135) ANSWER

A) Casein

D) Whey

RATIONALE

Casein and whey are often used as additives and stabilizers in processed foods. The client with lactose intolerance may have difficulty digesting these additives since they are milk products. Sodium phosphate is a preservative. Lecithin is an emulsifier. Maltodextrin is a sugar. Key term is lactose intolerance, indicating the client has difficulty digesting milk products. Recognize casein and whey as by products of milk.

134)  Answer

D. Acute renal failure

Rationale

•During a AAA repair, a stent graft is placed in the aorta to support the lumen and reduce pressure on the aneurysm sac. If the stent graft is placed wrong, it can block the renal arteries and cause renal failure.

•Hemorrhage is more common before the AAA repair, when the aneurym ruptures.

•Emboli and infection are also complications of a AAA repair, but they are less common than renal failure.

133) ANSWER

a.	breakthrough pain.

RATIONALE

Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.

132)ANSWER

d.	Oxygen saturation

RATIONALE

Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

131) ANSWER

c.	Warm, pink, and dry skin

RATIONALE

Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

130) ANSWER

a.	On the left side

RATIONALE

The patient should be positioned with the “good” lung in the dependent position to improve the match between ventilation and perfusion. The obese patient’s abdomen will limit respiratory excursion when sitting in the high-Fowler’s or tripod positions.

129) ANSWER

c.	Auscultate breath sounds.

RATIONALE

Because pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient’s admission diagnosis.