Miscellaneous Of Nursing Procedure

A. As a professional nurse is required to realize a precise skill that is based on

science and the scientific mindset. in this case at least three basic mindset
nurse should be accommodated in each their dedication in the hospital.

1. Mission : We provide the highest quality care through our nursing professional.

2. Vision : To build a trust between patient and our best nursing services offered to the
community.

3. Values : Our priority in safe nursing practice with the quality care provided to the
patients and their families enforced by our professional team work.

B. PPE, what is PPE ?, PPE is Personal Protective Equipment;

Donning : Gown,mask,goggles,gloves.
Removal : Gloves,goggles,gown,mask.

C. Isolation Precaution:

Airborne Precaution.
Droplets Precautions.
Contact Precautions.

Standard Precautions To Avoid Cross Infection

Use standard precautions for the case of all patients as a basic requirement;

1. Airborne Precaution (airborne droplet nuclei < 5 micron those remain in the air, dust
particles containing the infection agent;depend on environment factors eg: Measles &
chicken pox).
keep in single room or in the isolation room
keep door closed always
use N95 mask as one an instrument for facing the patient
minimize patient transportation and use surgical mask for if needed or if applicable.

2. Contact Precautions (Direct contact; skin to skin contact, Indirect contact: touching
contaminated environmental surfaces or patient care items eg; contaminated instrument
dressing).
keep in single room if available
discharge the patient as soon as possible
use gown,use and remove gloves before leaving the unit
limit transportation
use disposable equipments
for common equipment,clean and desinfect
3. Droplet Transmission (microorganisme > 5 microns that can be produced by the
patient while coughing, sneezing or talking)

4. Visitor
Restrict the visitors
visitor should report to the nursing station before entering the room
visitor should follow instructions
not more than two visitor at the same time
people with cough should not allowed enter to the room
was hand or hand rub before and after visiting the room

D. Waste Management,especially in ICU Unit;

Yellow Plastic Bag; for the clinical waste (contaminated with body fluid + infected
items).
Blue Plastic Bag; for general waste.
Red Plastic Bag; for bathroom.
Yellow Box; For sharp objects, needles.

Principle of Waste Management;

All used sharps must be discarded without reheating or recapping in a puncture

resistant container that is readily accessible.

Ensure that infection waste bags and sharps container are closed before they are
transported for treatment.

Never discard needles & sharp in the clinical waste bag as the house keeping staff
might get injured.

For the infected linens, soiled with blood, secretions, fecal matter, vomitous put in
isolation bag with proper label.

General Cleaning;

1 tablet of precept in 10 liter of water for any infected case.

8 ml of Cidezyme in 1 liter of water for cleaning steel item; trolleys,etc.

C How to Clean Blood Spillage and Blood Splash(Small blood drops) on the
floor?;
1. Localized the the blood area;

for Large blood spillage

a.put 3,5 tablet of Presept dilute in 1 liter of water and clean it with use small towel or
dressing gauze.

for small blood drop

a.put one tablet of precept dilute in 2,5 liter of water and use it for cleaning.

D. How To Transfer Patient From ICU to Ward?;

1. The patient must be seen first by unit doctor or physician and as agreed upon with
the ICU doctors.
2. ICU doctor will document by writing Discharge Summary patient can be shifted to
the ward.
3. Once patient confirm for transfer, inform the ward about bed availability.
4. If the patient having arterial line or central line, confirm or inquire to ICU doctor
whether to remove or not then document in nurses note.
5. When the ward staff came,endorsement using the Handover Transfer Check List and
Discharge Check list.
6. Register in ICU main book for documentation and for census purposes.

E. How to Transport Patient For Diagnostic Procedure: CT/MRI.

1. Patient has a confirmed appointment date and time of procedure.
2. Informed to anaesthetist on call regarding appointment.
3. Informed to Respiratory Therapist on duty to prepare the cardiac monitor,ventilator
and emergency kit.
4. If needed ambulance to call.
5. Prepare the patient for transport; infusion,central and arterial line to keep ready for
moving and connect the ventilator and cardiac monitor to the patient.
6. Informe radiology department and start to transport.

CRITICAL THINKING NURSINGACARE QUESTIONS from LIPPincotts

A Client is admitted to the hospital with diagnosis of a right hip fracture. She complains
of right hip pain and cannot move her right leg.

1. Which of the following assessments made by the nurse indicates that the client has a
typical sign of a hip fracture?,The client right leg is;

a. rotated internally.
b. held in a flexed position.
c. adducted.
d. shorter than the leg on the unaffected side.

(The correct answer is D, after a hip fracture, the leg on the affected side is
characteristically shorter than the unaffected leg. Typically, it is also abducted and
rotated externally. Pain is usually present).

2. The clients fracture is corrected by surgical internal fixation with the insertion of a
pin. The nurses plan of care reflects the understanding that internal fixation with a pin
is the treatment of choice for most older people because it;

a. is a simpler procedure.
b. promotes rapid healing.
c. carries less danger of infection.
d. makes earlier mobilization possible.

(The correct answer is D, Using pin for the internal fixation of a fractured hip has
various advantages. The procedure is especially favored for older clients because it
enables earlier postoperative ambulation and provides good fixation at the fracture site).

3. The nurse anticipates that the client will return from surgery with a drainage tube
incision site that is attached to suction. The purpose of this apparatus is to help

a. detect a wound infection.

b. eliminate the need for wound irrigation.
c. prevent fluid accumulation in the wound.
d. provide a way to instill antibiotics into the wound.

(The correct answer is C, The primary reason for applying suction to a wound drainage
tube is to prevent fluid from accumulating in the wound. This greatly enhances wound
healing and help prevent abscess formation).

4. Which of the following sign or symptoms would be of least importance when the
nurse evaluates the client for post operative peripheral nerve damage?
a. Pain.
b. Sensation.
c. Bleeding.
d. Pulselessness.

(The correct answer is C, nerve damage may be indicated by the presence of any of the
five Ps; pain,pallor,pulselessness,paresthesia and paralysis. Bleeding does not indicate
peripheral nerve damage can occur after almost any orthopedic surgery).

5. Which of the following pieces of equipment should the nurse plan to use to help
prevent external rotation of the clients leg postoperatively?;

a. Sandbags.
b. A high footboard.
c. A rubber air ring.
d. A metal bed cradle

(The correct answer is A, It is best to support the clients leg in its proper anatomic
position and to prevent external rotation by supporting the leg with sandbags. A
trochanter roll can be also be used. Sandbags should be placed along the length of the
tight and lower leg. Neither a footboard,a rubber air ring nor a metal frame bed cradle
will help prevent external rotation of the leg).

6. Which of the following nursing measures would be most important to implement to

decrease the risk of a surgical wound infection in this client?;

a. Inserting indwelling urinary catheter to prevent possible soiling of the dressing.

b. Accurately measuring drainage from the surgical drainage tube.
c. Changing the surgical dressings using sterile technique.
d. Monitoring the incision for signs of redness,swelling and warmth.

(The correct answer is C, Wound infection can best be prevented by using strict sterile
technique during dressing changes. Accurately measuring drainage and monitoring the
incision for sign of infection are important nursing action but will not prevent wound
infection. Inserting a foley catheter is an unnecessary action in this case and would
predispose the client to a urinary tract infection).

7. When the client is lying on her side,the nurse should place pillows or a splint between
her legs to prevent;

a. flexion of the knees.

b. abduction of the thighs.
c. adduction of hip joint.
d. hyperextension of the knees.

(The correct answer is C, After hip surgery for a fracture femur,the client should be
positioned on the nonoperative side with pillows or an abductor splint between the legs
to help prevent adduction of the operative leg.This positioning places the hip in proper
alignment. Dislocation of the hip can occur if the leg on the affected side is allowed to
adduct).

8. In which of the following chairs would it be best for the client to sit postoperatively?;

a. A desk-type swivel chair.

b. A padded upholstered chair.
c. A high backed chair with armrest.
d. A recliner with an attached footrest.

(The correct answer is C, A high backed straight chair with armrests is recommended to
help keep the client in the best possible alignment after surgery for a hip fracture. Soft,
Low and swivel chairs do not promote good body alignment or good security).

9. The nurse should teach the client that which of the following leg positions is
contraindicated for her while sitting in a chair?;

a. Crossing her legs.

b. Elevating her legs.
c. Flexing her ankles.
d. Extending her knees.

(The correct answer is A, Leg crossing causes adduction of the hips, after hip surgery
this may result in a dislocation of the operative hip. This client should not cross her legs.
Elevating the legs,flexing the ankles and extending the knees are not necessarily
contraindicated).
10. When assessing the client as a candidate for crutch walking,the nurse should take
into account that for some elderly people,crutch walking is an impractical goal primarily
because of decreased

a. visual acuity.
b. reaction time.
c. motor coordination.
d. level of comprehension.

(The correct answer is C, Some elderly people are not good candidates for crutch
walking because they are not strong enough to use crutches or are not coordinated
enough to walk safety with crutches. Such factor as visual acuity,reaction time and level
of comprehension may influence the ability to learn crutch walking but are not as
important as motor coordination).

11. Which of the following activities should the nurse plan to teach the client to
strengthen her and muscles in preparation for using crutch?;

a. Brushing her hair.

b. Squeezing a rubber ball.
c. Flexing and Extending her wrists.
d. Pushing her hands into the mattress while raising herself in bed.

(The correct answer is B, A client being prepared for crutch walking should be taught for
support her weight with her hand while crutch walking. Supporting weight in the axillae
is contraindicated owing to the risk of possible nerve damage and circulatory
obstruction. The client should be taught to squeeze a ball vigorously to help strengthen
her hands in preparation for weight bearing with the hands. Such activities as brushing
the hair, flexing and extending the wrists and doing push ups may be indicated,but they
are not likely to strengthen the hands).

12. The nurse assesses the clients home environment for the safe use of crutches.
Which one of the following would pose the greatest hazard to the clients safe use of
crutch at home?;

a. A 4 years old cocker spaniel.

b. Scatter rugs.
c. Snack tables.
d. Rocking chair.

(The correct answer is B, Scatter rugs are the single greatest in the home,especially for
elderly people who are unsure of walking. Falls have been found to account for nearly
half the accidental deaths that occur in the home)

A Client has been treated for Chronic open angle glaucoma for 5 years.
13. The client asks the clinic nurse,how does glaucoma damage my eyesight?, The
nurse reply should be based on the knowledge that chronic open-angle glaucoma

a. Result from chronic eye inflammation.

b. Caused increased intra ocular pressure.
c. Leads to detachment of the retina.
d. Is caused by decreased blood flow to the retina.

(The correct answer is b, In chronic open angle glaucoma, there is an obstruction to the
outflow of aqueous humor,leading to increase intra-ocular pressure.. The increased
intra-ocular pressure eventually causes destruction of retinas nerve fibers. This nerve
destruction causes painless vision loss. The exact cause of glaucoma is unknown).

14. If the client experienced any symptom of glaucoma, it will most like;
a. Eye pain.
b. Excessive lacrimation.
c. Colored light flashes.
d. Decreasing periperal vision.

(The correct answer is D, Although chronic open-angle glaucoma,is usually

asymptomatic in the early stage, periperal vision decreases as the disorder progresses).

15. The nurse reevaluates the clients ability to instill eye drops correctly. The client
correctly demonstrates the procedure when he;
a. Blow his nose immediately after administering the eye drops.
b. Position himself on the his right side to instill the eye drops.
c. Instills the eye drops into the conjunctival sac.
d. Wipes the tip of eye drop applicator with a disposable tissue.

(The correct answer is C, proper technique for instilling eye drops includes maintaining
sterile asepsis of the applicator tip, being in supine position and instilling the eye drops
in the conjunctival sac. There is no need for the client to blow his nose after eye drop
administration).

16. Miotics are frequently used in the basic treatment of glaucoma. The nurse should
understand that miotics work by;
a. paralyzing ciliary muscles.
b. constricting intraocular vessels.
c. constricting the pupil.
d. relaxing ciliary muscles.

(The correct answer is C, A miotics agent constricts the pupil and contracts ciliary
musculature. These effects widen the filtration angle and permit increased outflow of
aqueous humor. Miotics also cause vasodilation of the intraocular vessels,where intra
ocular fluids leave the eye, also increasing aqueous humor outflow. Mydriatics cause
Cyclopegia or Paralysis of the ciliary muscle).
17. The nurse would plan to teach the client to administer which of the following drugs
for open-angle glaucoma;
a. Pilocarpine hydrochloride.
b. Atropine sulfate.
c. Scopolamine hydrobromide.
d. Acetazolamide (diamox)

A Client has been treated for Chronic open angle glaucoma for 5 years.

18. The client asks the clinic nurse,how does glaucoma damage my eyesight?, The
nurse reply should be based on the knowledge that chronic open-angle glaucoma

a. Result from chronic eye inflammation.

b. Caused increased intra ocular pressure.
c. Leads to detachment of the retina.
d. Is caused by decreased blood flow to the retina.

(The correct answer is B, In chronic open angle glaucoma, there is an obstruction to the
outflow of aqueous humor, leading to increase intra-ocular pressure.. The increased
intra-ocular pressure eventually causes destruction of retinas nerve fibers. This nerve
destruction causes painless vision loss. The exact cause of glaucoma is unknown).

19. If the client experienced any symptom of glaucoma, it will most like;
a. Eye pain.
b. Excessive lacrimation.
c. Colored light flashes.
d. Decreasing periperal vision.

(The correct answer is D, Although chronic open-angle glaucoma,is usually

asymptomatic in the early stage, periperal vision decreases as the disorder progresses).

20. The nurse reevaluates the clients ability to instill eye drops correctly. The client
correctly demonstrates the procedure when he;
a. Blow his nose immediately after administering the eye drops.
b. Position himself on the his right side to instill the eye drops.
c. Instills the eye drops into the conjunctival sac.
d. Wipes the tip of eye drop applicator with a disposable tissue.

(The correct answer is C, proper technique for instilling eye drops includes maintaining
sterile asepsis of the applicator tip, being in supine position and instilling the eye drops
in the conjunctival sac. There is no need for the client to blow his nose after eye drop
administration).

21. Miotics are frequently used in the basic treatment of glaucoma. The nurse should
understand that miotics work by;
a. paralyzing ciliary muscles.
b. constricting intraocular vessels.
c. constricting the pupil.
d. relaxing ciliary muscles.

(The correct answer is C, A miotics agent constricts the pupil and contracts ciliary
musculature. These effects widen the filtration angle and permit increased outflow of
aqueous humor. Miotics also cause vasodilation of the intraocular vessels,where intra
ocular fluids leave the eye, also increasing aqueous humor outflow. Mydriatics cause
Cyclopegia or Paralysis of the ciliary muscle).

22. The nurse would plan to teach the client to administer which of the following drugs
for open-angle glaucoma;
a. Pilocarpine hydrochloride.
b. Atropine sulfate.
c. Scopolamine hydrobromide.
d. Acetazolamide (diamox).

(The correct answer is A, Pilocarpine hydrochloride is a commonly prescribed miotic that

produces negligible systemic effects. Atropine sulfate and scopolamine hydrobromide
have mydriatic effects. Acetazolamide, a carbonic anhydrase inhibitor, decreases
secretion of aqueous humor in the eye, thus lowering intra oclura pressure).

23. The Most effective health-promotion measure related to glaucoma that the nurse
can teach clients is;
a. prompt treatment of all eye infections.
b. avoidance of extended-wear contacts lenses by older people.
c. annual intraoccular pressure measurements for people older than 40 yeras.
d. appropriate blood pressure control.

(The correct answer is C, The most effective health-promotion measure associated with
glaucoma is annual intraocular pressure measurements after 40 years of age. People
who are at risk for developing glaucoma such as those with diabetes or hypertension,
African, Americans and people with history familys glaucoma should have their
intraocular pressure checked after 35 years of age. Glaucoma is insidious and basically
asymptomatic and must be diagnosed before the client having any vision changes).

24. Which of the following information should the nurse give the client when preparing
him for tonometry;
a. Oral pain medication will be given before the procedure.
b. It is a painless procedure with no side effect.
c. Blurred or double vision may occur after the procedure
d. Medication will be given to dilate the pupils before the procedure.

(The correct answer is B, Tonometry which measures intraocular pressure is a simple

and painless procedure that requires no particular preparation or post procedure care
and carries no side effects).
25. The nurse learns that the client uses Timolol Maleate (Timoptic) eye drops. The
nurse would understand that this B-adregenic blocker help control glaucoma by;
a. constricting the pupils.
b. dilating the canals of Schlemm.
c. reducing aqueous humor formation.
d. improving the ability of the ciliary muscle to contract.

(The correct answer is C, Timotol Maleate commonly administered to control glaucoma.

The drugs action is not completely understood,but it is believed to reduce aqueous
humor formation, there by reducing intraocular pressure).

26. The Nurse observes the client instill his eye drops. The client says. I just try to hit
the middle of my eye ball so the drops dont run out of my eye. The nurse explains to
the client that the method he is using now may cause;
a. scleral staining.
b. corneal injury.
c. excessive lacrimation.
d. systemic drug absorption

(The correct answer is B, The cornea is sensitive and can be injured by falling eye drops
falling onto it. Thus eye drops should be instilled into the lower conjunctival sac of the
eye to avoid the risk of cornea damage).

27.When reviewing the clients home care plan, the nurse encourage him to implement
which of the following measures?
a. Reducing daily fluid intake.
b. Wearing dark glasses in the bright sun.
c. Minimizing active exercise.
d. Adding extra light to his home.

(The correct answer is D, Miotic agents may compromise a client ability to adjust safety
to night vision. For safety,extra light should be added to the home. The client does not
need to curtail fluid intake. Bright lights are not harmful to the eyes and exercise is
permitted although excessive exertion should be avoided).

28.The client with glaucoma is scheduled for a minor surgical procedure. Which of the
following orders would requires clarification or correction before the nurse would carry it
out;
a. administer morphine sulfate.
b. administer atropine sulfate.
c. teach deep breathing exercises.
d. teach leg exercise.

(The correct answer is B, Atropine sulfate causes pupil dilation. This action is
contraindicated for the client with glaucoma because it increase intraocular pressure.
The drug does not have this effect on intraocular pressure in people who do not have
glaucoma).
29. The client asks when he can stop taking the eye medication for his chronic open-
angle glaucoma. The nurse should tell the client that he;
a. can stop using the eye drops when his vision improves.
b. needs use the eye drops only when he has symptoms.
c. can discontinue the eye drops after two months of normal eye examination.
d. must use the eye medication for the rest of his life.

(The correct answer is D, To control his increased intraocular pressure,the client need to
continue taking his eye medications the rest of his life. Any loss of vision that the client
has suffered will be permanent. Vision loss can occur gradually without any symptoms).

30.Which of the following clinical manifestations would the nurse associated with acute
narrow-angle glaucoma?
a. sudden loss of vision in one eye and headache.
b. acute light sensitivity and blurred vision.
c. double vision and headache.
d. sudden eye pain and colored halos arround light.

(The correct answer is D, Acute narrow angle glaucoma produces abrupt changes in the
angle of the iris. Clinical manifestations include severe eye pain, colored halos around
lights and rapid vision loss).

31. A Client has been diagnosed with an acute episode of narrow-angle glaucoma. the
nurse plans the clients nursing care with the understanding that acute narrow-angle
glaucoma;
a. Frequently resolves without treatment.
b. is Typically treated with sustained bed rest.
c. is the medical emergency that can rapidly lead to blindness.
d. is most commonly treated with steroid therapy.

(The correct answer is C, Acute narrow-angle glaucoma is a medical emergency that

rapidly leads to blindness if left untreated. treatment typically involves miotic drugs and
surgery usually Iridectomy or laser therapy. Both procedures create a hole in the
periphery of the iris,which allows the aqueous humor to flow into the anterior chamber).

The Client Under Going Nasal Surgery

A 27 years old woman is admitted for elective nasal surgery for a deviated septum.
32. The client returns from surgery from surgery after a submucosal resection with nasal
packing in place. Which of the following assessments would be a priority?

a. Determining the degree of pain the client is experiencing.

b. Assessing for air way obstruction.
c. Observing for ecchymosis in the periorbital region.
d. Assessing the clients appetite.
(The correct answer is B, Post operative nursing assessment for the client after nasal
surgery focuses on early detection of complications. Two common complications are air
way obstruction and hemorrhage. The nasal packing can slip out position and occlude
the clients air way. There for, assessing the client for air way obstruction is a priority
assessment).

33. Which of the following techniques is the most appropriate way to assess for
posterior nasal bleeding?.

a. Change the nasal drip pad frequently and note the amount of drainage.
b. Monitor the clients hemoglobin and hematocrit values every 8 hours.
c. Frequently assess if the client is nauseated.
d. Use a pen light to inspect the back of the pharynx for bleeding.

(The correct answer is D, The best way for the nurse to detect posterior nasal bleeding
is to use a pen light to observe the back of pharynx. The nasal drip pad will remain dry
with posterior nasal bleeding. Nausea can occur postoperatively for several reason,with
bleeding just one of them. Checking clients hemoglobin and hematocrit every 8 hours
will not help detect bleeding in its earliest stages).

34. After the client returns from surgery the nurse would anticipate placing her in what
position?;
a. Supine
b. Left side lying
c. Semi fowler
d. Reverse Tredendelenburgs.

(The correct answer is C, to assist in breathing, promote comfort and decrease edema
formation after surgery, the client is most appropriately placed in semi fowlers position).

35. Which of the following interventions would likely most effective for the client to use
at home when managing the discomfort of rhynoplasty the initial two days after surgery;

a. Applying warm, moist compresses.

b. Lying in prone position.
c. Blowing the nose gently.
d. Applying ice compresses.

(The correct answer is D, The most effective way to decrease discomfort is to decrease
local edema. Cold application, such as an ice compress or ice bag is effective. Heat
dilates local vessel and increases local congestion. Semi fowlers position help decrease
edema and prevent aspiration. Nose blowing should be avoided fro at least 48 hours
after nasal packing is removed because it can disrupt the surgical side and it lead to
bleeding).

36. Which of the following will be an important initial clue to the client that bleeding was
occurring even if the nasal drip pad remained dry and intact?
a.complains of nausea.
b.repeated swallowing.
c.Rapid respiratory rate.
d.feeling of anxiety.

(The correct answer is B, Because of the dense packing, it is relatively unusual for
bleeding to be apparent through the nasal drip pad. Instead the blood runs down the
throat, causing the client to swallow frequently. The back of the throat can be assessed
with a flash light. An accumulation of blood in the stomach may cause nausea and
vomiting. Increased respiratory rate occurs in shock but is not an early sign of bleeding
in the client after nasal surgery).

37. The client complains that the nasal packing is uncomfortable and asks when it will
be removed. What information should nurse give the about removal of the packing. The
nasal packing usually removed;

a. The day of surgery.

b. 24 to 48 hours after surgery.
c. After nasal edema subsides.
c. After pain has diminished.

(The correct answer is B, The packing help maintain hemostasis and prevent bleeding.
Removing packing is uncomfortable and must be done carefully. The pack is removing
the day after surgery. The client must be watched closely for bleeding after removing
the packing).

38. Because the packing blocks the clients nose, the clients nose, the client should be
instructed to include which of the following measures in her post operative home care?

a.Frequent mouth care .

b.Examine the nares of ulceration.
c.Monitor temperature every 4 hrs.
d.Normal saline nose drop.

(The correct answer is A, mouth breathing dries the oral mucous membrane. Frequent
mouth care is necessary for comfort and to combat the anorexia associated the taste of
blood and loss of sense smell. Monitoring temperature every 4 hrs and checking the
nares for ulceration are not necessary. Nose drops are not instilled with packing in the
place).at this time. Nasal packing make eating difficult and uncomfortable. The packing
blocks the passage of air through the nose, creating a partial vacuum during swallowing.
A sucking action make occurs when the client attempt to drink with a straw. Anti emetic
are needed only if the clients experiences nausea or vomiting).

39.Which of the following statements indicates the client has understood the instructions
to follow at home after cataract surgery?;

a.I may not to watch television for three week

b.I should keep my protective eye shield in place at all times
c.I should not bend over ti pick up object from the floor
d.I can lift what I want

(the correct answer is C, The client should be instructed to bend at the knees and keep
the head up and back straight when picking up objects from the floor.
The eye shield is usually worn only at night. The client may watch television and read in
moderation. Lifting should be restricted for the first week to less the 15 pounds)

40. The nurse would teach the client to implement, which of the following nasal care
measures after the nasal packing is removed;

a.Irrigate the nares with normal saline solution daily.

b.Remove old blood from inside the nares with cotton-tipped application.
c.Lubricate the membranes fro comfort with a water-soluble lubricant.
d.Avoid cleaning the nares fro at least two days.

(The correct answer is C, A Water soluble-lubricant offsets dryness and enhances

comfort while healing occurs. The lubricant also prevents secretion from drying and
crusting in the nose. The client should be cautioned not to disturb clots either with her
fingers or applicatotrs because bleeding may occurs).

41.The nurse should include which of the following information in the client discharges
teaching?;

a.The client should expect tarry stools fro several days at home.
b.Nausea is an expected outcome of surgery and may persist fro several days.
c.Brief episodes of epitaxis are expceted after the surgery.
d.The pain from surgery should be resolved with in 24 hours after surgery.

(The correct answer is A. Nasal bleeding gives stools a tarry appearance fro several
days, the client should be informed of this effect. Epistaxis and nausea are not expect
outcomes and some discomfort can be expected to persist after 24 hours).

42. The client is ready for discharge. Which of the following discharge instructions would
be appropriate fro the client?;

a.Avoid activities that elicit that valsalva maneuver.

b.Take aspirin to control nasal discomfort.
c.Avoid brushing teeth until the nasal packingis removed.
d.Apply heat to the nasal area to control swelling.

(The correct answer is A, The client should be instructed to avoid any activities that
cause Valsalvas Maneuver (eg; constipation, vigorous coughing,exercise) to reduce
bleeding and stress on suture lines. The client should not take aspirin because of its
antiplatelet properties,which may cause bleeding. Oral hygine is important to rid the
mouth of old dried blood and to enhance the clients appetite. Cool compresses, not
heat, should be applied to decrease swelling and control discoloration of the area).
43.Which one of the following statements would indicate to the nurse that the client has
understood the discharge instructions?;

a.I should not shower until my packing is removed

b.I will take stooll softeners and modify my diet to prevent constipation.
c.Coughing evry 2 hours is important to prevent respiratory complications
d.It is important to blow my nose each day to remove the dried secretions.

(The correct answer is B, Constipation can cause straining during defecation which can
include bleeding. The client should avoid blowing her nose for 48 hours after the packs
removal. Thereafter she should blow her nose gently using the open-mouth technique to
minimize bleeding in the surgical area. She should also take measures to prevent
coughing. Showering is not contraindicated).

44. Which of the following interventions would likely most effective for the client to use
at home when managing the discomfort of rhynoplasty the initial two days after surgery;

a. Applying warm, moist compresses.

b. Lying in prone position.
c. Blowing the nose gently.
d. Applying ice compresses.

(The correct answer is D, The most effective way to decrease discomfort is to decrease
local edema. Cold application, such as an ice compress or ice bag is effective. Heat
dilates local vessel and increases local congestion. Semi fowlers position help decrease
edema and prevent aspiration. Nose blowing should be avoided fro at least 48 hours
after nasal packing is removed because it can disrupt the surgical side and it lead to
bleeding).

The Client With Cataracts

A client is admitted to out patient surgery for a cataract extraction on the right eye.The
procedure is to be done under a local anesthetic.

45. The client asks the nurse,what causes cataracts in old people?,which of the
following the statements should form to the basis for the nurses response? Cataracts
most commonly:

a.result from chronic systemic disease

b.are a result of aging
c.result from eye injuries sustained early in life
d.result from prolonged use of toxic substances

(The answer is B,the most common cause of cataract is aging,followed by eye

injury.Other causes included ingestion of injurious substances,such as naphthalene and
systemic disease, such as diabetes}
46.The client asks what does the lens of my eye do?
The nurse should answer that the lens of the eye
a.produces aqueous humor
b.hold the rods and cones
c.focuses light rays onto the retina
d.regulates the amount of light entering the eye

(the correct answer is C, The lens focuses light rays onto the retina, The process of
bringing light rays onto focus from both near and far objects is called
Accommodation.The Ciliary bodies secrete aqueous humor. The retina houses the rods
and cones. The iris regulates
the amount of light entering the eye).

47. The client tells the nurse that she is afraid of being awake during eye surgery. Which
of the following responses by the nurse would be the most appropriate?

a.have you ever had any reactions to local anesthetics in the past?
b.what is it that disturbs you about idea of being awake?
c.by using a local anesthetic, you wont have nausea and vomiting after the surgery
d.theres really nothing to fear about being awake. You will be given a medication that
will help you relax
(The answer is B,the nurse should give a client who seems fear full of surgery an
opportunity to express her feelings. Only after identifying the clients concerns can the
nurse intervene appropriately. Premature explanations and cliches do not provide
needed assessment data and ignore the clients feeling.)

48. A client with a cataracts would most likely complain of which symptoms?

a.Halos and rainbows around light.

b.eye pain and irritation that worsens at night.
c.blurred and hazy vision.
d.eye strain and headache when doing close work.
(The correct answer is C, A client with cataracts usually complains of blurred and hazy
vision. This vision distortion is due to opacity of the lens,which blocks light rays from
reaching of the retina).

49.Before cataract surgery, the nurse is to instill several type of eye drops into a clients
right eye.The accepted the abbreviation for the right eye is;
a.OD
b.OS
c.OU
d.RE
(The correct answer is A,The accept abbreviation for the right eye is OD,which stands
for Oculus Dexter. OS(oculus sinister) refer to left eye. OU(oculus uterque) refers to
both eyes. RE is not accepted abbreviation for the right eye.)
50.The nurse to instill drops of the phenylephrine hydrochloride (neo-synephrine) into a
clients right eye before cataract removal surgery. This preparation acts in the eye to
procedure;

a.dilation of the pupil and blood vessels.

b.dilation of the pupil and constriction of blood vessels.
c.constriction of the pupil and constriction of blood vessels
d.constriction of the pupil and dilation of blood vessels.
(The correct answer is B, Instilled in the eye,phenylephrine hydrochloride acts as
mydriatic,causing the pupil to dilate. It also constricts small blood vessels in the eye.

51.A short time after surgery, the client complains of nausea. The nurse bests course of
action would be to;

a.instruct the client to take a few of deep breaths until the nausea subsides.
b.explain that this is common feeling that will pass quickly.
c.tell the client to call the nurse promptly if vomiting occurs.
d.medicate the client with an anti emetic,as ordered.
(The correct answer is D, prescribed anti emetic should be administered as soon as the
client who has undergone cataract extraction extraction complain of nausea. Vomiting
can increincrease intra ocular pressure,which should be avoided after eye surgery
because it can cause complication)

52.Which of the following statements indicates the client has understood the instructions
to follow at home after cataract surgery?;

a.I may not to watch television for three week

b.I should keep my protective eye shield in place at all times
c.I should not bend over ti pick up object from the floor
d.I can lift what I want
(the correct answer is C, The client should be instructed to bend at the knees and keep
the head up and back straight when picking up objects from the floor.
The eye shield is usually worn only at night. The client may watch television and read in
moderation. Lifting should be restricted for the first week to less the 15 pounds)

53.An essential aspect of the plan of care for the client after cataract removal surgery
would be to;

a.increase cardiac out put.

b.prevent fluid volume excess.
c.maintain a darkened environment.
d.promote safety at home.
(The correct answer is D, promoting safety is a priority goal for this client. Her vision will
not be clear and she may need to wear an eye patch after surgery. Orienting the client
to the physical environment, assisting her during ambulation, and following others safety
precautions to reduce the risk of injury are required).
54.The client is discharged home on the day of surgery. Which of the following potential
nursing diagnoses would be most appropriate for the client at this time?

a.Diversional activity deficit related to activity limitations after surgery.

b.Chronic pain related to post operative incisional discomfort.
c.High Risk for injury related to limited vision after surgery.
d.Self Feeding deficit related to inability to visualize food.
(The correct answer is C, safety of the client is the major concern on the return home.
The home environment should be assessed for safety hazards should be implemented.
Arrangements for home care,if necessary should be made before surgery. Oral pain
medication should control the clients discomfort. The client is usually able to return to
the activities of daily livingcrapidly, so Diversional activity deficits and self feeding
deficits would not typically be anticipated).

55. What information about vision would be most important for the nurse to include in
the clients discharge plan?

a.The client will need to wear corrective glasses or contact lenses.

b.The client will need to wear glasses only until the eye heals
c.cataract glasses correct vision by magnifying objects
d.The client will need to relearn to judge distances accurately.
(The correct answer is D, After cataract surgery, a client must relearn to judge distance
accurately to walk safety. The client will need glasses or contact lenses to restore vision
and cataract glasses do correct vision by magnifying object, however, these points are
not as a important in discharge planning as is relearning to judge distance accurately)

56. After returning home, the client will need to continue to instil eye drops in the
affected eye. The client is instructed to apply slight pressure against the nose at the
inner canthus of the eye after instilling the eye drops. Applying the pressure:

a.prevents the medication from entering the tears duct.

b.prevents the drug from running down the clients face
c.allows the sensitive cornea to adjust to the medication.
d.facilitates distribution of the medication over the eye surface.
(The correct answer is A, applying pressure against nose at the inner canthus of the
closed eye after administering eye drop prevents the medication from entering the
lacrimal (tear) duct. If the medication enter the tear duct,it can enter the nose and
pharynx,where it may be absorbed and cause toxic symptoms. Eye drops should be
placed in the eyes lower Conjunctival sac).

57. Which the following activities would be appropriate for achieving the goal of the
decreasing intraocular pressure after eye surgery, The client will avoid;

a.lying supine.
b.coughing.
c.deep breathing.
d.ambulation.
(The correct answer is B, coughing is contraindicated after cataract extraction because it
increase intraocular pressure. Other activities that are contraindicated because they
increase intraocular pressure including turning to operative side, sneezing, crying and
straining . Lying, supine, ambulating and deep breathing do not affected intraocular
pressure).

58. After cataract removal surgery, the nurse teaches the client about activities that she
can do at home. Which of the following activities would be contraindicated.

a.walking down to the hall unassisted.

b.performing isometric exercise.
c.lying in bed on the non operative side.
d.bending over the sink to wash her hair.
(The correct answer is D, Bending over the sink to wash hair is contraindicated after
cataract surgery because it increase intraocular pressure. The client should be though to
tilt her head backward slightly when washing her hair. Activities such as walking,lying in
bed on the non operative side and performing isometric exercises are not
contraindicated).

59. After cataract removal surgery, the client is instructed to report any complaints of a
sharp pain in the operative eye because it could be indicate, which of the following post
operative complication?

a.detached retina.
b.prolapse of the iris.
c.extracapsular erosion.
d.intraocular hemorrhage.
(The correct answer is D, Sudden,sharp pain after eye surgery should suggest to the
nurse that the client may experiencing intraocular hemorrhage. The physician should be
notified promptly).

60. Outcome criteria for the client after cataract removal surgery would include which of
the following the client stat;

a.her vision is clear

b.her infection is under control
c.methods to decrease intraocular pressure.
d.she is able to administer parental pain medication.
(The correct answer is C, decreasing intraocular pressure is the primary concern after
cataract removal. Vision will remain un clear temporarily after surgery. Infection
although it may occur, is not anticipated. Parenteral pain medication at home is not
required).

The Client With a Retinal Detachment

A Client is admitted through the emergency department with a diagnosis of detached

retina in the right eye. His eyes bilaterally patched on admission.
61. As a nurse completes admission history, the client reports that before the physician
patched his eye, he saw many spot or floaters. The nurse should explain to the client
that these spot were caused by;

a.places of the retina floating in the eye.

b.blood cells released into the eye by detachment.
c.contamination of the aqueous Humor.
d.spasms of the retinal blood vessels traumatized by the detachment.
(The correct answer is B, The spot or floaters,commonly reported by clients with retinal
detachment are blood cells released into the vitreous humor by the detachment).

62.The client does not understand what happened to his eye. Which of the following
explanations by the nurse would most accurately describe the pathology of retinal
detachment?.

a.A tear in the retina permits the escape of vitreous humor from the eye.
b.The optic nerve is damages when it is exposed to the vitreous humor.
c.The two layers of retina separate,allowing fluid to enetr betwen them.
d.Retinal injury produces inflammation and oedema which increase intraocular
pressure.
(The correct answer is C, In retinal detachment the two layers of then a separate as a
result of small hole or tear, trauma or degeneration. Vitreous humor seeps into the tear
and separates the retina layers. Vitreous humor does not leak out of the eye or cause
any direct damage to the optic nerve. Increased intraocular pressure is not associated
with retinal detachment).

63.The client asks the nurse why his eyes have to be patched. The nurses reply should
be based on the knowledge that eye patches serve to.

a.reduce rapid eye movements

b.decrease the irritation of light entering the damaged eye
c.protect the injured eye from infection.
4.rest the eyes to promote healing.
(The correct answer is A, patching the eyes help decrease random eye movements that
could enlarge and worsen retinal detachment).

64.The client is extremely apprehensive. He states, I am afraid of going blind. It would

be so hard to live that way. what factor should the nurse consider before responding to
his statement?

a.Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable.

b.The surgery will only delay blindness in the right eye, but vision is preserved in the left
eye.
c.More and More services are available to help newly blind people adapt to the daily
living.
d.Optimism is justified because surgical treatment has 90% to 95% success rate.
(The correct answer is D, untreated retinal detachment and eventual blindness, but 90%
to 95% of clients can be successfully treated with surgery. If necessary , the surgical
procedure can be repeated about 10 to 14 days after the first procedures. Many more
services are available for newly blind people, but ideally this client will not need them).

65. In the immediate post operative period after scleral buckling, the clients nursing
care should include which of the following?

a.Encouraging deep breathing and coughing every 2 hours.

b.Assessing for eye drainage.
c.Applying pressure dressings to both eyes.
d.Enforcing strict bed rest.
(The correct answer is B, After eye surgery, the eyes should be assessed for excessive
or purulent drainage, which may indicate infection. Pressure dressing are not applied to
eyes after surgery, although general eye patching may temporarily be used. Coughing
should be avoided. Activity may vary but usually is limited to bed rest with bathroom
privileges).

66.Which of the following statements would provided the best guide for activity for the
client during his rehabilitation period?

a.Activity is resumed gradually and he can resume his usual activities in 5 to 6 weeks.
b.Activity level is determined by the clients tolerance and he can be as active as he
wishes
c.Activity levels will be restricted for several months,so he should plan on being
sedentary.
d.Activity resumption is controlled by a graduated series of buckle exercise .
(The correct answer is A, The scarring of the retinal tear needs time to heal completely.
Therefore, resumption of activity should be gradual the client may resume hie usual
activities in 5 to 6 weeks. Successful healing should allow the client to return to his
previous level of functioning).

67. Which of the following clinical manifestation commonly occur in retinal detachment?.

a.sudden,sever eye pain and colored halos around lights.

b.Inability to move the eye and loss of the light accommodation.
c. A tearing sensation and increased lacrimation.
d.flashing lights and visual field loss.
(The correct answer is d, A client with retinal detachment frequently reports flashing
lights in the affected eye followed by a loss of vision commonly described as a curtain
being slowly drawn across the eye. The detachment is painless, does not involved the
eye muscle and does not cause lacrimation).

68. Which of the following will be priority goal for a client who has under gone surgery
for retinal detachment?

a.control pain.
b.increase intraocular pressure.
c.promote a low sodium diet.
d.maintain a darkness environment.
(the correct answer is A, After surgery to correct the detached retina, the client required
analgesics for pain management. Decreasing intraocular pressure is another priority
goal. Low sodium diets and providing a darkened environment are not a priority goals
for this client).

69. Before the surgical repair of the detached retina, the client is placed on the flat bed
rest. The nurse understands thst the rationale for this position that it;

a.helps reduce intraocular pressure.

b.facilitates drainage from the eye.
c.keeps the client safe while confined to bed.
d.help prevent further retinal detachment or tearing.
(The correct answer is D, The clients position is determined by the location of the
retinal tear. The rationale for rest is the hope that the retina will fall back into places as
much as possible before surgery,which will facilitate adherence of the retina to the
coloroid . Increased intraocular pressure is not problem in retinal detachment. There
should be no external drainage from the eye).

70. Scleral buckling, a procedure used to treat retinal detachment, involves;

a.removing the torn segment of the retina and stitching down the remaining segment.
b.replacing the torn segment of the retina with a strip of retina from a donor.
c.stitching the retina firmly to the optic nerve to give it support.
d.creating s splint to hold the retina together until a scar can form and seal off the tear.
(The correct answer is D, a choroidal scar will form a permanent seal to close the hole
or tear in the retina. A scleral buckle serve as a splint to hold the retina and choroid
together until this scar can form. Loss of a portion of or the whole retina would interfere
with sight. Retina transplants are not performed. The retina is never stitched to the optic
nerve).

71. In discharge planning after scleral buckling, the nurse should ensure that the client
understands the need for initial activity restriction at home. Which of the following
activity will contraindicate during the early recovery period.

a.watching television.
b.reading
c.talking on the telephone.
d.walking in the yard.
(The correct answer is B, Although restful, reading involved too much jerky eye
movement and should be avoided during recovery. Watching television, walking out
doors and visiting with friends are all appropriate activities and can be encouraged).

72. The nurse would evaluate that the client understands his home care instructions
after Scleral Buckling for a detached retina if he says his activity should include;
a.avoiding abrupt movements of the head.
b.exercises the eye muscle each every day.
c.turning the entire head rather than just the eyes for sight.
d.avoiding activities requiring good depth perception.
(The correct answer is A, during recovery the client should be instructed to avoid abrupt
or jarring head movements. Such activities as shampooing or brushing the hair may be
restricted. No specific eye exercises are prescribed and depth perception is not specially
affected by this surgery).

A Patient is admitted to the hospital with peripheral vascular disease of the lower
extremities. She is scheduled for an amputation of the right leg

73. Which one the following symptoms is not typically associated with peripheral arterial
disease?;

a. Ankle edema.
b. Intermittent claudication.
c. Decreased or absent pulses.
d. Cool skin.

(The correct answer is A, Inadequate arterial circulation produce symptoms of hypoxia.

The skin is cool to the touch,pulses are difficult or impossible to palpate and exercise
cause moderate to sever cramping pain. Ankle edema is associated with venous
insufficiency and stasis).

74. To assess the patients dorsalis pedis pulse, the nurse will palpate the;

a. medial surface of the ankle.

b. area behind the ankle.
c. ventral aspect of the top of the foot.
d. medial aspect of the dorsum of the foot.

(Th correct answer is D, The dorsalis pedis pulse is found on the medial aspect of the
dorsal surface of the foot in line with the big toe. The posterior tibial pulse is on the
medial surface of the ankle just behind the medial malleolus. The popliteal pulse is
behind the knee).

75. The nursing notes the following assessment findings regarding the patients
peripheral vascular status;cramping leg pain relieved by rest;cool,pale,feet;and delayed
capillary refilling. Based on these data,the nurse would make a nursing diagnosis of

a. Impaired skin Integrity.

b. Impaired Gas Exchange.
c. Altered Peripheral Tissue Perfusion.
d. Impaired Physical Mobility.

(The correct answer is C, The data obtained by the nurse are major defining
characteristics for the nursing diagnosis Altered Peripheral Tissue Perfusion. The data do
not indicate that the patients skin integrity or physical mobility has been impaired at this
time. The diagnosis Impaired Gas Exchange is used to describe patient with respiratory
insufficiency).
76. The patient says,Ihave really tried to manage my condition well, which of the
following routines would the nurse evaluate as having been appropriate for him?;

a. Resting with his legs elevated above the level of his heart.
b. Walking slowly but steadily for 30 minutes twice a days.
c. Minimized activity.
d. Wearing antiembolisme stocking at all times when out of bed.

(The correct answer is B, Slow, steady walking is a recommended activity for patient
with peripheral arterial disease because it stimulates the development of collateral
circulation. The patient with peripheral arterial disease should not remain inactive.
Elevating the leg above the heart and wearing antiembolisme stockings are strategies
for venous congestion and may worsen peripheral arterial disease)

77. Which of the following clinical manifestations will be most indicative of complete
arterial obstruction in the lower extremities?

a. Aching pain.
b. Burning sensation.
c. Numbness and tingling.
d. Coldness.

(The correct answer is D, Coldness is assessment finding most consistent with complete
with arterial obstruction.Other expected findings would include paralysis and pallor.
Aching pain, burning sensation and numbness and tingling are earlier sign of tissue
hypoxia and ischemia and are associated with incomplete obstruction).

78. While the nurse is providing preoperative teaching,the patient says.I hate the idea
of being an invalid after they cut of my leg, Most the therapeutic answer from the
nurse would be

a. You will still will have one good leg to use.

b. Tell me more about how you are feeling.
c. Lts finish the preoperative teaching.
d. You are fortunate to have a wife who can take care of you.

(The correct answer is B, Encouraging the patient undergoing amputation to verbalize

feelings is the most therapeutic nursing intervention. By eliciting information,the nurse
may be able to provide Information may be help the patient cope. The nurse should
avoid value-laden responses that may make the patient feel guilty or hostile and block
further communication. The nurse should not ignore patients expressed concerns. The
nurse should not reinforce the patients concern about invalidism and dependency or
assume that his wife is willing to care for him).

79. The patient asks the nurse Why the doctor cannot tell me exactly how much of my
leg hes going to take off? Dont you think I should know that? The nurse responds
knowing that the final decision on the level of amputation will depend primarily on
a. the need to remove as much of the leg as possible.
b. the adequacy of the blood supply to the tissue.
c. the ease with which a prosthesis can be fitted.
d. the patient ability to walk with a prosthesis.

(The correct answer is B, The level of the amputation often cannot be accurately
determine until surgery,when the surgeon can be directly assess the adequacy of the
circulation of the residual limb. A longer residual limb facilitates prosthesis-fitting and
this aspect can be considered in the final decision,but it is not primary factor).

80. The patient returns from surgery postoperative below knee amputation with the
residual limb covered with dressing and a woven elastic bandage. At first the bandage
was dry but now 30 minutes later the nurse notice a small amount of bloody drainage.
What the first priority action?;

a. Notify the physician.

b. Mark the area of drainage.
c. Change the dressing.
d. Reinforce the dressing.

(The correct answer is B, The nurse should mark the blood stain and observe it again in
10 minutes. There is no need to notify the physician immediately because some oozing
and bloody drainage,there is no need either to reinforce or change dressing).

81. The patients room should contain which emergency equipment when the patient
return from surgery?;

a. Suction equipment.
b. Emergency cart.
c. Airway.
d. Tourniquet.

(The correct answer is D, Hemorrhage is an unexpected,but possible,complication of

radical surgery such as amputation. A tourniquet should be available at the bed side
during the early post operative period to deal with such a complication).

82. What will the most important nursing intervention in caring for the patients residual
limb during the first 24 hours post surgery?;

a. Keeping the residual limb flat.

b. Abducting the residual limb on a scheduled basis.
c. Applying traction to the residual limb.
d. Elevating the residual limb on a pillow.

(The correct answer is D, Elevating the residual limb on a pillow for the first 24 hours
after surgery helps prevent edema and promotes comfort by increasing venous return.
Elevating the residual limb for longer than the first 24 hours is contraindicated because
of a potential for developing contractures. Adducting the residual limb on a scheduled
basis prevents abduction contracture)

83. Which of the following nursing goals would take priority when planning for the
patient physical mobility after amputation?;

a. Preventing contractures.
b. Promoting comfort.
c. Preventing edema.
d. Preventing phantom-limb pain.

(The correct answer is A, Preventing joint contractures is essential to physical mobility.

Promoting comfort and preventing edema are appropriate immediate postoperative
nursing goals but attaining them does not affect physical mobility in the immediate and
extended postoperative periods. Phantom-limb pPhantom-limb pain begins two weeks to
two months after amputation. It occurs briefly in about 30% of patient but only about
2% experience persistent pain).

84. The second morning after surgery,the patient says,This sound crazy,but I feel my
left toes tingling. This statement would indicate to the nurse that he is experiencing

a. denial reaction.
b. phantom-limb sensation.
c. hallucination.
d. body image disturbance.

(The correct answer is B, Description of sensations,painful and otherwise in the

amputated part are common and are known as phantom limb sensation. The patient
should be reassured that these sensations are normal and are not sign of a mental
problem. Denial may be present after amputation;sign include refusal to look at or talk
about the amputation. Hallucination indicate a serious,possibly psychotic condition and
should be thoroughly assessed. Referral to an appropriate health care provider is in
order. Body image disturbance can developed after amputation due to fear,grief,loss of
locomotion and decreased self-esteem related to the loss of the body part).

85. The patient is to be fitted with a functioning prosthesis. The nurse has been
teaching him to care for his residual limb. Which behavior would demonstrate that the
patient has an understanding of proper residual care? The patient

a. applies powder to the residual limb.

b. inspect the residual limb weekly with a mirror.
c. removes the prosthesis whenever he sit down.
d. washes and dries the residual limb daily.

(The correct answer is D, Washing and thoroughly drying the residual limb daily are
important hygiene measure to prevent infection. Nothing should be applied to the
residual limb after it is cleansed. Powder may cause excessive drying and cracking of the
skin and cream may soften the skin excessively. The residual limb should be inspected
daily with a mirror for early signs of skin breakdown. To reduce residual limb
swelling,the prosthesis should be removed only at night).

86. The patient will crutches while his prosthesis being adjusted. Which of the following
exercises would best prepare for him for using crutches?

a. Range of motion exercises of the shoulder.

b. Isometric exercises of the shoulders.
c. Quadriceps and gluteal setting exercises.
d. Triceps exercises.

(The correct answer is D, Using crutches requires significant strength from the triceps
muscles and efforts should be focused on strengthening these muscles in anticipation of
crutch walking. Bed and wheel chair push up are excellent exercises targeted at the
triceps muscles).

87. When using crutches,the patient should be tought to support his weight primarily on
his;

a. axillae.
b. elbow.
c. upper arms.
d. hands.

(The correct answer is D, Using crutches properly requires supporting body weight
primarily on the hands.Using crutches improperly can cause nerve damage from excess
pressure. Careful instruction and evaluation of crutch use is essential).

88. The patient is to be discharged on a low-fat,low cholesterol,low sodium diet. What

would be the nurses first step in planning dietary instructions?;

a. Determine the patients knowledge level about cholesterol.

b. Ask the patient to name foods high in fat,cholesterol and salt.
c. Explain the importance of complying with the diet.
d. Assess the familys food preferences.

(The correct answer is D, Before beginning dietary interventions, the nurse must assess
the patients pattern of food intake,life cycle,food preferences and ethnic,cultural and
financial influences).

89. The nurse has been instructing the patient on how to prepare meals that are low in
fat,cholesterol and sodium. Which of these comments would indicate that he needs
additional teaching?;

a. I will eat only water packed-tuna.

b. I will use a Teflon-coated pan when cooking.
c. I will eat more liver with onions.
d. I will avoid using steak sauce and catsup.
(The correct answer is C, Liver and organ meats are high in cholesterol and saturated
fat and should be limited. Water packed tuna is one of the leanest fish available. Using a
Teflon coated pan when cooking reduces the need for shortening. Steak sauce and
catsup are high in sodium)

A Patient has diagnosed with Herniated Lumbar disk at the L4-5 inter space.

90. During first patient interview,the nurse most likely learn that the symptom that first
caused the patient to seek health care was;

a. Loss of bladder control.

b. Loss of voluntary muscle control.
c. Back pain that is relieved with resting.
d. Back pain radiates to the shoulder.

(The correct answer is C, A typical symptom of a herniated lumbar disk is low back pain
that is usually relieved by rest and aggravated by activity that causes an increase in fluid
pressure in the spine,such as sneezing,coughing,lifting and bending. Muscle weakness
and sensory losses may occur and there is generally a change in tendon reflexes. Pain
radiating to the shoulders is a typical symptom of cervical disk herniation. Loss of
voluntary muscle control which may cause chorea-like movements and loss of urinary
control are not typically early symptoms of lumbar disk problem).

91. Which one the following positions will be most comfortable for the patient?;

a. Prone.
b. Supine.
c. Semi-fowlers.
d. Right or left Sims.

(The correct answer is C, In this position the patient will feel comfortable. hyper
extension to the spine will make discomfort for a patient with a herniated disk; thusthe
prone position is contraindicated for this patient).

92. The patient having schedule for a myelogram the patient was asking to the nurse
about what is procedure going to do. The nurse will explain to the patient that
radiographs will be taken after the patient spines injected by;

a. sterile water.
b. normal saline solution.
c. liquid nitrogen.
d. radiopaque dye.

(The correct answer is D, A radiopaque dye (usually an iodized oil but in some instances
a water soluble compound) is used for myelogram. Air may be used for an air-contrast
study. Myelography is used to determine the exact location of a herniated disk).
93. The patient returns from the procedure of myelography,for which an iodized oil
(Pantopaque) was used. Which one of the following nursing measures will be included in
this care;

a. Bed rest with bathroom privileges.

b. Restricted fluid intake.
c. Head of the bed elevated 45 degrees.
d. Assessment of lower extremity movement and sensation.

(The correct answer is D, Nursing care of the client after myelography depends in part
on the type of dye used. For example if an oil contrast such as Pantopaque was
used,the patient usually will lie flat for 8 to 12 hours. If a water soluble contrast was
used,the head of the bed is elevated 45 degrees for 8 to 12 hours. This position reduces
the rate of upward dispersion of the contrast medium. Regardless of the type of the dye
used for the test,bed rest is required for several hours after a myelogram. Fluid intake is
encouraged to replace cerebrospinal fluid,to reduce headache and to facilitate
absorption of retained contrast media. Neurological status in the lower extremities is
assessed frequently,as is the patients ability to avoid).

94. Which of the following categories of medications would the nurse anticipate being
included in the conservative management of a patient of a herniated lumbar disk?;

a. Muscle relaxants.
b. Sedatives.
c. Tranquilizers.
d. Parenteral analgesics.

The correct answer is A, Muscle relaxants and non steroidal anti-inflammatory drugs are
frequently prescribed for the conservative management of herniated lumbar disks. In
addition,the patient may receive oral analgesics. Sedatives,Tranquilizers and parenteral
analgesics are not typically used in the conservative treatment of herniated lumbar
disks).

95. The patient under goes a lumbar laminectomy. Which the following would most
likely be a priority nursing diagnosis for the patient in the post operative phase?;

a. Impaired Physical Mobility related to fear of back pain.

b. Altered Nutrition;Less Than Body Requirements.
c. Bowel Incontinence related to decreased physical activity.
d. Body Image disturbance related to fear of disfiguring surgical scar.

(The correct answer is A, Post operative back pain related to the surgical incision and
muscle spasms is common after laminectomy. The patient may avoid movement to
prevent pain in nursing measures are not implemented to control pain. Depending to
activity order, the patient may be returned to his side oh have the head of the bed
elevated for meals. Constipation is more likely to be a problem postoperative owing to
inactivity. Surgical laminectomy scars are small and typically do not cause fear of
disfigurement).
96. Postoperative,the nurse administers trimethobenzamide hydrochloride (Tigan) to the
Patient. The nurse will evaluate that the medicine was effective if it controlled the
patients

a. muscle spasms.
b. nausea.
c. shivering.
d. dry mouth.

(The correct answer is B, Tigan is a centrally acting antiemetic that helps control nausea
and vomiting. It does not control muscle spasms,shivering or dry mouth).

97. The patient asks to be turned onto his side. It will be most appropriate for the nurse
to

a. ask the patient to help by using an overhead trapeze to turn himself.

b. turn the patients shoulders first,followed by his hips and legs.
c. inform the patient that because of his laminectomy,he may only lie supine.
d. get another nurse to help logroll the patient into position.

(The correct answer is D, After a laminectomy,the patients spine must be maintained in

proper alignment. The patient who had a laminectomy may be turned to his side by
logrolling him in one unit while keeping his back straight. It take at least two people to
perform this procedure correctly. Having the patient turn him self or moving his
shoulders and hips separately,does not allow the back remain in straight alignment).

98. The nurse helping the patient apply the back brace he is to wear. Which one the
following positions should the patient assume before the brace is applied?

a. Standing.
b. Lying on his side on the bed.
c. Sitting in a straight chair.

(The correct answer is B, A back brace should be applied before the patient who has
had back surgery is out of bed and placing weight on the legs and back. The brace is
placed on the bed while the patient assumes a side lying position. The patient is then is
rolled onto the brace. Hyper extension of the back after back surgery is
contraindicated).

99. To protect the patients skin under the brace, the nurse should

a. place padding as necessary for a snug fit.

b. have the patient wear a thin cotton shirt under the brace.
c. lubricate the areas where the patients brace will contact the skin surface.
d. apply powder to the areas where the patients brace will contact the skin surface.
(The correct answer is B, Having the patient wear a thin cotton shirt under a brace helps
to protect the skin and to keep the brace free of skin oils and perspiration. Using
padding may increase pressure points. Lubricating and powdering the skin under the
brace will not provide the best protection from irritation by the brace).

100. When the patient ambulates for the first time after surgery,he begins to feel
faint.Which one nursing action will be best until help arrives a. Have the patient close
the eyes for a few minutes.
b. Maneuver patient to sitting position on the floor.
c. Separate her or his feet to form a wide base of support and have the patient rest
against the nurses hip.
d. Have the patient separate his feet to form a wide best of support and then bend at
the at waist to place his head near to knees.

(The correct answer is C, A patient who feel faint while walking with the nurse should
rest on the nurses hip. This maneuver is relatively easy and can be maintained until
help is available. Having the patient close his eyes is unlikely to relieve symptoms of
fainting. Maneuvering the patient to the floor requires considerable strength and may
injury the patient especially when done quickly. This patient should not bend the waist
because of his resent back surgery).

102. The nurse will know that the patient understands her postoperative instruction
when she place her feet in which of the following positions when sitting in a chair?;

a. Flat on the floor.

b. On low footstool.
c. In any position of comfort while keeping his legs uncrossed.
d. On a high footstool so that his feet are about at the same level as the chair seat.

(The correct answer is A, The patient who has had back surgery should place the feet
flat on the floor,this ordinarily provides the greats comfort because it places no strain on
the operative area).

103. Which of the following activities will contraindicated for the patient in first
postoperative days?;

a. Assisting with her daily hygiene.

b. Lying flat on her back on the bed.
c. Walking in the hall.
d. Sitting in her room to read or watching television.

(The correct answer is D, After a laminectomy,a patient should either lie flat on bed or
in good alignment or should walk. Sitting for a long period is contraindicated because
pressure is increased to the operative area and alignment is compromised).

104. Which of the following instruction regarding body mechanics will be most
appropriate for helping the patient avoid further back injury?;
a. Pull object rather than pushing them.
b. Sleep on s a soft mattress.
c. Avoid prolong sitting and standing.
d. Sit on a chair with soft cushions.

(The correct answer is C, Prolonged sitting and standing should avoided. When sitting
the patient should choose a chair with good support and a straight back. The patient
should sit with feet flat on the floor. Pushing objects rather than pulling them will help
decrease back strain. Patient should select a semi-firm to firm mattress to provide back
support).

The patient, a 25 years old woman,fell during a rock climbing trip. She is alert and
conscious but cannot move her arms or legs on command.

105. The priority concern when planning to move a person with a person with a possible
spinal cord injury is to

a. wrap and support the extremities,which can be easily injured.

b. move the person gently to help reduce pain.
c. immobilize the head and neck to prevent further injury.
d. cushion the back with pillows to ensure comfort.

(The correct answer is C, The immediate concern to immobilize the head and next to
prevent further trauma when the fractured vertebra may be unstable and easily
displaced. Pain is usually not a significant consideration with this type of injury).

106. It is determined that the client suffered a C7 spinal cord injury. Which of the
following would be the most important nursing intervention during the acute stage of
her care?;

a. Turning and re positioning every 2 hours.

b. Maintaining proper alignment.
c. Maintaining a patent airway.
d. Monitoring vital sign.

(The correct answer is C, Initial care is focused on establishing and maintaining a

patient airway and supporting ventilation. Intervention to the intercostal muscles is
affected;if spinal edema extends to the C4 level,paralysis of the diaphragm usually
occurs. The effects and extent of edema are unpredictable in the first hours and
respiratory status must be closely monitored. Suction equipment should be ready
available).

107. The nurse recognizes that spinal shock is likely to persist for the first several weeks
after the injury. Which of the following symptoms would be unexpected during the
period of spinal shock?;

a. Tachycardia.
b. Rapid respiration.
c. Hypertension.
d. Dry,warm skin.

(The correct answer is C, Spinal shock produces massive vasodilation and subsequent
pooling of blood in the peripheral circulation. The client is relatively hypovolemic and
exhibits tachycardia,tachypnea,anxiety and flushed but dry skin. Hypertension would not
be expected)

108. During the period of spinal shock,the nurse should expect the clients bladder
function to be

a. spastic.
b. normal.
c. atonic.
d. uncontrolled.

(The correct answer is C, During the period of spinal shock, the bladder is completely
atonic and will continue to fill passively unless the client is catheterized. No reflex
activity occurs during this period, so reflex emptying does not occur).

109. Passive Range of Motion exercise for legs and assisted Rang of Motion exercise for
the arms are part of the clients care regimen. Which observation by the nurse would
indicate a successful outcome of this statement?;

a. Free,easy movement of the joints.

b. Absence of paralytic foot drop.
c. External rotation of the hips at rest.
d. Absence of tissue ischemia over bony prominence.

(The correct answer is A, Rang of Motion exercise help preserve joint motion and
stimulate circulation. Contractures develop rapidly in client with spinal cord injury and
the absence of this complication indicates statement success. External rotation of the
hips is prevent by using trochanter rolls. Local ischemia over bony prominence is
prevented by following a regular turning schedule).

111. The clients fracture is surgically repaired. Once healing has begun,daily physical
therapy sessions are scheduled that include using a tilt table. After the therapist places
the client at a 45 degree angle,the nurse should monitor her for which of the following?

a. Hypertension.
b. Pedal edema.
c. Facial flushing.
d. Dizziness.

(The correct answer is D, Lack of vasomotor tone in the lower extremities causes venous
pooling and the client may become hypotensive and dizzy when positioned upright. The
tilt table is used to help the client overcome vasomotor instability and tolerate an upright
position. Some pedal edema could occurs but it would develop gradually and would be
less problematic than the hypotension. Elastic stockings are sometimes used to facilitate
venous return from the legs. Signs and symptoms of insufficient cerebral circulation are
pallor,diaphoresis,tachycardia and nausea).

112. After a month of therapy,the client begins to experience muscle spasms in her
legs.She calls the nurse in excitement to report the leg movement. Which response by
the nurse would be the most accurate?;

a. These movement indicate to move all the affected muscles.

b. This is a good sign. Keep trying to move all the affected muscles.
c. The return of movement means that eventually you should be able to walk again.
The damage is not permanent.
d. The movements occurs from muscle reflexes. They cannot be initiated or controlled
by the brain.

(The correct answer is D, After the period of spinal shock,the muscles gradually become
spastic owing to an increased sensitivity of the lower motor neurons. The movement is
not voluntary and cannot be brought under voluntary control. It is expected but does
not indicate that healing is taking place).

113. The nurse realizes that the client is at risk for autonomic dysreflexia. Which of the
following symptoms would indicate this condition?;

a. Sudden sever hypertension.

b. Bradycardia.
c. Paralytic ileus.
d. Hot,dry skin.

(The correct answer is A, With a cervical injury, the client has sympathetic fibers that
can be stimulated to fire reflexively. The firing is cut off from brain control and is both
reflexive and massive. It classically produces pounding headache and dangerously
elevated blood pressure,goose bumps and profuse sweating. Hot and dry
skin,bradycardia and paralytic ileus typically occur during spinal shock not during
autonomic dysreflexia).

114. If autonomic dysreflexia occurs,what would be the priority nursing intervention?;

a. Administer nitropusside sodium (Nipride) intravenously.

b. Call the physician.
c. Place the client in Fowlers position.
d. Send a urine sample for culture.

(The correct answer is C, Autonomic dysreflexia is a medical emergency.Although

notifying the physician is important,it is more essential that the nurse intervene
immediately in this situation. The rising blood pressure can cause cerebrovascular
accident,blindness or even death.Placing the client in fowlers position lowers blood
pressure. Administering nitropusside sodium intravenously is appropriate if conservative
measures are ineffective. A urine sample for culture should be obtained if the client has
an elevated temperature and no other cause for the dysreflexia is found. A urinary tract
infection may be causing symptoms).

115. The nurse assesses the client to determine the cause of the autonomic dysreflexia.
The nurse would prioritize assessmengt based on the knowledge that the most common
stimulus for an autonomic dysreflexia episode is;

a. bowel distention.
b. bladder distention.
c. anxiety.
d. rising intracranial pressure.

(The correct answer is B The dysreflexia occurs from a sympathetic response to

autonomic nervous system stimulation. A distended bladder is the common cause;bowel
fullness may also trigger the syndrome. After placing the client in Fowlers position,the
nurse should check the Foley catheter for patency and the rectum for fecal impaction).

116. The orthotics department make a custom trunk brace for the client. The nurse
would plan to apply this brace at which time?;

a. While the client is sitting in a chair.

b. Before the client get out of bed.
c. As soon as the client become fatigued.
d. When the client is standing on the tilt table.

(The correct answer is B, Braces are designed to be applied while the client is lying
down. They are custom-designed to fit contours of the chest and buttocks and may not
fit properly if applied while the client in other positions. A poor fit could result in
pressure areas or inadequate support)

GOODLUCK.. GODBLESS RNs