Correct Answer: C

(A) Giving too high a concentration of O2 to a client with em-physema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea.

Correct Answer: A

(A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand. (B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand.

Correct Answer: D

(A, C) The nurse should provide good distractors because these symptoms indicate that PIH has become more severe and may precede the convulsive or eclamptic phase. (B) This is the oppositeside effect of this medication. (D) This is a common side effect of this medication and needs to be monitored and recorded frequently.

Correct Answer: A

(A) Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood the reach the systemic circulation. (B) A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the systemic circulation. (C) In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. (D) Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.

Correct Answer: D

(A) The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a priority nursing diagnosis postoperatively. (B) The client will have a Foley catheter for a day or two after surgery. Urinary retention is usually not a problem once the Foley catheter is removed. (C) A client having a cholecystectomy should not be physically impaired. In fact, the client is encouraged to begin ambulating soon after surgery. (D) Because of the location of the incision, the client having a cholecystectomy is reluctant to breathe deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.

Correct Answer: B

(A) Local anesthetics do temporarily relieve the pain but leave an unpleasant taste and numb feeling that are not conductive to eating. (B) Such a diet is less irritating to the damaged mucosa and is easier for the child to tolerate. (C) This intervention is helpful if the child has only anorexia. It does not work if the type and texture of the food increase oral discomfort. (D) Lemon glycerin swabs and milk of magnesia dry the oral mucosa and should be avoided.

Correct Answer: D

(A) Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. (B) Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. (C) Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. (D) This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.

Correct Answer: D

(A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members. (C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off. (D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.

Correct Answer: C

(A) Eating alone is not recommended for anorexic clients because they tend to hoard food instead of eating it. (B) The client should be praised for whatever she eats, which is usually a small portion or percentage of what is served. Praise should not be withheld until she eats everything. (C) The client should be observed eyeto- eye for at least 1 hour following meals to prevent discarding food stashed in her clothing at mealtime or engaging in selfinduced vomiting. (D) If offered these choices, the client would choose low-caloric foods, not a nutritious diet.

Correct Answer: A

(A) Because the eustachian tube is short and straight in the infant, formula that pools in the back of the throat attacks bacteria which can enter the middle ear and cause an infection. (B) Asthma is not associated with propping the bottle. (C) Conjunctivitis is an eye infection and not associated with propping the bottle. (D) Tonsillitis is usually a result of pharyngitis and not propping the bottle.