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Renee Camille L.

Laguda ANSWER KEY


BSN III
1. B. Stress on the suture line should be avoided. Prevent flexion or hyperextension of the neck, and provide a
small pillow under the head and neck. Neck muscles have been affected during a thyroidectomy, support
essential for comfort and incisional support.
2. D. In response to the question of the client, the nurse needs to provide brief, accurate information. Some
clients who have had gastrectomies are able to tolerate three meals a day before discharge from the hospital.
However, for the majority of clients, it takes 6-12 months before their surgically reduced stomach has
stretched enough to accommodate a larger meal.
3. B. Exercise enhances glucose uptake, and the client is at risk for an insulin reaction. Snacks with
carbohydrates will help.
4. D. Given the data, presurgical anxiety is suspected. The client needs an opportunity to talk about concerns
related to surgery before further actions (which may mask the anxiety).
5. D. Physical assessment guidelines recommend listening for at least 2 minutes in each quadrant (and up to 5
minutes, not at least 5 minutes).
6. C. The best early intervention would be to increase fluid intake, because constipation is common when
activity is decreased or usual routines have been interrupted.
7. C. At about 48-72 hours, the client must be turned onto the abdomen to prevent flexion contractures.
8. C. A quick look at the client can help identify the type and cause of the ventilator alarm. Disconnection of the
tube from the ventilator, bronchospasm, and anxiety are some of the obvious reasons that could trigger an
alarm.
9. B. The priority is to maintain clients safety. With syncope and vertigo, the client is at high risk for falling.
10. C. A hot tub bath or shower in the morning helps many patients limber up and reduces the symptoms of early
morning stiffness. Cold and ice packs are used to a lesser degree, though some clients state that cold
decreases localized pain, particularly during acute attacks.
11. B. Assessment and more data collection are needed. The client may have gastrointestinal or neurological
problems that account for the symptoms. The anorexia could result from medications, poor dentition, or
indigestion, the bruises may be attributed to ataxia, frequent falls, vertigo, or medication.
12. C. C = the normal CVP is 0-8 mmHg. This value reflects hypervolemia. The right ventricular function of this
client reflects fluid volume overload, and the physician should be notified.
13. B. Bland feedings should be given in small amounts on a frequent basis to neutralize the hydrochloric acid
and to prevent overload.
14. D. These substances stimulate the production of hydrochloric acid, which is detrimental in peptic ulcer
disease.
15. A. Because the clients ability is to react to stress is decreased, maintaining a quiet environment becomes A
nursing priority. Dehydration is a common problem in Addisons disease, so close observation of the clients
hydration level is crucial. To promote optimal hydration and sodium intake, fluid intake is increased,
particularly fluid containing electrolytes, such as broths, carbonated beverages, and juices.
16. B. Whole milk should be avoided to include in the clients diet because it has 120 mg of sodium in 8
0z of milk
17. A. Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K
deficiency. This could be a sign of bleeding.
18. A. Alcohol is extremely drying and contributes to skin break down. An emollient lotion should be
used.
19. D. The three-point gait is appropriate when weight bearing is not allowed on the affected limb. The
swing-to and swing-through crutch gaits may also be used when only one leg can be used for
weight bearing.
20. A. This allows the client to elaborate his concern and provides the nurse a baseline of assessment.