Comprehensive 2A

CGFNS
BOOT CAMP
1) D: Conduction

Conduction is the
conveyance of energy such
as heat, cold or sound by
direct contact
Convection is the transfer
of heat by the actual
movement of the warmed
matter
Radiation:
Electromagnetic waves
that directly transport
ENERGY through space
2) D: Explore the client’s feelings
about her facial disfigurement
Facial lesions can contribute to
decreased self esteem and an
altered body image.
Discussing AIDS with a client
whose diagnosis isn’t final may
be inappropriate and doesn’t
provide emotional support.
Pretending not to notice the
visible lesions ignores the client’s
concerns.
The primary caregiver, not the
nurse, should inform the client of
the biopsy result.
3) C: 7-10 days

The life span of a normal

platelet is 7-10 days.
In idiopathic
thrombocytopenia, the life
span is reduced to 1-3 days
Normal RBC lifespan: 120
days
4) C: Renal dysfunction

20% of Multiple myeloma clients with

hypercalcemia and hyperuricemia
develop renal insufficiency.
Hypocalcemia causes muscle spasm
Hyperkalemia causes myocardial
irritability.
5) D: Gangrene
Clostridium welchii
(perfringens) is a spore
forming bacterium that
produces a toxin that
decays muscle, releasing
a gas.
It is one of the major
causative agents for gas
gangrene
6) B: Topical application of steroids

Steroids are
applied locally and
the lesion is usually
covered with
plastic (or Saran
Wrap)
7) A: This client should be turned
every hour
Change the client’s
position at least
every hour to
relieve pressure on
tissues and
promote
circulation.
The nurse is
negligent in not
doing this.
8) A: A weak acid

This will chemically neutralize residual

alkali still on the skin.
It will not reverse the chemical burns
already caused by the alkali but will
minimize additional chemical change.
9) C: An autograft
Autograft: tissue that is taken from
one site and grafted to another site on
the same person; "skin from his thigh
replaced the burned skin on his arms"
Allograft/Homograft: tissue or organ transplanted
from a donor of the same species but different
genetic makeup
Xenograft: tissue from an animal of one species
used as a temporary graft (as in cases of severe
burns) on an individual of another species
10) A: Tetanus toxoid

Clostridium
tetanii can
develop in partial
and full
thickness burns
that contain
dead tissue.
11) D: Critical
A partial thickness burn over 30% of the
body is considered critical. Shock,
infection, electrolyte imbalance, and
respiratory distress are life threatening
complications that can occur.
12) D: Prevent pressure on
peripheral blood vessels

The circulating air

bed disperses
body weight over a
larger surface
This reduces
pressure against
the capillary beds
allowing for tissue
perfusion.
13) B: Protective techniques are
required

Medical and surgical

asepsis are essential
for prevention of
infection with the
exposure method.
No dressings
Room temp. 850 F,
humidity 40-50%
14) C: Cleansing the wound with
soap and water
Infection is caused
by viral contact
with the dermal
layer of the skin;
cleansing the
wound with soap
and water helps
remove superficial
contaminants.
15) C: Protect the sperm from high
abdominal temperatures
Sperm cells are
very fragile and
can be destroyed
by heat, resulting in
sterility.
16) C: Sacrum

This is the anatomic direction of the

vaginal tract in the back lying position
17) B: It is very upsetting to have to
wait for a biopsy report
This recognizes the client’s feeling of
anxiety as valid.
18) B: Irreversible damage occurs
after a few hours
When the testes are twisted, a
decrease in their blood supply occurs.
This can result in gangrene.
19) C: Wear a gown and gloves
when giving direct care
The exudate from herpes virus type 2
is highly contagious; gown and gloves
provide a carrier, a concept related to
medical asepsis.
20) C: When my child gets out of
the tub I just pat the skin dry
Patting of the skin, removes the
excess moisture without excoriating it.
Pat the skin dry to remove excess
water. Do NOT rub.
21) D: Changing diapers after birth

HIV infection can occur vertically

during pregnancy or vaginal birth or
through breastfeeding.
22) D: ELISA
ELISA is the first
screening test for HIV.
Western Blot confirms
a (+) ELISA test
Other blood tests that
support the diagnosis
of HIV include CD4
and CD8 counts, CBC,
Immunoglobulin
levels, p24 antigen
assay, and
quantitative
ribonucleic acid
assays.
23) D: Create a scar that aids in
healing retinal tears
The main goal of surgery is to close the
retinal break. Long-term closure of retinal
breaks may require permanent reduction or
elimination of vitreoretinal traction and
techniques to offset the harmful effects of
fluid currents in the vitreous cavity
24) B: It is painless procedure with
no side effects
Tonometer tonometer
measures the pressure in
the eye.

Procedure (Applanation
Tonometry)_
1) Eye would be
anesthetized with drops.
2) The patient would be
asked to sit at the slit lamp
3) A plastic prism would be
lightly push against his eye
in order to measure your
IOP.
25) A: An opacity of the lenses
26) D: myringotomy
Done to relieve
pressure. Usually
with insertion of
ventilation tubes.
Tympanoplasty is
repair of perforated Perforated eardrum
eardrum often
done with
ossiculoplasty.
Mastoidectomy is
reserved for
mastoiditis with
cholesteatoma Cholesteatoma
27) C: Fluctuating hearing loss
Ménière's disease is
usually characterized
4 symptoms.
1) Periodic episodes
of rotatory vertigo or
dizziness.
2) Fluctuating,
progressive, low-
frequency hearing loss
3) Tinnitus
4) A sensation of
"fullness" or pressure
in the ear.
28) D: Assume a reclining or flat
position
1) Promotes safety
2) Decreases
movement which
aggravates the
vertigo
29) A. Alteration in Nutrition

SIGNS &
SYMPTOMS
INCLUDE:
Nausea, vomiting
Loss of appetite
Weight loss
Pain in upper/mid
abdomen
jaundice
30) D: Giving my babies fewer
bottles will help to reduce diaper
irritation

Fluids are the only source of nutrition

for babies (e.g. Milk). Decreasing the
number of bottles would seriously
compromise the baby’s nutritional
status.
31) A: Shock

the 2 major short

term complications
of burns are
infection and
dehydration
32) A: Cool water
33) B: Large, moist vesicles
a partial thickness
burn destroys the
epidermis and typically
causes the formation
of moist vesicles, a
pink or mottled-red
skin appearance that
blanches under
pressure, and pain in
the burned area.
Because the
epidermal cells lining
the hair follicles are
not destroyed, the hair
follicles are not easily
pulled out.
34) A: Poor personal hygiene
Exacerbations appear
to be linked to certain
genetic and
environmental factors,
such as stress,
infection, and surgical
incisions; an alteration
in the immune system
causing rapid
proliferation may also
be involved.
35) A: Thorough hand washing and
the use of gloves.
Respiratory isolation is not effective because
of the mode of transmission, which is by
contact of the fluid-filled vesicles, not by
droplets in the air.
Reverse isolation is inappropriate.
Limiting sexual contacts would not prevent
herpes zoster transmission; herpes genitalis,
not herpes zoster, is transmitted by sexual
contact.
Fluid filled
Vesicles in
Herpes genitalis
36. C: Checking the patient’s most
recent blood glucose level
The nurse should first check the
patient’s glucose level by the
fingerstick method.
If the patient is hypoglycemic, no sugar will be found in the
urine.
If the patient’s glucose is low, a longer-acting carbohydrate,
such as skim milk, is recommended.
If the patient is hypoglycemic, as indicated by weakness and
tremors, the patient will not require insulin.
37. C: Decreased peripheral
sensation
The nurse must carefully assess the
patient with chronic diabetes mellitus
to determine the presence of pain,
paresthesia, numbness, orthostatic
changes and gastrointestinal
symptoms.
The most frequently occurring complications of
diabetes mellitus include retinopathy, neuropathy,
and nephropathy.
38. A: Establish a structured daily
routine
A structured daily routine provides
the patient with a sense of
independence and control over the
environment.
Social withdrawal is a common behavior of patients with
schizophrenia. These patients usually need encouragement
to interact with others.
Setting unrealistic goals leads to frustration and failure. The
nurse should provide feedback regarding how realistic the
patient’s goals are, so that the patient does not set
him/herself up for failure.
Studies show that without medication, schizophrenics have a
relapse rate of 60%
39. A: Hypocalcemia

During thyroid surgery, parathyroid

tissue may be removed inadvertently
or damaged.
The post-operative thyroidectomy
patient is at risk for hypocalcemia
40. B: “I will use the bronchodilator
before I use the steroid inhaler.”
Patients using bronchodilator inhalant
medications along with other
inhalants should be instructed to use
the bronchodilator first, and wait 5
minutes before administering the
other medications. Dilation of the
bronchi allows for greater distribution
and absorption of the other inhalants.
41. D: Avoid exposure to noxious
odors.
The nurse should instruct the patient
to avoid odorous food if morning
sickness occurs.

Morning sickness is due to fluctuating

glucose levels. Dry foods, such as
crackers, before arising seem to alleviate
some of the nausea.
42. C: Folic acid

Diets deficient in folate have been

implicated as a risk factor in the
development of neural tube defects in
the fetus.
43. A: “You seem scared.”

It is not possible to logically discuss

illogical ideas. The nurse should focus
on the patient’s feelings of anxiety.
The nurse needs to avoid becoming incorporated into the
signs and symptoms of the delusion.
Paranoid schizophrenic patients are keenly sensitive to
rejection. When these patients sense that others are
avoiding them, they feel inadequate.
The nurse should not attempt logical explanations of
delusions, since the paranoid patient will only defend the
delusions more vigorously.
44. A: Using a low-pitched voice

Elderly hearing loss typically involves

diminished hearing of high-pitched
sounds.
Over-enunciating words does not make lip-reading easier
and is demanding to the patient.
Varying voice intonation includes use of high-pitched tones,
which the patient will have difficulty hearing.
The hearing loss seen in older adults does not require
reinforcement of sound with pictures. This action also would
be demeaning to the patient.
45. C: “I will exhale for twice as long
as I inhale.”
Pursed-lip breathing helps the patient
with COPD to prolong expiration time
and rid the lungs of some of the air
trapped in the alveoli.

The patient should sit in a comfortable position during

exercises.
The patient should be instructed to inhale through the nose
and exhale through the mouth.
46. A: “I will lie down for 30 minutes
after meals.”
The patient with gastroesophageal
reflux disease should not lie down
immediately after eating. This would
encourage backflow of gastric
contents.
Dietary restrictions include avoiding spicy, acidic and fatty
foods, as well as drinks containing caffeine, such as coffee,
tea, and colas.
Sleeping with the chest elevated 6-8 inches, placing a pillow
under the chest or elevating the head on 2 pillows helps to
prevent nocturnal reflux.
47. C: Advise the patient to have
the BP re-checked in one week.
The BP reading is the sole
determinant of hypertension. It
should be measured 3
consecutive times before making
a diagnosis of hypertension.
The patient with a BP of 158/100 does not require
treatment in an emergency department. The BP
should be checked again before determining that
the patient has hypertension.
The patient does not need to keep a food diary at
this time.
48.D: A lapse of spontaneous
breathing for 20 or more seconds
Preterm infants are periodic
breathers.
Apnea is primarily an extension of this
periodic breathing and can be defined
as a lapse of spontaneous breathing
for 20 or more seconds, which may or
may not be followed by bradycardia
and color change.
49. C: Persistent tongue thrusting

Developmentally, infants are not

ready for solid food. The extrusion
(protrusion) reflex is strong and often
causes food to be pushed out of the
mouth.
Between 4 and 6 months of age, the
extrusion reflex fades.
50. D: Having the patient lean
forward and pinch the nose.
Immediate intervention for the
patient experiencing epistaxis,
or nosebleed, includes
applying pressure to the nose
to stop the bleeding and
positioning the patient upright
with the head tilted forward.
51. C: Rubor with dependency
When the feet of a patient with arterial
insufficiency are placed in a
dependent position, the skin becomes
red. This is known as dependent
rubor.
The pain of arterial insufficiency is described as cramping,
aching pain that develops in the calf or thigh and
occasionally the buttocks. It is not described as tenderness
of the foot.
Peripheral edema accompanies venous insufficiency.
Reduced capillary refill and reduced arterial blood flow are
signs of arterial insufficiency.
52. D: Distract the child with an
age-appropriate video
A number of non-pharmacologic techniques can
be used with children to relieve pain. By definition,
any pain intervention that is not a drug falls into
this category. Using an age-appropriate video is a
good distraction. This will allow the child to focus
on the program and not his pain.

The child should maintain a position of comfort. Children may

complain of increased pain upon ambulation. For some children,
maintaining a side-lying position with knees flexed may provide the
most comfort.
Applying warm compresses increases the possibility of rupture of
the appendix and should not be done.
Pain medication may mask the symptoms of appendicitis and delay
the initial diagnosis.
53. A: Administering the prescribed
morphine
Morphine is administered to promote
analgesia, reduce anxiety, and
decrease the workload of the heart.

Medical management of myocardial infarction is focused on

controlling pain and limiting infarct size. Management
includes the use of oxygen, nitrates, morphine, beta
blockers, ACE inhibitors and rest.
54. A: In the early morning

Diuretics should be administered in

early morning, if ordered daily,
because diuretic administration later
in the day may cause nocturia.

The only time diuretics should be taken at a time other than

in the early morning is if the patient has a job that requires
him/her to sleep during the day.

END HERE..
101. C: Intussusception
invagination or telescoping of one portion of the
intestine onto another.
episodes of acute , colicky abdominal pain and
the abdomen becomes tender and distended.
The classic currant jelly-like stool occurs later
102. D: Serum potassium

The nurse should monitor the

patient’s electrolyte status closely,
paying particular attention to sodium
and potassium levels. Diuretics can
deplete serum potassium and
enhance the toxic effects of digitalis.

Urinalysis, urine ketones and blood glucose are not

significant to digitalis administration.
103. C: Pyloric stenosis
Pyloric stenosis is the narrowing of the
sphincter leading from the stomach to the
small intestine.
vomiting usually starts during the second or
third week of life
The vomiting usually becomes forceful and
projectile.
The emesis contains milk or formula and is
not bile-stained.
Initially, the infant may be hungry and
irritable; later, the infant becomes lethargic,
dehydrated and malnourished.
104. D: Cessation of abdominal
pain
Signs of peritonitis usually include
fever and sudden relief from pain after
perforation.
There may be a subsequent increase
in pain, which is usually diffuse and
accompanied by rigid guarding of the
abdomen and progressive abdominal
distention.
105. B: Creatinine, 1.0 mg/dL

Signs of transplant rejection include

decreasing creatinine clearance,
increasing serum creatinine, elevated
BUN levels, fever, weight gain,
decreased urine output and increased
BP.
106. A: “I can stop my medicine
when I don’t hear the voices
anymore.
Studies show that without
medication, schizophrenics
have a relapse rate of 60%.
The patient should be
instructed to not stop the
medication.
107. A: Electrolyte balance
The most reliable indicator of improvement
in the patient with anorexia nervosa is
electrolyte balance.
As the patient starved herself, the body
entered a hypometabolic state. Decreased
nutrients and the loss of electrolytes
through vomiting and laxative use
contribute to electrolyte imbalances.
As the patient begins eating and ceases
purging, electrolytes begin returning to
normal.
108. C: At the umbilicus

Fundal height at 20 weeks

will be at the level of the
umbilicus.
109. B: Hyponatremia

The nurse caring for a patient with

SIADH should be alert for low urinary
output with a high specific gravity, a
sudden weight gain or a serum
sodium decline.

Hyperglycemia an dysphagia are not manifestations of

SIADH.
The patient with SIADH has a low urinary output and may
need diuretics to remove excess fluid volume.
110. C: Respiratory failure

A patient with status asthmaticus

occasionally develops acute
respiratory failure late in an attack.
Exhaustion, coma, and deteriorating
pulmonary function indicate lack of
response to therapy or deterioration;
altered arterial blood gas levels
indicate respiratory failure.
111. C: Assisting him with range of
motion exercises
Range of motion exercises maintain
joint mobility and muscle strength and
prevent muscle atrophy in the patient
on bed rest.

Contact with family and friends is need for the patient’s

psychological well-being, but because the patient is on
respiratory isolation, his contact should be restricted to close
family during this highly infectious period.
The patient should not visit the lounge or other patient’s
rooms while on respiratory isolation.
112. D: “Increase your salt intake.”

Corticosteroids cause water retention

and resultant weight gain in the body.
Increasing salt intake will cause more
water retention, leading to more
weight gain and eventual
complications, such as edema and
hypertension.
113. C: Relieve anxiety and tension

Diazepam relieves anxiety and

tension related to organic or
functional conditions. This drug has
no analgesic effect. Because
diazepam enhances muscle
relaxation, it decreases muscle
activity as well as respiratory rate.
114. C: Rust colored

Rust colored sputum indicates

bacterial pneumonia.

Bright red sputum indicates active bleeding in the lung

tissue.
Pink-tinged sputum suggests a lung tumor.
Thin, mucoid sputum may indicate viral pneumonia.
115. A: Turbulent blood flow through
stenotic blood vessels
Bruits are abnormal sounds caused
by turbulent blood flow through
stenotic (partially occluded) blood
vessels.

Bruits are not associated with occluded blood vessels,

hypotension, or collateral circulation.
116. C: Moving and exercising the
leg frequently
Frequent leg movements and
exercises increase venous return
from the legs.

Avoiding ambulation causes venous stasis, increasing the

risk of thrombosis.
Hyperreflexion of the knees interferes with venous return by
compressing blood vessels.
The proper use of support stockings increases venous return
by applying even pressure on superficial veins.
117. B: Rupture of the aneurysm

Rupture of the aneurysm may cause

hypovolemia and can be fatal.

Embolism in the foot is a possible complication, but it does

not endanger the patient as seriously as rupture does.
Cerebrovascular accident and myocardial infarction are not
complications of abdominal aortic aneurysm.
118. C: Denial

Typically, a patient experiences denial

in the first 24 hours after MI. He
denies the cause and seriousness of
the problem, especially after he
begins to feel better.

Bargaining and depression are two other stages of grief the

patient experiences before acceptance, the final stage.
119. C: Pain in the distal, left lower
extremity
Pain in the distal, left lower extremity
more likely indicates embolism; it is
not characteristic of cardiogenic
shock.

Disorientation, narrow pulse pressure and thready pulse, and

ST segment elevations in leads II, III, aVF are manifestations
of cardiogenic shock.
120. C: Chorea

A discrete, jerky, purposeless

movement seen in the distal
extremities and face is called chorea.

Athetosis is gross, writhing, wormlike movement.

Dystonia is prolonged twisting movement.
Myoclonus is a sudden muscle contraction of varying
intensity, which may involve only a small part of one
extremity or the entire body.
121. C: Vertigo

The strongest indication of

Meniere’s disease is vertigo, a
sensation of irregular or
whirling motion of oneself or
of surrounding objects.
122. B: Suctioning every 2 hours to
maintain a patent airway
Suctioning may cause hypoxemia,
which leads to increased BP; this may
increase ICP.
Elevating the head of the bed increases cerebral venous
return, decreasing ICP.
Teaching the patient not to strain during bowel movements
helps prevent the increased intrathoracic pressure and ICP
this can cause.
Providing respiratory care is appropriate because
hypercapnia and hypoxia cause cerebral vasodilation, which
increases cerebral circulating volume and ICP.
123. C: Warn her not to stop taking
her medication without medical
supervision.
Sudden withdrawal of antiseizure
medication can cause an increase in
seizure frequency or precipitate status
epilepticus.
124. B: Abdominal pain and
tenderness
Because the patient’s spinal cord is
transected, he will have no sensory
function below the C5 level and
cannot experience abdominal pain or
tenderness.
To assess for intra-abdominal bleeding and stress
ulcers, the nurse must rely on objective signs,
such as expanding abdominal girth, melena,
and a gradual drop in hematocrit.
125. A: Cimetidine
Cimetidine (Tagamet), a histamine
receptor antagonist, decreases
hydrochloric acid secretion, facilitating
ulcer healing.
Antacids, such as aluminum hydroxide (Amphojel), provide
symptomatic relief from ulcer pain by neutralizing gastric
acid.
Sucralfate (Carafate), an agent used to treat duodenal
ulcers, coats the ulcer site with a protective barrier resistant
to acid.
Aspirin, which is associated with ulcer development, is
contraindicated in the patient with a duodenal ulcer.
126. C: Weak, warm tea

Weak, warm tea is the least irritating

of the beverages listed.

Orange juice, hot chocolate, and such carbonated drinks as

cola are contraindicated because they may be chemically or
mechanically irritating to the bowel.
127. A: Impaired clotting
mechanisms
Cirrhosis causes decreased
absorption of vitamin K; this decrease
results in thrombocytopenia, leading
to impaired clotting.

Although varix formation, inadequate nutrition, and trauma

also increase the risk of excessive bleeding, impaired
clotting is the most significant factor.
128. D: Shoulder pain and facial
edema
A dislodged central venous catheter
causes subcutaneous emphysema,
resulting in facial edema; because the
catheter is located in the vena cava or
right atrium, shoulder pain also is
present.
129. C: High carbohydrate, low fat

As acute pancreatitis subsides, the

patient’s diet changes from liquids to
5-6 small low-fat, high-carbohydrate
meals daily. Foods high in
carbohydrates stimulate the pancreas
less than other foods.
Because pancreatitis impairs fat digestion, the patient’s fat
intake should be limited.
Caloric intake will be low because of the limited intake of
fats, which usually supply a high proportion of calories.
130. A: Elevating the head of the
bed and observing the patient.
Elevating the patient’s head reduces
the pressure on the diaphragm
caused by fluid accumulation in the
abdomen, which can cause shortness
of breath.
131. C: Helping the patient maintain
fluid restrictions.
The degree of restriction
varies depending on the
kidney output; only enough
fluids to replace losses is
allowed.
132. D: He will require 3 months of
immunosuppressant therapy after
surgery.
A kidney donor is treated like
any post-nephrectomy patient;
immunosuppressant drugs
are not used because donor is
not receiving the transplant.
133. C: Secreting glucocorticoids
and mineralocorticoids
Aldosterone, the principal
mineralocorticoid, increases
sodium reabsorption and
potassium excretion.
Glucocorticoids also affect water
balance, which may be related to
glucose levels creating an
osmotic pull.
134. C: An extremely painful, hard,
red nodule surrounding several hair
follicles.
Because the
infection is not
walled off,
absorption of the
infecting organism
occurs, causing an
•A painful, hard, red nodule
elevated WBC surrounding a single hair follicle
count, fever, and is a furuncle or boil.
•Extensive erythema and local
pain. tenderness indicate cellulitis.
•Macular erythema with oozing
vesicles is associated with
impetigo.
135. C: Bright red drainage on the
cast
Bright red drainage on a cast usually
indicates active bleeding; the nurse
should report this finding to the
physician immediately.
Some edema of the fingers is expected with this type of
injury; elevating the arm should reduce the edema.
Warm, mobile fingers indicate adequate circulation and need
not be reported.
Leaving the patient’s wrist dependent may cause pain and
increased edema; this should be avoided.
136. B: On her unaffected side

An abductor pillow or splint is placed

between the patient’s legs to prevent
leg adduction and possible dislocation
of the prosthesis.
The patient with a hip prosthesis should not cross her legs
for 3-4 months after surgery because this may cause
dislocation.
137. A: Colchicine
Colchicine (Colsalide)is the drug of choice for
treating gout because of its effective anti-
inflammatory action; it appears to inhibit the
migration of leukocytes into the inflamed area,
decreasing the inflammatory response.
Colchicine is most effective if given early in the
course of the disease.
The other choices typically are used to treat gout only after colchicine
proves ineffective.
Allopurinol (Zyloprim) reduces uric acid production.
Probenecid (Benemid) is a uricosuric agent which blocks the reabsorprtion
and promotes the excretion of urates.
Indomethacin (Indocin) is an NSAID which is used to treat rheumatoid
arthritis as well as gout.
138. C: Positive Tinel’s sign

A positive Tinel’s sign – a tingling

sensation when the median nerve is
tapped – indicates nerve irritability.
A positive Homan’s sign – pain in the calf when the foot is
dorsiflexed – indicates thrombophlebitis or thrombosis.
Tinnitus is a ringing heard in one or both ears, which
indicates Meniere’s diseas.
Raynaud’s phenomenon refers to intermittent attacks of
ischemia of the fingers and toes; it occurs with various
diseases, including scleroderma, a systemic lupus
erythematosus, and Raynaud’s disease.
139. C: Pulse rate of 74 beats per
minute
A pulse rate of 74 bpm is within the
normal range, indicating normal
activity of the thyroid gland (euthyroid
state).
Irritability would indicate a hyperthyroid state.
Bradycardia would indicate a hypothyroid state.
A decreased T4 level, not an increased one, would indicate
an euthyroid state.
140. D: Reevaluation cultures are
needed when therapy is completed.
The CDC recommends 1 week of
antibiotic treatment for the patient with
chlamydia but does not recommend
reevaluation cultures after therapy.
All sexual partners should be treated simultaneously to
prevent reinfection.
Because the infection is sexually transmitted, the patient
should follow the prescribed therapy for the specified time
even if symptoms disappear earlier.
Once treatment has been completed, the patient may
resume sexual activity.
141. D: “This is an adverse effect of
estrogen therapy.”
The nurse should provide information
explaining the cause of decreased libido;
therefore, stating that it is an adverse effect
of estrogen therapy in male patients is the
most appropriate response.
Because this adverse effect is common, the nurse does not need to
alert the physician immediately.
The nurse should not tell the patient that this effect will resolve itself
shortly; it will persist as long as estrogen therapy continues.
Decreased libido is not an allergic response.
142. B: Vincristine (Oncovin)

The patient with stage III B Hodgkin’s

disease receives a cyclic drug
combination of mechlorethamine
(Mustargen), vincristine (Oncovin),
procarbazine (Matulane), and
prednisone (Orasone)
These drugs are given for 14 days,
with 14 days’ rest between cycles.
143. B: Giving more than 3 L of fluid
daily.
The daily fluid intake of the patient
with multiple myeloma should be 3-4
liters. A high fluid intake helps dilute
the calcium overload and prevent
protein from precipitating in the renal
tubules.
Restricting fluids would increase the risk of renal stones.
Milk would increase the patient’s blood calcium level,
possibly contributing to calcium excretion in the urine.
144. A: The patient is under local
anesthesia during the procedure.
The donor is under general or spinal
anesthesia during bone marrow
transplantation.

The procedure involves the aspiration of approximately 600

mL of bone marrow from the iliac crest.
The marrow is mixed with heparin or frozen until given
intravenously to the recipient.
Recipients are primed with Cytoxan for 4 days before the
transplant.
145. C
146. B: Rejection

The AIDS patient commonly feels

isolated and rejected by friends and
stigmatized by the disease.
Rejection would probably be the
patient’s strongest feeling in this
situation because he has had no
visitors.
147. A: Nausea and vomiting
A patient in metabolic alkalosis would
not demonstrate nausea and
vomiting; this finding is associated
with acidosis.

The rising pH causes stimulation of the central nervous

system, resulting in belligerence and irritability.
Decreased thoracic movement and shallow respirations also
would be present as the body attempts to compensate by
conserving carbon dioxide.
High pH also increases protein binding of calcium, causing
hypocalcemia; Chvostek’s sign would be positive.
148. C: Give the drug with an
antacid as ordered
Oral corticosteroids, such as prednisone,
cause gastric distress by increasing gastric
secretions, which causes bleeding and
peptic ulceration. To prevent this, the nurse
should give the drug with an antacid.

If the physician does not order an antacid, the nurse should give the
drug after meals.
Administering steroids first with multiple drug therapy has no effect
unless all are given after meals or with an antacid.
Mixing prednisone with food may cause the patient to develop a
dislike for the particular food.
149. B
In clients who have not had surgery to the
face or neck, the answer would be
answer A; however, in this situation, this
could further interfere with the airway.
Increasing the infusion and placing the
client in supine position would be better.
Answers C is incorrect because it is not
necessary at this time and could cause
hyponatremia and further hypotension.
Answer D is not necessary at this time.
150. C
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