finding. Immediate therapy based on current assessment should be initiated. Giving an osmotic diuretic requires a doctor's order. Elevating the head of the bed is contraindicated with the type of surgery. Option D is indeed helpful, but also needs a doctor's order.

Question 20

An adult patient was admitted to the emergency department after sustaining a spinal cord injury above the T6 level. Which adaptation is important for a clinical nurse specialist to monitor when concerned about spinal shock?

Accepted Answer

An adaptation that is important for a clinical nurse specialist to monitor when concerned about spinal shock is hypoventilation. A cervical spine injury can result in respiratory distress due to impaired muscle function. Respiratory monitoring can aid in the decision to use mechanical ventilation. If not treated, it can lead to atelectasis, pneumonia, and aspiration.

Quiz 1: Adult