NCLEX RN EXAM PACK SET 12 LATEST UPDATE 2023

UPDATED VERSION 2023 NCLEX RN EXAM PACK SET 12 75 QUESTIONS & ANSWERS WITH EXPLAINED OPTIONS 1.1 . Question Among the following signs and symptoms, which would most likely be present in a client with mitral regurgitation? o A. Altered level of consciousness o B. Exertional Dyspnea o C. Increase creatine phosphokinase concentration o D. Chest pain Correct Answer: B. Exertional Dyspnea Mitral regurgitation (MR) is defined as an abnormal reversal of blood flow from the left ventricle (LV) to the left atrium (LA). Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation. The patient will usually complain of significant dyspnea at rest, exacerbated in the supine position, as well as cough with clear or pink, frothy sputum. o Option A: An altered level of consciousness does not occur in clients with mitral regurgitation. Physical examination may reveal altered mental status, tachycardia (or bradycardia if there is ischemic involvement of the conduction system), hypotension, tachypnea, hypoxemia, and cyanosis. o Option C: Creatine phosphokinase (CPK) is an enzyme in the body. It is found mainly in the heart, brain, and skeletal muscle. High levels of CPK may be seen in people who have brain injury, convulsions, heart attack, myocarditis, and myopathy. o Option D: The client feels no chest pain, but may feel palpitations as a result of chronic atrial dilatation. They may also endorse symptoms associated with myocardial ischemia, such as chest pain radiating to the neck, jaw, shoulders, or upper extremities, nausea, and diaphoresis. 2 . Question Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is of renal origin, the nurse should assess whether the client has discomfort or pain in the: o A. Urinary meatus o B. Pain in the labium o C. Suprapubic area o D. Right or left costovertebral angle Correct Answer: D. Right or left costovertebral angle Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side. Flank or costovertebral angle (CVA) tenderness is most commonly unilateral over the involved kidney, although bilateral discomfort may be present. Discomfort varies from absent to severe. This finding is usually not subtle and may be elicited with mild or moderately firm palpation. o Option A: Pain or discomfort in the urinary meatus can also be indicative of urethritis or acute urinary tract infection. In both men and women, common causes of urethral pain include sexually transmitted diseases (STDs) such as chlamydia, local irritation from soaps or spermicides, and urinary tract infections (UTIs). In men, prostatitis isn’t an uncommon cause, whereas in women, vaginal dryness due to menopause can be an issue. o Option B: Pain in the labium can be due to a swollen labia or vulva. Chronic yeast infections and bacterial infections can both cause pain that ranges from mild discomfort and itching to severe burning or throbbing. Viral and bacterial infections, such as bacterial vaginosis and the herpes simplex virus, can also cause vulvar pain or discomfort. o Option C: Suprapubic pain has a wide variety of causes, and can include pyelonephritis, perinephric abscess, and nephrolithiasis. Gynecological causes are common with suprapubic pain. Suprapubic pain happens in the lower abdomen near where the hips and many important organs, such as the intestines, bladder, and genitals, are located. Suprapubic pain can have a wide variety of causes, so the doctor may need to do tests of vital functions before diagnosing the underlying cause. 3 . Question Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal function. o A. Blood pressure o B. Consciousness o C. Distension of the bladder o D. Pulse rate Correct Answer: A. Blood pressure Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of cardiac output. Over time, uncontrolled high blood pressure can cause arteries around the kidneys to narrow, weaken or harden. These damaged arteries are not able to deliver enough blood to the kidney tissue. Damaged kidney arteries do not filter blood well. Kidneys have small, finger-like nephrons that filter the blood. o Option B: Consciousness is not an indicator of renal function. Administration of medications that can alter consciousness may have an effect on renal function, according to studies conducted by The Journal of Pharmacology and Experimental Therapeutics. During consciousness, maximal renal vasodilation by papaverine or acetylcholine did not increase UNaV or fractional Na excretion. o Option C: Checking the distention of the bladder is not an accurate indicator of renal function. It mostly indicates an obstruction or a loss of tone in the bladder muscles that fail to detect increased pressure exerted by urine. It is usually associated with pain and urge to urinate. Bladder catheterization should be performed. o Option D: Individuals with a high resting heart rate and a low beatto-beat heart rate variability have an increased risk of developing kidney disease, according to a new study by the American Society of Nephrology. However, it is not the most accurate indicator of renal function. 4 . Question John suddenly experiences a seizure, and Nurse Gina notices that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure? o A. Tonic seizure o B. Absence seizure o C. Myoclonic seizure o D. Clonic seizure Correct Answer: C. Myoclonic seizure Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group. Myoclonus is defined as rapid, brief, jerky, or shock-like movements involving muscle or group of muscles. Among all hyperkinetic movement disorders, Myoclonus is considered to be the most rapid and brief. When caused by sudden muscle contraction, it is known as “positive myoclonus,” while a brief loss of muscular tone results in “negative myoclonus” as in asterixis. o Option A: A tonic seizure causes a sudden stiffness or tension in the muscles of the arms, legs, or trunk. The stiffness lasts about 20 seconds and is most likely to happen during sleep. After the seizure, the client may feel tired or confused. o Option B: An absence seizure causes the client to blank out or stare into space for a few seconds. They are also called petit mal seizures. Absence seizures are most common in children and typically don’t cause any long-term problems. o Option D: Clonic seizures are characterized by repeated jerking movements of the arms and legs on one or both sides of the body, sometimes with numbness or tingling. If it is a focal (partial) seizure, the client may be aware of what’s happening. During a generalized seizure, the client may be unconscious. 5 . Question Smoking cessation is a critical strategy for the client with Buerger’s disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication? o A. Paracetamol o B. Ibuprofen o C. Nitroglycerin o D. Nicotine (Nicotrol) Correct Answer: D. Nicotine (Nicotrol) Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome. Nicotine replacement therapy (NRT) is for those who want to quit smoking, as abruptly quitting can cause withdrawals and cravings. Nicotine withdrawal occurs after smoking cigarettes discontinued suddenly. Using NRT helps one to reduce the motivation of smoking cigarettes because the body still gets nicotine from another safer method. o Option A: Paracetamol (acetaminophen) is a pain reliever and a fever reducer. Acetaminophen (APAP) is considered a non-opioid analgesic and antipyretic agent used to treat pain and fever. Clinicians can use it for their patients as a single agent for mild to moderate pain and in combination with an opioid analgesic for severe pain. o Option B: Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. Ibuprofen is used to reduce fever and treat pain or inflammation caused by many conditions such as headache, toothache, back pain, arthritis, menstrual cramps, or minor injury. o Option C: Nitroglycerin belongs to a class of drugs called vasodilators. It works by relaxing the smooth muscle and blood vessels in the body. This increases the amount of blood and oxygen that reaches the heart. In turn, the heart doesn’t work as hard. This reduces chest pain. 6 . Question Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology of the disease is unknown but it is characterized by: o A. Episodic vasospastic disorder of capillaries o B. Episodic vasospastic disorder of small veins o C. Episodic vasospastic disorder of the aorta o D. Episodic vasospastic disorder of the small arteries Correct Answer: D. Episodic vasospastic disorder of the small arteries Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involve fingers and toes. In Raynaud phenomenon, blood-flow restriction occurs during cold temperatures and emotional stress. Specifically, in Raynaud phenomenon, there is vasoconstriction of the digital arteries and cutaneous arterioles. o Option A: Only the arteries are affected in Raynaud’s disease. With cold temperatures, the sympathetic nervous system causes the release of vasoconstricting neuropeptides and norepinephrine leading to vasoconstriction of arteriole smooth muscle and decreased blood flood to the skin. Of note, in secondary Raynaud phenomenon, endothelin-1 is released by endothelial cells which causes vasoconstriction. o Option B: The veins are unaffected by the vasospasm occurring with Raynaud’s disease. In the primary Raynaud phenomenon, an increase in alpha-2 adrenergic sensitivity in the digital and cutaneous vessels results in the vasoconstrictive response to cold temperatures and emotional stress. Alpha-2 adrenergic receptors are present on the distal arterial smooth muscles of the digits and affected by the sympathetic nervous system. o Option C: The aorta is a major blood vessel unaffected by Raynaud’s disease. In the secondary Raynaud phenomenon, the underlying disease is the factor that disrupts normal vessel reactivity to cold temperatures. Usually, the endothelial function of the digital and cutaneous vessels is compromised leading to eventual vasoconstriction with resulting tissue ischemia. 7 . Question Nurse Jamie should explain to a male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because: o A. More accurate o B. Can be done by the client o C. It is easy to perform o D. It is not influenced by drugs Correct Answer: A. More accurate Urine testing provides an indirect measure that may be influenced by kidney function while blood glucose testing is a more direct and accurate measure. Accurate measurement of blood glucose is superior to the capillary blood glucose test. However, this is dependent on the laboratory meeting established industry standards. o Option B: Both tests can be done by the client himself. Equipment used includes a lancet used to prick the skin, a glucometer, and test strips. Glucometers have a range of features with modern smart machines requiring a very small sample of blood ( from 0.3 to 1 microL), have Bluetooth capabilities that synchronize data with paired applications (apps) on smartphones. These machines and apps record data and provide trends in glucose measurements undertaken. o Option C: Both procedures can be easily performed by the client. Blood samples can also also be sourced from alternate sites such as the earlobe, heel, forearm, palm. Alternate site testing provides similar results to finger-prick testing, especially in the fasting and twohour post meal times. Using alternate sites may be less painful but may need a deeper lance. o Option D: When the client has taken a drug before performing a procedure, this procedure could be affected by the drug taken. Blood glucose monitoring may support the diagnosis and management of the client with impaired glucose metabolism or diabetes. Regular monitoring of blood glucose levels is not recommended for patients with type 2 diabetes on oral antidiabetic drugs and or dietary management. 8 . Question Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost: o A. 0.3 L o B. 1.5 L o C. 2.0 L o D. 3.5 L Correct Answer: C. 2.0 L One liter of fluid approximately weighs 2.2 pounds. A 4.5-pound weight loss equals to approximately 2L. Diuresis is necessary for a variety of non-edematous and edematous conditions, which require clearing out excess water when the body abnormally sequesters fluid in third space in the form of edema. o Opt ion A: Option A has a very low amount of fluid loss and is incompati ble with the weight that the client has lost. Diuretics are drugs that pharmacol ogically tilt the renal fluid regulation in favor of excretion of water and electrolyte s. Thus, diuretics are substances that increase the production and volume of urine. This class of drugs achieves this objective primarily by suppressin g receptors that aid in reabsorpti on of Na+, the most abundant extracellul ar cation, from the renal tubules, thereby increasing the osmolality of the renal tubules and consequen tly suppressin g water reabsorpti on. o Option B: 1.5 L is not an accurate amount of fluid loss based on the client’s weight loss. The most common adverse effect for any diuretic is mild hypovole mia, which can lead to transient dehydratio n and increased thirst. When there is an overtreatment with a diuretic, this could lead to severe hypovole mia, causing hypotensi on, dizziness, and syncope. o Option D: 3.5 L is more than the amount of fluid loss based on the client’s amount of weight loss. Diuretic treatment calls for careful assessmen t of extracellul ar fluid volume, urine output, electrolyte levels in plasma and urine, body weight, acid-base status, serum glucose, and BP regularly with particular emphasis on patients with cardiovasc ular, hepatic, renal, or metabolic disorders and in elderly individuals . 9 . Question Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of: o A. Osmosis o B. Diffusion o C. Active transport o D. Filtration Correct Answer: A. Osmosis Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration. In physiology, osmosis (Greek for push) is the net movement of water across a semipermeable membrane. Across this membrane, water will tend to move from an area of high concentration to an area of low concentration. It is important to emphasize that ideal osmosis requires only the movement of pure water across the membrane without any movement of solute particles across the semipermeable membrane. o Option B: Diffusion is the movement of a substance from an area of high concentration to an area of low concentration. Passive transport, most commonly by diffusion, occurs along a concentration gradient from high to low concentration. No energy is necessary for this mode of transport. Examples will include diffusion of gases across alveolar membranes and diffusion of neurotransmitters such as acetylcholine across the synapse or neuromuscular junction. o Option C: Active transport is the process of transferring substances into, out of, and between cells, using energy. Active transport is an energy-driven process where membrane proteins transport molecules across cells, mainly classified as either primary or secondary, based on how energy is coupled to fuel these mechanisms. o Option D: Filtration is a process used to separate solids from liquids or gases using a filter medium that allows the fluid to pass through but not solid. The term “filtration” applies whether the filter is mechanical, biological, or physical. The fluid that passes through the filter is called the filtrate. The filter medium may be a surface filter, which is a solid that traps solid particles, or a depth filter, which is a bed of material that traps the solid. 10 . Question Myrna, a 52-year-old client with a fractured left tibia, has a long leg cast and she is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with crutch walking? o A. Left leg discomfort o B. Weak biceps brachii o C. Triceps muscle spasm o D. Forearm weakness Correct Answer: D. Forearm weakness Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae. Crutch palsy is observable in axilla crutch users who rest their weight on the shoulder rest. The pressure on the brachial plexus can result in palsy to the radial and ulnar nerves. Extra padding on the shoulder rest can aid in preventing crutch palsy. o Option A: The left leg would be at rest since the fracture is at the left tibia. Crutches are vital in the shortterm and long-term management of orthopedic and neurologic injuries. Through offloading body weight to the injured extremity optimal conditions are provided to allow healing of acute injuries. o Option B: All the strength spent in crutch walking falls on the forearms, not the biceps brachii. Crutches provide ambulatory support and mobility options to those with neurologic injuries or chronic orthopedic injuries enabling the individual to stay mobile and active. Crutches are a vital adjunct for those with acute and chronic injuries to maintain mobility and independence. o Option C: The triceps would not be as affected than the forearms after crutch walking The user’s strength and coordination should undergo evaluation before issuing them a set of crutches. The use of the wrong crutches can lead to injury. Most injuries are a direct result of falling. 11 . Question Which of the following statements should the nurse teach the neutropenic client and his family to avoid? o A. Performing oral hygiene after every meal o B. Using suppositories or enemas o C. Performing perineal hygiene after each bowel movement o D. Using a filter mask Correct Answer: B. Using suppositories or enemas Neutropenic clients are at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract. An ly administered enema can damage tissue in your rectum/colon, cause bowel perforation and, if the device is not sterile, infections. o Option A: Performing oral hygiene consistently after meals could help prevent infection of the oral mucous membranes. Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes. Hard-bristled toothbrushes can compromise the integrity of the mucous membrane and provide a port of entry for pathogens. o Option C: Proper perineal hygiene helps prevent urinary tract infections. Wash hands or perform hand hygiene before having contact with the patient. Also impart these duties to the patient and their significant others. Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another. o Option D: Wearing a mask, especially in a crowded place, would help prevent contagious respiratory infections. Provide surgical masks to visitors who are coughing and provide rationale to enforce usage. Instruct visitors to cover mouth and nose (by using the elbows to cover) during coughing or sneezing; use of tissues to contain respiratory secretions with immediate disposal to a no-touch receptacle; perform hand hygiene afterward. 12 . Question A female client is experiencing a painful and rigid abdomen and is diagnosed with a perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in o A. Sims position o B. Supine position o C. Semi-fowlers position o D. Dorsal recumbent position Correct Answer: C. Semi-fowlers position Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity. Initiation of fluid resuscitation should start as soon as the diagnosis is made. Insertion of a nasogastric tube to decompress the stomach and a Foley catheter to monitor urine output are essential steps. o Option A: Placing the client in a Sims position could let the stomach contents spill out of the perforation. Tachycardia and abdominal tenderness with rigidity are common clinical signs. Severe pain, systemic inflammatory response from chemical peritonitis, and fluid deficit either due to poor intake or vomiting or pyrexia lead to compensatory tachycardia. o Option B: The supine position could aggravate the pain of the ulcer. PPU is a surgical emergency associated with high mortality if left untreated. In general, all patients with PPU require prompt resuscitation, intravenous antibiotics, analgesia, proton pump inhibitor medications, nasogastric tube, urinary catheter, and surgical source control. o Option D: Placing the patient in a dorsal recumbent position would put pressure on the stomach contents and still aggravate the pain. When PUD worsens and eventually perforate, gastric juice and gas enter the peritoneal cavity leading to chemical peritonitis. Sudden onset of abdominal pain or acute deterioration of the ongoing abdominal pain is typical of PPU. Typically the pain never completely subsides despite usual premedical remedies and forces the patient to seek medical attention. • 13 . Question Which nursing intervention ensures adequate ventilating exchange after surgery? o A. Remove the airway only when the client is fully conscious o B. Assess for hypoventilation by auscultating the lungs o C. Position client laterally with the neck extended o D. Maintain humidified oxygen via nasal cannula Correct Answer: C. Position client laterally with the neck extended Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of secretions and oxygen and carbon dioxide exchange can occur. This position promotes oxygenation via maximum chest expansion and is implemented during events of respiratory distress. Do not let the client slide down; this causes the abdomen to compress the diaphragm, which could cause respiratory change. o Option A: The client should be weaned first before removing the airway. Weaning from mechanical ventilation is the process of reducing ventilatory support, ultimately resulting in a patient breathing spontaneously and being extubated. This process can be achieved rapidly in ?80% of patients when the original cause of the respiratory failure has improved. o Option B: Assessing hypoventilation through the lungs would provide inadequate results. Changes in the respiratory rate and rhythm are early signs of possible respiratory distress. As moving air in and out of the lungs becomes more difficult, the breathing pattern changes to include the use of accessory muscles to increase chest excursions. o Option D: Oxygen may be maintained after surgery but this might be inadequate. The key is that the client receives oxygenation support at all times until mechanical ventilation is no longer required. • 14 . Question George, who has undergone thoracic surgery has a chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in the water-seal chamber, the nurse should: o A. “Strip” the chest tube catheter o B. Check the system for air leaks o C. Recognize the system is functioning correctly o D. Decrease the amount of suction pressure Correct Answer: B. Check the system for air leaks Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion. Know the location of air leak (patient- or system-centered) by clamping thoracic catheter just distal to exit from the chest. If bubbling stops when the catheter is clamped at the insertion site, leak is patient-centered (at insertion site or within the patient). o Option A: Stripping the chest tube has not shown to have clinical benefits. Stripping may cause negative pressure to burst up to 20 times the routine suction pressure applied. This may cause tissue injury. Stripping is usually uncomfortable for the patient because of the change in intrathoracic pressure, which may induce coughing or chest discomfort. Vigorous stripping can create very high intrathoracic suction pressure, which can be injurious (invagination of tissue into catheter eyelets, collapse of tissues around the catheter, and bleeding from rupture of small blood vessels). o Option C: The presence of excessive bubbling is not a normal finding. Observe for abnormal and continuous water-seal chamber bubbling. With suction applied, this indicates a persistent air leak that may be from a large pneumothorax at the chest insertion site (patient-centered) or chest drainage unit (systemcentered). o Option D: Decreasing the amount of suction pressure without any appropriate orders may cause the system to be ineffective. Check suction control chamber for a correct amount of suction (determined by water level, wall or table regulator at correct setting. Water in a sealed chamber serves as a barrier that prevents atmospheric air from entering the pleural space should the suction source be disconnected and aids in evaluating whether the chest drainage system is functioning appropriately. • 15 . Question A client who has been diagnosed with hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that: o A. I can eat celery sticks and carrots o B. I can eat broiled scallops o C. I can eat shredded wheat cereal o D. I can eat spaghetti on rye bread Correct Answer: C. I can eat shredded wheat cereal Wheat cereal has a low sodium content. Sodium controls fluid balance in the body and maintains blood volume and blood pressure. Eating too much sodium may raise blood pressure and cause fluid retention, which could lead to swelling of the legs and feet or other health issues. o Option A: Celery and carrots are both high in sodium content. With 50 milligrams of sodium in both a large stock of celery and a large carrot, these vegetables provide that familiar savory flavor in soups and stews, without several pinches of salt. o Option B: Seafoods are rich in sodium. According to the American Heart Association, 1,500 mg of sodium per day is the recommended intake. Three ounces of scallops can give about 325 mg of sodium-20% of the recommendation. While most fish runs relatively low on the sodium scale, its ocean brethren can top the natural sodium charts. Shrimp, lobster, crab, and scallops (to name a few) can all contain hundreds of milligrams of sodium per 3- ounce serving o Option D: Rye bread has a high sodium content. Actions of industry in reducing the sodium in the processed food supply are important in the public health effort to lower the sodium of what we eat. Gorton7 gives insight into the dialogue of industrial bakers in lowering the sodium in their products. Salt plays an important role in gluten modification, yeast control, and microbial inhibition in baked products. 16 . Question A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulting from ascites. The nurse should be aware that the ascites is most likely the result of increased: o A. Pressure in the portal vein o B. Production of serum albumin o C. Secretion of bile salts o D. Interstitial osmotic pressure Correct Answer: A. Pressure in the portal vein Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting in ascites. Portal pressure increases above a critical threshold and circulating nitric oxide levels increase, leading to vasodilation. As the state of vasodilatation becomes worse, the plasma levels of vasoconstrictor sodiumretentive hormones elevate, renal function declines, and ascitic fluid forms, resulting in hepatic decompensation. o Option B: There is a decrease in the production of serum albumin in clients with ascites, leading the fluid to leak or escape from the interstitial spaces into the peritoneal cavity. Ascitic fluid protein and albumin are measured simultaneously with the serum albumin level to calculate the serum-ascites albumin gradient ( SAAG ). o Option C: The function of bile salts is to help process and digest the fats. Bile salts inhibit cholesterol 7alpha-hydroxylase, decreasing the synthesis of bile acids. Despite the increased water solubility of bile salts, they are amphipathic molecules overall. This critical property allows them to effectively emulsify lipids and form micelles with the products of lipid digestion. o Option D: Osmotic pressure is defined as a pressure that must be applied to the solution side to stop fluid movement when a semipermeable membrane separates a solution from pure water. Osmotic pressure is the pressure caused by water at different concentrations due to the dilution of water by dissolved molecules (solute), notably salts and nutrients. 17 . Question A newly admitted client diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure? o A. Vital signs o B. Incision site o C. Airway o D. Level of consciousness Correct Answer: C. Airway Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange. When the numbness wears off, the throat may feel scratchy for several days. After the test, the cough reflex will return in 1 to 2 hours. Then the client may eat and drink normally. o Option A: The vital signs should be assessed after the procedure, but this may come after assessing the airway first. Infection is relatively rare and can be treated with antibiotics. Numbness can occur if the biopsy is done near nerves. Any numbness typically disappears within a couple of months. o Option B: The incision site should be assessed regularly, but this would not be the priority after the procedure. The patient should contact the physician if any redness, increased swelling, or increased pain develops at the surgery site. Patients may shower or bathe normally. The patient may get water on the incision. If there are stitches, they may get wet. If there is a plastic bandage over the incision, the patient may get this wet. o Option D: The client has only undergone local anesthesia, his level of consciousness should not be a cause of concern. Pain and tenderness can last for a few days after a biopsy. Once the client gets home, he should keep the biopsy site clean and dry at all times. The doctor may ask the client to avoid showers or baths for a couple of days after the surgery. 18 . Question A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock? o A. Systolic blood pressure less than 90mm Hg o B. Pupils unequally dilated o C. Respiratory rate of 4 breath/min o D. Pulse rate less than 60 bpm Correct Answer: A. Systolic blood pressure less than 90 mm Hg Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg. The first changes in vital signs seen in hypovolemic shock include an increase in diastolic blood pressure with narrowed pulse pressure. As volume status continues to decrease, systolic blood pressure drops. As a result, oxygen delivery to vital organs is unable to meet oxygen demand. o Option B: Unequally dilated pupils refer to anisocoria. Acute onset should be considered an emergency because it may be due to brain mass lesions which cause oculomotor nerve palsy. Anisocoria is a condition characterized by unequal pupil size. The etiology of anisocoria is complex, ranging from benign to potentially life-threatening causes. There are many pathways involved in pupil size. Some potential etiologies of anisocoria include systemic drug use, topical ophthalmic drug use, headaches, and autonomic ganglion pathology. o Option C: This indicates a very low respiratory rate or bradypnea. Tachypnea is seen in clients with class II hemorrhage (loss of 15-30%). Similar to examining pulse pressure variation, measuring respiratory variation in inferior vena cava diameter as a measure of volume responsiveness has only been validated in patients without spontaneous breaths or arrhythmias. o Option D: The cardiovascular system initially responds to hypovolemic shock by increasing the heart rate, increasing myocardial contractility, and constricting peripheral blood vessels. Patients with volume depletion may complain of thirst, muscle cramps, and/or orthostatic hypotension. Severe hypovolemic shock can result in mesenteric and coronary ischemia that can cause abdominal or chest pain. Agitation, lethargy, or confusion may result from brain malperfusion. • 19 . Question Nurse Lucy is planning to give preoperative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included? o A. Results of the surgery will be immediately noticeable postoperatively o B. Normal saline nose drops will need to be administered preoperatively o C. After surgery, nasal packing will be in place 8 to 10 days o D. Aspirin-containing medications should not be taken 14 days before surgery Correct Answer: D. Aspirin-containing medications should not be taken 14 days before surgery Aspirin-containing medications should not be taken 14 days before surgery to decrease the risk of bleeding. Impaired coagulation may cause postoperative complications. Patients should be asked about a history of excessive bruising or bleeding, consumption of drugs, supplements, or vitamins that alter coagulation cascade or history of thrombotic events in the past. Any drug, vitamins, or supplement that impairs coagulation might have to be suspended preoperatively. o Option A: Results would not be seen immediately, as swelling on the postoperative part will be prominent after surgery. Preoperative photos have to be taken for previous analysis and planning and for medico-legal purposes. Frontal, both profiles, and a basal view are the minimum requirements. They should be taken using a dark background with good lighting settings. o Option B: There is no indication for normal saline nose drops after surgery. Closed rhinoplasty can be performed either with general anesthesia or local anesthesia and sedation, both with similar results in experienced hands.The patient is placed in the supine position, with a slight reverse Trendelenburg, to minimize bleeding. o Option C: Internal dressings or nasal packings remain in place for 1 to 7 days after the surgery. After mucosal incisions are closed with resorbable sutures, Silastic splints are placed and sutured to each side of the septum in order to provide septal support and enhance mucosal healing. Several strips of paper tape are distributed over the dorsum and a cast over it, which is removed 7 days postoperatively. • 20 . Question Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem? o A. Regular insulin o B. Potassium o C. Sodium bicarbonate o D. Calcium gluconate Correct Answer: A. Regular insulin Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose. Administration of insulin corrects this problem. The discovery of insulin, along with the antibiotics, has led to a drastic decrease in mortality with DKA, down to 1%. Intravenous insulin by continuous infusion is the standard of care. Previous treatment protocols have recommended the administration of an initial bolus of 0.1 U/kg, followed by the infusion of 0.1 U/kg/h. o Option B: Potassium is an essential mineral constituent of the human body and is the chief cation found within the intracellular fluid of all cells. Multiple salts of potassium exist and can be useful as a medication for a wide range of indications. The chief indication for potassium administration is potassium deficiency or hypokalemia, a condition in which serum potassium level falls below a critical range. o Option C: Sodium bicarbonate is a medication used in the management and treatment of multiple disease pathologies. It is a general chemical compound by classification. Under arrhythmias and cardiovascular instability, sodium bicarbonate can be administered to adults at 4 to 8 hour IV infusions. Each dose should be monitored and planned in a standard protocol to help evaluate the degree of response expected and predicted to understand the necessity to advance further infusions or withhold administration, given its fluid overloading effects. o Option D: Calcium gluconate belongs to a class of drugs called Antidotes; Calcium Salts. It is an over-thecounter and a prescription medicine used to treat symptoms of hypocalcemia and as a calcium supplement. Calcium gluconate is used to treat conditions arising from calcium deficiencies such as hypocalcemic tetany, hypocalcemia related to hyperparathyroidism, and hypocalcemia due to rapid growth or pregnancy. • 21 . Question Dr. Marquez tells a client that an increased intake of foods that are rich in Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are: o A. Fish and fruit jam o B. Oranges and grapefruit o C. Carrots and potatoes o D. Spinach and mangoes Correct Answer: D. Spinach and mangoes Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the following foods: wheat germ, corn, nuts, seeds, olives, spinach, asparagus and other green leafy vegetables. Food sources of betacarotene include dark green vegetables, carrots, mangoes and tomatoes. o Option A: Fish is rich in protein, while fruit jams are rich in fiber and carbohydrates. Fish is filled with omega-3 fatty acids and vitamins such as D and B2 (riboflavin). Fish is rich in calcium and phosphorus and a great source of minerals, such as iron, zinc, iodine, magnesium, and potassium. The American Heart Association recommends eating fish at least two times per week as part of a healthy diet. o Option B: Oranges and grapefruit are rich in Vitamin C. Lemons, limes, grapefruits, and oranges are high in phytonutrients, such as carotenoids, flavonoids, and polyphenols. These nutrients are types of antioxidants and give the fruits their bright colors and strong scents. They can also help protect the body and prevent many health issues. o Option C: Carrots are rich in beta-carotene, a compound the body changes into vitamin A, which helps keep the eyes healthy. And beta-carotene helps protect the eyes from the sun and lowers the chances of cataracts and other eye problems. Yellow carrots have lutein, which is also good for the eyes. Studies have linked potatoes and their nutrients to a variety of impressive health benefits, including improved blood sugar control, reduced heart disease risk, and higher immunity. They may also improve digestive health and combat signs of aging. • 22 . Question A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every meal, the client should: o A. Rest in a sitting position o B. Take a short walk o C. Drink plenty of water o D. Lie down at least 30 minutes Correct Answer: A. Rest in a sitting position Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus. Instruct to remain in an upright position at least 2 hours after meals; avoiding eating 3 hours before bedtime. Helps control reflux and causes less irritation from reflux action into the esophagus. o Option B: Walking after meals may cause regurgitation of stomach contents. Instruct the patient regarding eating small amounts of bland food followed by a small amount of water. Instruct to remain in an upright position at least 1–2 hours after meals, and to avoid eating within 2–4 hours of bedtime. o Option C: The client should drink moderate amounts of water. Instruct the patient to avoid highly seasoned food, acidic juices, alcoholic drinks, bedtime snacks, and foods high in fat. These can reduce the lower esophageal sphincter pressure. o Option D: Lying down would cause a reflux of the stomach contents. Avoid placing the patient in a supine position, have the patient sit upright after meals. Supine position after meals can increase regurgitation of acid. • 23 . Question After gastroscopy, an adaptation that indicates major complication would be: o A. Nausea and vomiting o B. Abdominal distention o C. Increased GI motility o D. Difficulty in swallowing Correct Answer: B. Abdominal distention Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis. Bowel perforation occurs in less than 0.3 % of cases, and infection is rarely reported. Complications typically are identified in the first 24 hours after the procedure. Perforation is identified due to fever, tachycardia, abdominal pain or discomfort. o Option A: It is normal to feel nauseous a day or two after surgery. Complications following esophagogastroduodenoscopy (EGD) are rare, occurring in less than 2% of patients. These could be related to sedation, endoscopy, and complications related to diagnostic or therapeutic maneuvers. o Option C: An increase in GI motility is not a cause for concern. The risk of bleeding following EGD with biopsy is 0.3%. Post mucosal biopsy bleeding can occur as intraluminal hemorrhage or intraluminal hematoma. A duodenal hematoma is a rare complication of EGD with an unknown incidence and seems to occur more often in children than adults. o Option D: There would be difficulty in swallowing after the surgery until the local anesthesia fades. Adverse events from over sedation include hypoxemia, hypoventilation, hypotension, airway obstruction, arrhythmias, and aspiration. The complications following diagnostic EGD include infection, bleeding, duodenal hematoma, and bowel perforation. • 24 . Question A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that: o A. “Most people need to eat a high protein diet for 12 months after surgery” o B. “I should not eat those foods that upset me before the surgery” o C. “I should avoid fatty foods as long as I live” o D. “Most people can tolerate regular diet after this type of surgery” Correct Answer: D. “Most people can tolerate regular diet after this type of surgery” It may take 4 to 6 months to eat anything, but most people can eat anything they want. Start with clear liquids after the surgery to prevent nausea, vomiting, and constipation, (soup, Jell-O, juices, popsicles, and carbonated beverages.) then advance to a regular low-fat diet. Eat smaller meals more often instead of fewer larger meals. o Option A: A high protein diet is unnecessary. A healthy meal should include small amounts of lean protein. If the patient has diarrhea, he should try avoiding spicy foods, dairy products, fatty foods, and alcohol. If diarrhea continues for more than 2 weeks, he should talk to his doctor. o Option B: High-fat foods should be avoided not only before the surgery, but it should be restricted a week after surgery as well. The patient can eat a normal diet, but avoid eating fatty foods for about one (1) month. Fatty foods include hamburgers, whole milk, cheese, and many snack foods. If the stomach is upset, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt o Option C: Fatty foods, fried and greasy foods, and sauces should be avoided for at least a week after surgery. Eat lots of whole grains, fruits, and green leafy vegetables. Avoid foods that cause constipation such as dairy products, red meat, processed foods such as pizza, frozen dinners, pasta, and sugar products such as cakes, pies, pastries, doughnuts, and drinks containing caffeine. • 25 . Question Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is: o A. Restlessness o B. Yellow urine o C. Nausea o D. Clay-colored stools Correct Answer: D. Clay-colored stools Clay-colored stools are indicative of hepatic obstruction. Acute HAV infection is typically a self-limited illness characterized by nausea, vomiting, right upper quadrant abdominal discomfort, malaise, anorexia, myalgia, fatigue, and fever. Patients may develop dark urine and pale stools within a week, followed by jaundice, icteric (yellow-tinted) sclera, and pruritus. o Option A: Restlessness is not a symptom related to hepatitis A. The incubation period usually ranges from 14 to 28 days but can last up to 50 days. The severity of symptoms varies with age and comorbidities, particularly underlying chronic liver disease. Most children with acute HAV infection are asymptomatic. o Option B: One of the symptoms of hepatitis A is dark urine. Patients usually have elevated levels of serum alanine aminotransferase, aspartate aminotransferase, bilirubin, alkaline phosphatase, and lambda-glutamyl transpeptidase. These lab abnormalities typically resolve within 1 to 6 weeks following the onset of symptoms. o Option C: Sudden nausea and vomiting are some of the symptoms, but it is not of immediate concern. Extrahepatic manifestations rarely occur but may include pancreatitis, rash, acute kidney injury with interstitial nephritis or glomerulonephritis, pneumonitis, pericarditis, hemolysis, and acute cholecystitis. • 26 . Question Which of the following antituberculosis drugs can damage the 8th cranial nerve? o A. Isoniazid (INH) o B. Para Aminosalicylic acid (PAS) o C. Ethambutol hydrochloride (Myambutol) o D. Streptomycin Correct Answer: D. Streptomycin Streptomycin is an aminoglycoside and damage to the 8th cranial nerve (ototoxicity) is a common side effect of aminoglycosides. Ototoxicity and vestibular impairment are often thought to be the hallmark of streptomycin toxicity. In extreme cases, deafness may occur due to ototoxicity, thus caution must be exercised when combining streptomycin with other potentially ototoxic drugs. Vestibular impairment usually manifests during the course of treatment and is typically permanent. o Option A: Isoniazid may cause serious damage to the liver. Isoniazid is metabolized primarily by the liver, by acetylation of Nacetyltransferase 2 (NAT2). Three metabolites have implications that correlate with the liver injury associated with the drug: acetyl hydrazine (AcHz), hydrazine (Hz), and a metabolite from the bioactivation of isoniazid itself. There is considerable variation in acetylation rate and elimination half-life from individual to individual, which is not accounted for by dose and concentration, and this appears to contribute to risk for hepatotoxicity as well as the other adverse effects associated with isoniazid. o Option B: Despite having excellent efficacy against TB in both in vitro experiments and clinical trials, PAS was eventually replaced with better-tolerated ethambutol due to gastrointestinal disturbance associated with the usage of PAS. o Option C: One of the most well-known adverse effects is ototoxicity. The effect of ototoxicity is dose-related, with greater than 40% of adults developing toxicity at doses that were greater than 50 mg/kg and around 0 to 3% of adults developing toxicity at 15 mg/kg/daily. The manifestation of EMB-induced optic neuropathy appears to be from EMB’s chelation of copper. A study with 60 patients undergoing treatment with ethambutol monitored their serum copper levels. • 27 . Question The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers are the result of which of the following: o A. Genetic defect in gastric mucosa o B. Stress o C. Diet high in fat o D. Helicobacter pylori infection Correct Answer: D. Helicobacter pylori infection Most peptic ulcers are caused by Helicobacter pylori which is a gram-negative bacterium. H. pylorus is a gram-negative bacillus that is found within the gastric epithelial cells. This bacterium is responsible for 90% of duodenal ulcers and 70% to 90% of gastric ulcers. H. pylori infection is more prevalent among those with lower socioeconomic status and is commonly acquired during childhood. The organism has a wide spectrum of virulence factors allowing it to adhere to and inflame the gastric mucosa. This results in hypochlorhydria or achlorhydria, leading to gastric ulceration. o Option A: Peptic ulcers are not genetic in nature. They occur when acid in the digestive mucosa eats away at the inner surface of the stomach or small intestine. Peptic ulcer disease (PUD) has various causes; however, Helicobacter pylori-associated PUD and NSAIDassociated PUD account for the majority of the disease etiology. o Option B: Stress is not a cause of peptic ulcers. Nonsteroidal antiinflammatory drugs use is the second most common cause of PUD after H. pylori infection. The secretion of prostaglandin normally protects the gastric mucosa. NSAIDs block prostaglandin synthesis by inhibiting COX-1 enzyme resulting in a decrease in gastric mucus and bicarbonate production and a decrease in mucosal blood flow. o Option C: Common causes of peptic ulcer include a bacteria (H. pylori), regular use of certain pain relievers, and use of certain medications along with NSAIDs. Apart from NSAIDs, corticosteroids, bisphosphonates, potassium chloride, steroids, and fluorouracil have been implicated in the etiology of PUD. Smoking also appears to play a role in duodenal ulcers, but the correlation is not linear. Alcohol can irritate the gastric mucosa and induce acidity. • 28 . Question Ryan has undergone a subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery? o A. Bile green o B. Bright red o C. Cloudy white o D. Dark brown Correct Answer: D. Dark brown 12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested food. Assess color, amount, and odor of gastric drainage, noting any changes in these parameters or the presence of clots or bright bleeding. Initial drainage is bright red. It becomes dark, then clear or greenish-yellow over the first 2 to 3 days. A change in the color, amount, or odor may indicate a complication such as hemorrhage, intestinal obstruction, or infection. o Option A: Bile green color of gastric drainage is due to the presence of bile and is not expected during the first 12 to 24 hours. Normal color of gastric drainage is light yellow to green in color due to the presence of bile. o Option B: Bloody drainage may be expected in the first 6 to 12 hours after gastric surgery but must be monitored closely. Bright red blood may indicate bleeding from the esophagus, the stomach or swallowed from the lungs o Option C: Cloudy white drainage is not expected during the first 12 to 24 hours. Gastric aspirates were most frequently cloudy and green, tan or off-white, or bloody or brown. Intestinal fluids were primarily clear and yellow to bile-colored. In the absence of blood, pleural fluid was usually pale yellow and serous, and tracheobronchial secretions were usually tan or offwhite mucus. • 29 . Question Nurse Joan is assigned to come for a client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the postoperative period. Which of the following is best recommended for the client? o A. Watching circus o B. Bending over o C. Watching TV o D. Lifting objects Correct Answer: C. Watching TV Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not increase intraocular pressure. Once the patient gets home, it is recommended that they rest their eyes and nap. Several hours postsurgery, most people are able to watch some television or look at a computer screen for a short period of time. Because cataract surgery is only performed on one eye at a time, the patient may notice an imbalance in the vision until the second eye is operated on (usually 1–4 weeks later). o Option A: Watching a circus would require a lot of eye movement and might strain the eyes. It is normal for vision to be blurry in the beginning – the eye needs to heal and adjust. Vision will normally begin to improve within a few days of the surgery. It’s also normal for the eye to feel itchy and to experience mild discomfort for a couple of days – the doctor will ask the client to wear an eye patch or protective shield at night to ensure they don’t rub their eye while they sleep. This discomfort should disappear after a few days. o Option B: Bending over increases intraocular pressure. Immediately after the procedure, avoid bending over to prevent putting extra pressure on the eye. If at all possible, don’t sneeze or vomit right after surgery. Don’t rub the eye after surgery. o Option D: Lifting objects could cause an increase in intraocular pressure. Don’t do any heavy lifting or strenuous activity for a few weeks. Be careful walking around after surgery, and don’t bump into doors or other objects. Don’t expose the eye to irritants such as dust, dirt, wind, and pollen during the first few weeks after surgery. • 30 . Question A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter than the other leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing: o A. Fracture o B. Strain o C. Sprain o D. Contusion Correct Answer: A. Fracture Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus and swelling. These injuries are associated with symptoms of pain, deformity, swelling, and a wound that may be bleeding. It should be noted that the wound may not lie directly over the fracture site. The movement and neurovascular status of all involved limbs should be assessed to ascertain whether or not there is a possible nerve or vascular injury associated with the fracture. o Option B: A foot strain is a stretching or tearing of the tendons and muscles in the foot. Common symptoms of strain include muscle pain and tenderness, local muscle swelling, black and blue discoloration, decrease in muscle strength, difficulty in walking, or a pop in the muscle at the time of injury. o Option C: Symptoms of sprain include swelling, tenderness, bruising, pain, inability to put weight on the affected ankle, skin discoloration, and stiffness. Acute ankle sprains are commonly seen in both primary care and sports medicine practices as well as emergency departments and can result in significant short-term morbidity, recurrent injuries, and functional instability. o Option D: Symptoms of contusion include discoloration of the skin, swelling, and tightness in the affected muscle or stiffness in the affected joint. A contusion, or bruise, forms when soft tissue in the body is crushed but the skin doesn’t break. When this happens, blood from broken capillaries (small blood vessels) near the skin’s surface may leak out under the skin. With no place to go, the blood gets trapped, often forming a red or purplish mark that hurts when it is touched. • 31 . Question Nurse Jenny is instilling an otic solution into an adult male client’s left ear. Nurse Jenny avoids doing which of the following as part of the procedure o A. Pulling the auricle backward and upward. o B. Warming the solution to room temperature. o C. Pacing the tip of the dropper on the edge of the ear canal. o D. Placing the client in a side lying position. Correct Answer: C. Placing the tip of the dropper on the edge of the ear canal. The dropper should not touch any object or any part of the client’s ear. Don’t allow the dropper tip to touch the ear, fingers, or any other surface. It could pick up bacteria or other germs that can lead to an ear infection. o Option A: For adults, pull the auricle backward and upward to prepare the ear for insertion of the drop and ensure the drop reaches the required area. If the bottle has a dropper, draw some liquid into the dropper. If the bottle has a dropper tip, you’ll just need to turn the bottle upside down. o Option B: If indicated, the solution can be warmed by rolling the bottle in the hands for several minutes before the instillation. Warm the ear drops by holding the bottle in both hands for one to two minutes. This can help reduce any discomfort that could be caused by cold drops in the ear. o Option D: Side-lying position is the best position for instillation of the drops and this also ensures comfort for the service user. Position the head so that the ear faces upward. If giving the drops to someone else, it may be easiest if the person tilts their head or lies down on their side. • 32 . Question Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptoms? o A. Absence of drainage from the ileostomy for 6 or more hours o B. Passage of liquid stool in the stoma o C. Occasional presence of undigested food o D. A temperature of 37.6 °C Correct Answer: A. Absence of drainage from the ileostomy for 6 or more hours Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed. Sometimes the ileostomy does not function for short periods of time after surgery. This is not usually a problem, but if the stoma is not active for more than 6 hours and the patient experiences cramps or nausea, he may have an obstruction. o Option B: Passage of a moderate amount of stool in the stoma is expected during the first few days after surgery. With no large intestine to absorb as much water from it, stool becomes thinner. Stools may thicken up as the body adapts and the small intestine starts to absorb more water, but this is something that happens long-term. At first, the stool will be thin and output may be high. o Option C: As the body gets used to the stoma and ileostomy, the presence of undigested food every now and then can be normal. However, this piece of food might obstruct the stoma and cause abdominal pain and swelling. Avoid solid foods for the time being and drink plenty of water. o Option D: 37.6ºC is more than the normal range of temperature. Nursing interventions such as a tepid sponge bath may be done to decrease the temperature to the normal range. Pouchitis is when an internal pouch becomes inflamed. It’s a common complication in people with an ileo-anal pouch. • 33 . Question Jerry has been diagnosed with appendicitis. He develops a fever, hypotension, and tachycardia. The nurse suspects which of the following complications? o A. Intestinal obstruction o B. Peritonitis o C. Bowel ischemia o D. Deficient fluid volume Correct Answer: B. Peritonitis Complications of acute appendicitis are peritonitis, perforation and abscess development. Diffuse peritonitis and sepsis can also develop, which may progress to significant morbidity and possible death. Postoperative abscesses, hematomas, and wound complications are all complications that can be seen after appendectomies. If the wound does get infected, one may grow Bacteroides. “Recurrent” appendicitis can occur if too much of the appendiceal stump is left after an appendectomy. o Option A: Signs of intestinal obstruction include crampy abdominal pain, loss of appetite, constipation, vomiting, inability to have a bowel movement or pass gas, and swelling of the abdomen. Complications of appendicitis and appendectomy include surgical site infections, intra-abdominal abscess formation (3% to 4% in open appendectomy and 9% to 24% in laparoscopic appendectomy), prolonged ileus, enterocutaneous fistula, and small bowel obstruction. o Option C: Symptoms of bowel ischemia include sudden abdominal pain, an urgent need to have a bowel movement, frequent, forceful bowel movements, abdominal distention or swelling, bloody stool, and mental confusion in older adults. o Option D: Deficient fluid volume may be characterized by hypotension, concentrated urine, decreased skin turgor, decreased urine output, and dry mucous membranes. If diagnosed and treated early, within 24 to 48 hours, the recovery and prognosis should be very good. Cases that present with advanced abscesses, sepsis, and peritonitis may have a more prolonged and complicated course, possibly requiring additional surgery or other interventions. • 34 . Question Which of the following complications should the nurse carefully monitor a client with acute pancreatitis? o A. Myocardial Infarction o B. Cirrhosis o C. Peptic ulcer o D. Pneumonia Correct Answer: D. Pneumonia A client with acute pancreatitis is prone to complications associated with the respiratory system. The relationship between Mycoplasma pneumoniae infection and acute pancreatitis has been debated in the literature. In 1973, Mardh et al. reported four adult cases of acute pancreatitis following pneumonia due to MP; in three of the patients, the pancreatitis occurred in the 3rd week after the onset of cough, by which time the respiratory tract symptoms had almost disappeared. o Option A: Myocardial infarction is not a complication of pancreatitis. Acute pancreatitis may cause kidney failure, which can be treated with dialysis if the kidney failure is severe and persistent. o Option B: Kidney failure, not liver failure, can be caused by acute pancreatitis. Acute pancreatitis may cause kidney failure, which can be treated with dialysis if the kidney failure is severe and persistent. o Option C: Pancreatitis cannot cause peptic ulcer. It is most commonly caused by a bacteria called H. pylori. H. pylorus is a gram-negative bacillus that is found within the gastric epithelial cells. This bacterium is responsible for 90% of duodenal ulcers and 70% to 90% of gastric ulcers. H. pylori infection is more prevalent among those with lower socioeconomic status and is commonly acquired during childhood.