1. Mr. rani , 27-year-old, has fever and pain in the right upper quadrant that increases on eating fatty food and anorexia. She is recently diagnosed with cholelithiasis on abdominal ultrasound. The nurse explains to the patient food which she should avoid taking, is
a. Potato
Explanation: The patients with cholelithiasis are advised not to take food with high fat content such as dairy products like butter, cheese and ghee and should avoid fried foods. Because these fatty foods will further worsen the condition and result in severe pain to the patient. Other listed food items are appropriate for the client to consume.
2.The patient was diagnosed with Stage II liver cancer. The priority nursing diagnosis for this patient is
a. Fluid volume excess
b. Imbalanced nutrition
c. Impaired skin integrity
d. Disturbed body image
Ans. (b) Imbalanced nutrition
Explanation: A client with this condition is not able to digest and process the food materials and absorb the nutrient, hence he/she experiences weight loss and poor muscle tone. Thus, the priority nursing care plan should be focused on imbalanced nutrition which is less than the body requirements.
3. A male patient is admitted with Addison’s disease. Laboratory test report reveals low aldosterone. The patient is on high doses
of corticosteroids. The nurse is planning for a health teaching on dietary modifications. The nurse is aware that the following dietary modifications is NOT recommended for this patient.
a. High carbohydrate diet
b. Calcium rich food
c. Food rich in vitamin-D
d. Sodium restricted diet
Ans. (d) Sodium restricted diet
Explanation: Sodium should not be restricted in patient with low aldosterone levels. A patient with Addison’s disease (adrenal insufficiency) needs to take adequate sodium to prevent excess fluid loss and to maintain electrolyte balance. High doses of corticosteroids are linked to a higher risk of osteoporosis, so calcium and vitamin-D rich diet is recommended. The patient
should be instructed to have diet rich in complex carbohydrates and protein.
4. A 58-year-old male patient with Chronic Renal Failure (CRF) is on hemodialysis. He is advised to do peritoneal dialysis at home. While teaching the patient about how to perform peritoneal dialysis, the nurse instructs to warm the dialyzing solution to 37°C. The primary reason behind warming the dialyzing solution is to
a. Remove the waste materials from body cells
b. Relax the abdominal muscles
c. Dilate peritoneal blood vessels
d. Maintain a constant body temperature
Ans. (c) Dilate peritoneal blood vessels
Explanation: Warming the dialyzing solution to 37°C helps in the dilation of peritoneal blood vessels, which improves the rate of urea clearance. Warmed solution also helps in prevention of cold sensations and maintains body temperature, however, the primary reason is to dilate peritoneal blood vessels.
5.Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of
burn recovery?
a. Colloids
b. Crystalloids
c. Fresh-frozen plasma
d. Packed red blood cells
Ans. (b) Crystalloids
Explanation: The person undergone burn injury needs a priority action of fluid resuscitation rather than providing blood products,
Hence the crystalloids such as Ringer’s lactate and NS should be administered for fluid resuscitation and the blood products like
colloid are not appropriate for the fluid management.
6. The weight of Ms. Rajni is 63 kg using the Parkland Formula, the nurse calculates the total amount of Ringer’s Lactate that will be
given over the next 24 hours is:
a. 13, 608 mL
b. 12200 mL
c. 8625 mL
d. 6789 mL
Ans. (a) 13, 608 mL
Explanation: Here the client’s weight is 63 kg, therefore, according to the parkland formula, 4 mL should be multiplied with the
percentage of burned surface area (BSA) and the weight of the client, here the calculated BSA is 54% and the weight is 63 kg.
Therefore, it would be 4 × 54 × 63 = 13,608 mL fluid should be administered over next 24 hours. Out of this, half of the fluid needs
to be administered in the first 8 hours and remaining half in the next 16 hours.
7. Ms. Rajni, 30-year-old female, suffered with deep partial thickness burns on the front and back of both legs, and anterior
trunk. Calculate the burn area using the ‘rule of nine’
a. 27%
b. 36%
c. 45%
d. 54%
Ans. (d) 54%
Explanation: In the given patient, the burns had occurred over the front and back of the both legs, according to the Rule of nine, each complete leg occupies 18%, hence for the both legs it would be 36%and for the anterior trunk it covers 18%, hence the total burned
area would be 36 + 18 = 54%
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8. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?
a. Colloids
b. Crystalloids
c. Fresh-frozen plasma
d. Packed red blood cells
Ans. (b) Crystalloids
Explanation: The person undergone burn injury needs a priority action of fluid resuscitation rather than providing blood products, Hence the crystalloids such as Ringer’s lactate and NS should be administered for fluid resuscitation and the blood products like
colloid are not appropriate for the fluid management.
9. . The following anastomosis are done in Whipple procedure except ________?
a. Hepatica-jejunostomy
b. Pancreatic gastrectomy
c. Gastro jejunostomy
d. Jejuno-jejunostomy
Ans. (d) Jejuno-jejunostomy
10. Nurse Ramya is preparing a 45-year-old male client for gastrectomy surgery. The patient apprehensively asked the nurse about the possible complications of gastrectomy. Which of the following responses by the nurse is appropriate?
a. Dumping syndrome
b. Clay-colored stool
c. Ribbon like stool
d. Jaundice
Ans. (a) Dumping syndrome
Explanation: In Dumping syndrome, the stomach empties its contents into the small intestine (duodenum) faster than normal. Dumping syndrome is also known as rapid gastric emptying. The sudden influx of food into the intestine causes a lot of fluid to move from bloodstream into intestine. This extra fluid causes diarrhea and bloating.
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