View Questions 1. B. Left sided heart failure causes fluid accumulation in the capillary network of the lung.

Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. 2. B. Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock. 3. D. Seeing yellow spots and colored vision are common symptoms of digitalis toxicity 4. C. When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night. 5. B. The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergency requiring immediate intervention. 6. C. Decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem injury. 7. C. The most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea. 8. D. Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication. 9. A. By the 2nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without chest pain 10. B. The left side of the body will be affected in a right-sided brain attack. 11. A. After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining kidney also to detect renal failure early. 12. B. The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries. 13. C. Blood pressure is monitored to detect hypotension which may indicate shock or hemorrhage. Apical pulse is taken to detect dysrhythmias related to cardiac irritability. 14. A. Protamine Sulfate is used to prevent continuous bleeding in client who has undergone open heart surgery. 15. C. The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis. 16. B. Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation. 17. D. Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side. 18. A. Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of cardiac output. 19. C. Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group. 20. D. Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome. 21. D. Raynauds disease is characterized by vasospasms of the small cutaneous arteries that involves fingers and toes.

22. A. Urine testing provides an indirect measure that maybe influenced by kidney function while blood glucose testing is a more direct and accurate measure. 23. C. One liter of fluid approximately weighs 2.2 pounds. A 4.5 pound weight loss equals to approximately 2L. 24. A. Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration. 25. D. Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae. 26. B. Neutropenic client is at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract. 27. C. Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity. 28. C. 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. 29. B. Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion. 30. C. Wheat cereal has a low sodium content. 31. A. Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites. 32. C. 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. 33. A. Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg. 34. D. Aspirin containing medications should not be taken 14 days before surgery to decrease the risk of bleeding. 35. A. Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose. Administration of insulin corrects this problem. 36. D. 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 beta-carotene include dark green vegetables, carrots, mangoes and tomatoes. 37. A. Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus. 38. B. Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis. 39. D. It may take 4 to 6 months to eat anything, but most people can eat anything they want. 40. D. Clay colored stools are indicative of hepatic obstruction 41. D. Streptomycin is an aminoglycoside and damage on the 8th cranial nerve (ototoxicity) is a common side effect of aminoglycosides. 42. D. Most peptic ulcer is caused by Helicopter pylori which is a gram negative bacterium. 43. D. 12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested food. 44. C. Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not increase intraocular pressure.

45. A. Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus and swelling. 46. C. The dropper should not touch any object or any part of the clients ear. 47. A. 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. 48. B. Complications of acute appendicitis are peritonitis, perforation and abscess development. 49. D. A client with acute pancreatitis is prone to complications associated with respiratory system. 50. B. Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy.