- (Topic 7)
A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:

1. A. Administering diazepam (Valium) 10–15 mg po q4h and q1h prn for hyperventilating episode
2. B. Keeping the temperature in the client??s room at a high level to reduce respiratory stimulation
3. C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur
4. D. Using distraction to help control the client??s hyperventilation episodes

Correct Answer: C
(A) An adult diazepam dosage for treatment of anxiety is 2–10 mg PO 2–4 times daily. The order as written would place a client at risk for overdose. (B) A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. (C) Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. (D) Distraction will not prevent or control hyperventilation caused by anxiety or fear.

- (Topic 4)
Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to improving withdrawn behavior is:

1. A. Assigning her to occupational therapy
2. B. Having her sit with the nurses while they chart
3. C. Helping her to make friends
4. D. Facilitating communication

Correct Answer: D
(A) The nurse does not make this assignment. (B) One-to-one observation is not appropriate. It does not focus on the client or encourage communication. (C) The client is too suspicious to accomplish this goal. (D) The withdrawn individual must learn to communicate on a one-to-one level before moving on to more threatening situations.

- (Topic 2)
A complication for which the nurse should be alert following a liver biopsy is:

1. A. Hepatic coma
2. B. Jaundice
3. C. Ascites
4. D. Shock

Correct Answer: D
(A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver.

- (Topic 4)
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow??s menu. Which vitamin is the most essential in promoting tissue healing?

1. A. Vitamin C
2. B. Vitamin B1
3. C. Vitamin D
4. D. Vitamin A

Correct Answer: A
(A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B) Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.

- (Topic 7)
A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to ??Irrigate NG tube with sterile saline q1h and prn.?? The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:

1. A. Water will deplete electrolytes resulting in metabolic acidosis.
2. B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.
3. C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.
4. D. Saline will increase peristalsis in the bowel.

Correct Answer: A
(A) Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. (B) Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. (C) Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. (D) A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.