NCLEX RN Exam Pack Set 10.QUESTIONS AND ANSWERS LATEST UPDATE 2023, Exams of Nursing

Download NCLEX RN Exam Pack Set 10.QUESTIONS AND ANSWERS LATEST UPDATE 2023 and more Exams Nursing in PDF only on Docsity! NCLEX RN Exam Pack Set 10.QUESTIONS AND ANSWERS LATEST UPDATE 2023 1. 1. Question The nurse should visit which of the following clients first? o A. The client with diabetes with a blood glucose of 95mg/dL o B. The client with hypertension being maintained on Lisinopril o C. The client with chest pain and a history of angina o D. The client with Raynaud’s disease Correct Answer: C. The client with chest pain and a history of angina The client with chest pain should be seen first because this could indicate a myocardial infarction. Despite many advances in treatment, acute MI still carries a mortality rate of 5-30%; the majority of deaths occur prior to arrival to the hospital. In addition, within the first year after an MI, there is an additional mortality rate of 5% to 12%. The overall prognosis depends on the extent of heart muscle damage and ejection fraction. o Option A: The client in answer A has blood glucose within normal limits. The diagnosis of T1DM is usually through a characteristic history supported by elevated serum glucose levels (fasting glucose greater than 126 mg/dL, random glucose over 200 mg/dL, or hemoglobin A1C (HbA1c exceeding 6.5%) with or without antibodies to glutamic acid decarboxylase (GAD) and insulin. o Option B: The client in this option is maintained on blood pressure medication. Pharmacological therapy consists of angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), diuretics (usually thiazides), calcium channel blockers (CCBs), and beta-blockers (BBs), which are instituted taking into account age, race, and comorbidities such as presence of renal dysfunction, LV dysfunction, heart failure, and cerebrovascular disease. JNC-8, ACC, and ESC/ ESH have their separate recommendations for pharmacological management. o Option D: The client in answer D is in no distress. In Raynaud phenomenon, blood-flow restriction occurs during cold temperatures and emotional stress. Specifically, in Raynaud phenomenon, there is vasoconstriction of the digital arteries and cutaneous arterioles. • 2. Question A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication: o A. Once per day in the morning o B. Three times per day with meals o C. Once per day at bedtime o D. Four times per day Correct Answer: B. Three times per day with meals Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body in digesting needed nutrients. Chronic, supportive therapy for patients with CF includes regular pancreatic enzymes, fat-soluble vitamins (A, D, E, K), mucolytics, bronchodilators, antibiotics, and anti- inflammatory agents. o Option A: A new class of medications known as CFTR modulator therapies is designed Correct Answer: C. Constrict the pupils Miotic eye drops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. Pilocarpine is a muscarinic acetylcholine agonist that is effective in the treatment and management of acute angle-closure glaucoma and radiation- induced xerostomia. Although not a first-line treatment for glaucoma, it is useful as an adjunct medication in the form of ophthalmic drops. o Option A: The cornea and conjunctiva can be anesthetized by drops of any of the local anesthetics. Bupivacaine, for example, is effective as an eyedrop. Bupivacaine is a potent local anesthetic with unique characteristics from the amide group of local anesthetics, first discovered in 1957. Local anesthetics are used in regional anesthesia, epidural anesthesia, spinal anesthesia, and local infiltration. Local anesthetics generally block the generation of an action potential in nerve cells by increasing the threshold for electrical excitation. o Option B: The eye doctor may dilate the pupils with a special medication called a mydriatic, so they can see the inside of the eye during a slit lamp test. Typically, mydriasis reverses within 4 to 8 hours. However, it may take 24 hours for the mydriatic effect to wear off in some individuals. Weaker strength may cause mydriasis with little cycloplegia. o Option D: Scopolamine ophthalmic is an anticholinergic agent that blocks constriction of sphincter muscle of iris and ciliary body muscle, which, in turn, results in mydriasis (dilation) and cycloplegia (paralysis of accommodation). Scopolamine competitively inhibits G-protein coupled post-ganglionic muscarinic receptors for acetylcholine and acts as a nonselective muscarinic antagonist, producing both peripheral antimuscarinic properties and central sedative, antiemetic, and amnestic effects. • 5. Question A client with a severe corneal ulcer has an order for Gentamicin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops? o A. Allow 5 minutes between the two medications. o B. The medications may be used together. o C. The medications should be separated by a cycloplegic drug. o D. The medications should not be used in the same client. Correct Answer: A. Allow 5 minutes between the two medications. When using eye drops, allow 5 minutes between the two medications. Antibiotic eye drops are prescribed by a doctor to treat bacterial eye infections. They work by killing the bacteria (microscopic organism) that entered the eye and caused the infection. o Option B: Allow 5 minutes interval before administering the next eyedrops. Take the full course, don’t stop early/without consulting your doctor, even if things seem better. Antibiotic eye drops usually help symptoms get better after three days. Call your doctor if your symptoms don’t go away. o Option C: It is not necessary to use a cycloplegic with these medications. Eye infections cause redness, tearing and drainage (yellow- green pus or watery), and can be highly contagious. A certain type of eye infection—a bacterial eye infection—may need treatment with a medicine called an antibiotic eye drop. o Option D: These medications can be used by the same client. Don’t use anyone else’s prescription. Don’t keep unused prescriptions around to use later. Ask your ophthalmologist or pharmacist if it’s OK to keep the drops in the refrigerator. When the drops are cold it might be easier to feel the drop when it hits the eye, so you can tell where it has landed. • 6. Question The client with color blindness will most likely have problems distinguishing which of the following c olors? o A. Orange o B. Violet o C. Red o D. White Correct Answer: B. Violet Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The most common forms are protanopia and deuteranopia, conditions arising from loss of function of one of the cones, leading to dichromic vision. Protanopia is the loss of L cones (red) resulting in green-blue vision only. Deuteranopia is the loss of M cones (green) resulting in red-blue vision only. o Option A: Color vision results from the combination of signals from three visual pigment types within cones: that of red, green, and blue, which correspond to cone types L, M, and S (RGB-LMS). Those colors correspond to the wavelengths of peak light absorption intensities of the modified chromophores. L cones have peak absorptions at 555 nm to 565 nm, M cones at 530 nm to 537 nm, and S cones at 415 nm to 430 nm. o Option C: Similar to above, but not as severe in its symptoms, is the condition anomalous trichromatic vision (tritanomaly), where all three cones are present but the color vision is aberrant. The two common forms, protanomaly, and deuteranomaly result in L or M cones, respectively, being replaced with a cone of intermediate spectral tuning. Both are X-linked and occur in 7% of males. o Option D: In addition to disorders of proper color recognition, many diseases in vision display phototransduction defects affecting many portions of the signal pathway and its regulation. Here, not only is color vision function lessened but scotopic (low-light, rod-associated) vision as well. • 7. Question here. Bladder training programs often recommend that, once you have emptied your bladder first thing in the morning and perhaps again after breakfast, you try to keep the intervals between bathroom visits as regular as possible. o Option C: Even if you have a very strong urge to go to the bathroom, it usually only lasts a few minutes and then dies down again. You can practice not emptying your bladder as soon as you feel the need to go. Going to the bathroom calmly and at a slow pace rather than rushing to get there can help too. o Option D: You can try to wait longer between trips to the bathroom, but do so at a slow pace and without any stress. A voiding schedule can be helpful here too. You can use it to remember, for example, that you want to try to wait 5 minutes before emptying your bladder in the first few days, and then keep this up for about half a week. You can then lengthen that “waiting period” to 10, 15 and finally 20 minutes. • 9. Question Which of the following diet instructions should be given to the client with recurring urinary tract infections? o A. Increase intake of meats. o B. Avoid citrus fruits. o C. Perform peri care with hydrogen peroxide. o D. Drink a glass of cranberry juice every day. Correct Answer: D. Drink a glass of cranberry juice every day. Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria do not grow freely in acidic urine. A 2003 study that included 324 women found that frequently drinking freshly squeezed, 100% juice — especially berry juice, as well as consuming fermented dairy products like yogurt, was associated with a decreased risk of UTI occurrence o Option A: Increasing intake of meats is not associated with urinary tract infections, so answer A is . Red meat and other animal proteins have high potential renal acid loads (PRALs), meaning that they make urine more acidic. Conversely, fruits and vegetables have low PRALs, making urine less acidic. o Option B: The client does not have to avoid citrus fruits. The aforementioned study in 4,145 men and women showed that citrus juice intake was associated with a 50% reduction in lower urinary tract symptoms in men only o Option C: Peri care should be done, but hydrogen peroxide is drying. Other factors claimed to increase the chances of developing a UTI include wearing tight underwear, hot tub use, not urinating after sex, and douching, although strong evidence to support these claims is lacking. • 10. Question The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs? o A. "I will make sure I eat breakfast within 2 hours of taking my insulin." o B. "I will need to carry candy or some form of sugar with me all the time." o C. "I will eat a snack around three o'clock each afternoon." o D. "I can save my dessert from supper for a bedtime snack." Correct Answer: C. “I will eat a snack around three o’clock each afternoon.” NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. It is on the list of essential medicines of the world health organization (WHO).NPH insulin is FDA- approved in the adult and pediatric population for the control of type 1 and type 2 diabetes mellitus. It is currently the most widely used basal insulin that simulates the physiological basal insulin action. Basal insulin provides a constant supply of insulin in the body that is necessary for glucose regulation despite fasting, such as between meals and overnight. o Option A: NPH insulin onsets in 90–120 minutes, so answer A is . American Diabetes Association guidelines recommend NPH insulin dose of 0.4 to 1.0 units/kg/day subcutaneously for the management of type 1 diabetes mellitus. A higher dose is necessary during medical illness and puberty. A dose of 0.1 to 0.2 units/kg/day subcutaneously is recommended in type 2 diabetes mellitus depending on body weight and the patient’s hyperglycemia. o Option B: NPH insulin is time-released and does not usually cause sudden hypoglycemia. NPH insulin is an isophane suspension of human insulin and categorized as an intermediate-acting insulin. It helps increase the cellular intake of glucose in the liver, adipose tissue, and skeletal muscles. It acts as basal insulin and stimulates the liver to promote hepatic glycogen synthesis, fatty acid metabolism for lipoprotein synthesis. o Option D: The client should eat a bedtime snack. NPH cannot classify as ideal basal insulin. It shows much variability in its absorption and action after subcutaneous injection. This situation leads to fluctuations in blood glucose control and causes hypoglycemic episodes. For this reason, it requires o D. Mother’s desire to breastfeed Correct Answer: D. Mother’s desire to breastfeed Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue breastfeeding until the infant and mother have time to adapt. Breastfeeding is an important part of a newborn’s life. Breastfeeding or lactation provides total nutritional and emotional dependency of the baby on the mother. The strong emotional bonding between the mother-child dyad is needed for successfully prolong breastfeeding. o Option A: Baby and maternal factors can influence this bonding. Skin-toskin contact in the first 2 hours after birth is essential for successful initiation of lactation. The breast crawl, soon after birth, while the baby is alert will initiate the bonding, and it will be an assurance by giving comfort and calm to the mother. The breast crawl is when the baby is placed on the mother’s abdomen after birth; the baby finds its way to the breast to suckle. o Option B: Successful breastfeeding factors related to the baby include proper latching, alertness of the baby, rooting reflex, and active sucking reflex. Although lactation is a natural process, the mother needs support and education for proper positioning and latching. The ability of the baby to empty the breast will determine the subsequent milk volume. o Option C: Maternal factors like pain, anxiety, emotional instability, among others should be addressed before and after delivery. Lactation consultants or knowledgeable nurses can also be helpful with initiating of breastfeeding. • 13. Question The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physici an immediately? o A. The presence of scant bloody discharge o o B. Frequent urination C. The presence of green-tinged amniotic fluid o D. Moderate uterine contractions Correct Answer: C. The presence of green-tinged amniotic fluid Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. Amniotic fluid should be clear, or straw tinged with small vernix particles in the fluid. Brown or green staining of the fluid indicates the passage of meconium. Because the fetus swallows amniotic fluid in utero, meconium can be present in the infant’s oropharynx at delivery. During delivery, if meconium-stained amniotic fluid is noted, a neonatal resuscitation team should be promptly involved o Option A: In the third trimester, bleeding is concerning for placental abruption, placenta previa, or labor. Each of these pathologies has its entry discussing its presentation and pathophysiology. Although bleeding in pregnancy is not considered ―normal,‖ it is common, affecting about one in three pregnancies. o Option B: An increased urge to urinate can be a result of the baby’s head dropping into the pelvis. The low position of the baby’s head puts even more pressure on the urinary bladder, so many women approaching labor might feel a frequent need to urinate. o o Option D: Although precisely determining when labor starts may be inexact, labor is generally defined as beginning when contractions become strong and regularly spaced at approximately 3 to 5 minutes apart. Throughout pregnancy, women may experience painful contractions that do not lead to cervical dilation or effacement, referred to as false labor. • 14. Question The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions? A. Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction. o B. Duration is measured by timing from the end of one contraction to the beginning of the next contraction. o C. Duration is measured by timing from the beginning of one contraction to the end of the same contraction. o and even fetal death, can result. • 16. Question A client wit h diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding i nsulin needs during pregnancy? o A. Insulin requirements moderate as the pregnancy progresses. B.A decreased need for insulin occurs during the second trimester. o C. Elevations in human chorionic gonadotropin decrease the need for insulin. o D. Fetal development depends on adequate insulin regulation. Correct Answer: D. Fetal development depends on adequate insulin regulation. Fetal development depends on adequate nutrition and insulin regulation. Significant alterations in maternal metabolism during pregnancy ensure a continuous supply of nutrients to the fetus. Glucose is the primary energy source for the fetus. In early pregnancy, increases in maternal insulin sensitivity enable the storage of energy and nutrients. o Option A: Insulin requirements do not moderate as the pregnancy progresses. To counteract insulin resistance and achieve adequate metabolic control in late pregnancy, the dose of insulin may need to be increased. Understanding insulin requirements in o pregnant women with type 1 diabetes would help them to maintain tight glycemic control. o Option B: Insulin needs to increase during the second and third trimesters. In late pregnancy, maternal insulin resistance develops due to increases in pregnancy-related hormones, such as progesterone, human placental lactogen and prolactin, as well as inflammatory cytokines, such as tumor necrosis factor-?. These changes facilitate the supply of glucose toward the fetus. o Option C: Elevated human chorionic gonadotropin elevates insulin needs, not decreases them. Insulin dose prior to pregnancy was associated with pre- pregnancy body weight, BMI, and HbA1c levels before pregnancy and in the first trimester. Insulin dose prior to pregnancy was higher in patients with male infants than patients with female infants. • 17. Question A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to: o A. Providing a calm environment o B. Obtaining a diet history o C. Administering an analgesic o D. Assessing fetal heart tones Correct Answer: A. Providing a calm environment A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Establish measures to lessen likelihood of seizures; i.e., keep the room quiet and dimly lit, limit visitors, plan and coordinate care, and promote rest. Lessens environmental factors that may stimulate irritable cerebrum and cause a convulsive state. o Option B: Obtaining a diet history should be done later. Determine patient’s nutritional status, condition of hair and nails, and height and pregravid weight. Establishes guidelines for determining dietary needs and educating the patient. Malnutrition may be a contributing factor to the onset of PIH, specifically when the client follows a low-protein diet, has insufficient caloric intake, and is overweight or underweight by 20% or more before conception. o Option C: Administering an analgesic is not indicated because there is no data in the stem to indicate pain. MgSO4 a CNS depressant, decreases acetylcholine release, blocks neuromuscular transmission, and prevents seizures. It has a transient effect of lowering BP and increasing urine o B. Calcium gluconate o C. Dinoprostone (Prostin E.) o D. Bromocriptine (Parlodel) Correct Answer: C. Dinoprostone (Prostin E.) The client with a missed abortion will have induction of labor. Prostin E. is a form of prostaglandin used to soften the cervix. Prostaglandin E2 (PGE2), also known by the name dinoprostone, is a naturally occurring compound that is involved in promoting labor, though it is also present in the inflammatory pathway. Prostaglandin E2 is FDA approved for cervical ripening for the induction of labor in patients for which there is a medical indication for induction. o Option A: Magnesium sulfate is used for preterm labor and preeclampsia. Magnesium sulfate is a naturally occurring mineral used to control low blood levels of magnesium. Magnesium injection is also used for pediatric acute nephritis and to prevent seizures in severe pre- eclampsia, eclampsia, or toxemia of pregnancy. o Option B: Calcium gluconate is the antidote for magnesium sulfate. Calcium gluconate is typically administered intravenously (IV) or orally in the treatment of hypocalcemia, cardiac arrest, or cardiotoxicity due to hyperkalemia or hypermagnesemia. Calcium gluconate has also been used off-label in the management of ?-blocker toxicity, calcium- channel blocker (CCB) toxicity, magnesium toxicity, and hydrofluoric acid burns. o Option D: Pardel is a dopamine receptor stimulant used to treat Parkinson’s disease. Bromocriptine is also used as an early treatment for PD to delay the onset of the use of levodopa, ultimately delaying the likely dyskinesia and motor fluctuations that occur with chronic use. • 20. Question A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should: o A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure o B. Stop the infusion of magnesium sulfate and contact the physician o C. Slow the infusion rate and turn the client on her left side o D. Administer calcium gluconate IV push and continue to monitor the blood pressure Correct Answer: A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure The client’s blood pressure and urinary output are within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8–9.6mg/dL. Magnesium levels must be monitored frequently by checking serum levels every 6 to 8 hours or clinically by following patellar reflexes or urinary output. o Option B: Do not stop the infusion. If serum concentration levels are low, a proper dose of magnesium sulfate can be given parenterally to replete low serum concentrations with recommended follow up laboratory testing. o Option C: There is no need to stop the infusion at this time or slow the rate. If patients exhibit signs and symptoms of hypermagnesemia, the recommendation is to discontinue magnesium sulfate products immediately. If the patient consumed magnesium sulfate orally, then the use of magnesium-free enemas or cathartics can be useful in removing excess magnesium from the GI tract. o Option D: Calcium gluconate is the antidote for magnesium sulfate, but there is no data to indicate toxicity. Patients should receive parenteral doses of calcium gluconate to help alleviate symptoms, but continued doses may be necessary as the calcium provides temporary improvement. IV hydration should also occur if clinically appropriate. • 21. Question Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders? o A. An affected newborn has unaffected parents. o B. An affected newborn has one affected parent. o C. Affected parents have a one in four chance of passing on the defective gene. o D. Affected parents have unaffected children who arecarriers. Correct Answer: C. Affected parents have a one in four chance of passing on the defective gene. Autosomal recessive disorders can be passed from the parents to the infant. If both parents pass the trait, the child will get two abnormal genes and the disease results. Parents can also pass the trait to the infant. Patients affected with autosomal recessive (AR) diseases have a disease allele on each chromosome. The pattern of individuals affected with an AR disease can be traced o B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy. o C. It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism. o D. Fetal growth is arrested if thyroid medication is continued during pregnancy. Correct Answer: B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy. During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. During pregnancy, there are increased metabolic needs of the maternal body resulting in changes in thyroid physiology. These changes in thyroid physiology reflect in altered thyroid function tests. o Option A: There could be a need for thyroid medication during pregnancy. The serum TSH concentration is the initial and most reliable measure of thyroid function during pregnancy. As elaborated above, there are physiologic changes in TSH levels during pregnancy which warrants close monitoring of TSH levels. As per the latest American Thyroid Association (ATA) guidelines, serum TSH levels during pregnancy should be defined using population and trimester-specific based reference ranges. o Option C: The thyroid function does not slow. When population and trimester-specific normal ranges are not available, the ATA guidelines recommend reducing the lower limit of TSH by 0.4 mU/L and the upper limit by 0.5 mU/L. It would correspond to the TSH reference range of 0.1 to 4.0 mU/L during the first trimester with a gradual return of TSH towards the non-pregnant normal range during second and third trimesters. o Option D: Fetal growth is not arrested if thyroid medication is continued. There is an increase in iodine requirement during pregnancy due to an increase in maternal thyroid hormone production as well as an increase in renal iodine clearance. Along with the above two factors, there is also a fetal iodine requirement; therefore, dietary iodine requirements are higher during pregnancy. • 24. Question The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse would expect to find: o A. An apical pulse of 100 o B. An absence of tonus o C. Cyanosis of the feet and hands o D. Jaundice of the skin and sclera Correct Answer: C. Cyanosis of the feet and hands Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. Acrocyanosis is bluish discoloration around the mouth and extremities, with the remaining area pink. It is a benign finding often seen in healthy newborns and is common in the initial days of life due to initial peripheral vasoconstriction. This is managed by routine newborn care. The routine newborn care management which involves pulse oximetry and screening of congenital heart disease (CHD). o Option A: An apical pulse should be 120–160. The next step would be cardiac auscultation, making a note of the rate, rhythm, and quality of sounds. Heart sounds should have a single first heart sound and second split heart sound. Neonatal murmurs on the first day of life are common and are usually transient. o Option B: The baby should have muscle tone, making answer B . A neurological exam should include a more thorough assessment of tone & level of alertness than the initial inspection. Tone can be assessed by holding up the newborn under the bilateral axilla. o Option D: Jaundice immediately after birth is pathological jaundice and is abnormal. Pathologic jaundice may occur in the first 24 hours of life and is characterized by a rapid rate of rising in the bilirubin level more than 0.2 mg/dl per hour or 5 mg/dl per day. • 25. Question A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for: o A. Supplemental oxygen o B. Fluid restriction o C. Blood transfusion o D. Delivery by Caesarean section you may also be given an injection of a harmless substance called a contrast agent before the scan, as this can make the images clearer. o Option D: The client should withhold voiding, not food, before an ultrasound. Avoid eating or drinking for several hours before the scan – this may be needed before a scan of your digestive system, including the liver and gallbladder. • 27. Question An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year? o A. 14 pounds o B. 16 pounds o C. 18 pounds o D. 24 pounds Correct Answer: D. 24 pounds By 1 year of age, the infant is expected to triple his birth weight. Between six months and one year, weight gain slows down a little. Most babies double their birth weight by five to six months of age and triple it by the time they are a year old. By one year, the average weight of a baby girl is approximately 19 pounds 10 ounces (8.9 kg), with boys weighing about 21 pounds 3 ounces (9.6 kg). o Option A: During the first few days of life, it’s normal for both breastfed and bottle-fed newborns to lose weight. A bottle-fed baby may lose up to 5% of his body weight, and an exclusively breastfed newborn can lose up to 10%. o Option B: On average, babies gain about one pound each month for the first six months. The average weight at six months is about 16 pounds 2 ounces (7.3 kg) for girls and 17 pounds 8 ounces (7.9 kg) for boys. o Option C: Most infants will gain about a pound over their birth weight by month one. At this age, infants are not as sleepy, they begin developing a regular feeding pattern, and they have a stronger suck during feedings. • 28. Question A pregnantclient with a history of alcohol addiction is scheduled for a nonstress test. The nonstress te st: o A. Determines the lung maturity of the fetus o B. Measures the activity of the fetus o C. Shows the effect of contractions on the fetal heart rate o D. Measures the neurological well-being of the fetus Correct Answer: B. Measures the activity of the fetus A nonstress test is done to evaluate periodic movement of the fetus. Prenatal non-stress test, popularly known as NST, is a method used to test fetal wellbeing before the onset of labor. A prenatal non-stress test functions in overall antepartum surveillance with ultrasound as a part or component of the biophysical profile. The presence of fetal movements and fetal heart rate acceleration is the most critical feature of the non- stress test. o Option A: It is not done to evaluate lung maturity as in answer A. It is usually estimated by examination of the amniotic fluid, obtained by transabdominal amniocentesis, for lecithin, lecithin/sphingomyelin (L/S) ratio. The Lecithin-to-Sphingomyelin Ratio (L/S ratio) is one of several methods for clinicians to assess fetal lung maturation. This biochemical test was first introduced in the 1970s, where a sample of amniotic fluid was collected via addition, the urethral meatus is usually in an abnormal location. If the infant has a complete foreskin, the hypospadias may become obvious after circumcision. • 30. Question A gravida 3 para 2 is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is: o A. Alteration in coping related to pain o B. Potential for injury related to precipitate delivery o C. Alteration in elimination related to anesthesia o D. Potential for fluid volume deficit related to NPO status Correct Answer: A. Alteration in coping related to pain Transition is the time during labor when the client loses concentration due to intense contractions. Assess nature and amount of vaginal show, cervical dilation, effacement, fetal station, and fetal descent. Cervical dilation should be approximately 1.2 cm/hr in the nullipara and 1.5 cm/hr in the multipara; vaginal show increases with a fetal descent. Choice and timing of medication is affected by the degree of dilation and contractile pattern. o Option B: Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is . Monitor uterine activity manually and/or electronically, noting frequency, duration, and intensity of contraction. The uterus is susceptible to possible rupture if a hypertonic contractile pattern develops spontaneously or in response to oxytocin administration. Placental separation and hemorrhage can also occur if contraction persists. o o Option C: Encourage periodic attempts to void, at least every 1–2 hr. Pressure of the presenting part on the bladder often reduces sensation and interferes with complete emptying. Regional anesthesia (especially in conjunction with IV fluid infusion and use of Stadol) also may contribute to voiding difficulties/bladder distension. o Option D: Monitor for signs and symptoms of excess fluid loss or shock (i.e., check BP, pulse, sensorium, skin color, and temperature). Hemorrhage associated with fluid loss greater than 500 ml may be manifested by increased pulse, decreased BP, cyanosis, disorientation, irritability, and loss of consciousness. • 31. Question The client with varicella will most likely have an order for which category of medication? 5 A. Antibiotics 6 B. Antipyretics Correct Answer: C. Antivirals Varicella is chickenpox. This herpes virus is treated with antiviral medications. In adults, infection tends to be more severe, and treatment with antiviral drugs (acyclovir or valacyclovir) is advised if they can be started within 24 to 48 hours of rash onset. In children, acyclovir decreases symptoms by one day if taken within 24 hours of the start of the rash, but it has no effect on complication rates, and it is not recommended for individuals with normal immune function. o Option A: The pharmacology behind antibiotics includes destroying the bacterial cell 5 C. Antivirals 6D. Anticoagulants by either preventing cell reproduction or changing a necessary cellular function or process within the cell. Antimicrobial agents are classically grouped into 2 main categories based on their in vitro effect on bacteria: bactericidal and bacteriostatic. o Option B: The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone, so answer B is . Nonsteroidal anti-inflammatory drugs (NSAIDs) are a drug class FDA- approved for use as antipyretic, anti- inflammatory, and analgesic agents. These effects make NSAIDs useful for the treatment of muscle pain, dysmenorrhea, arthritic conditions, pyrexia, gout, migraines, and used as opioid-sparing agents in certain acute trauma cases. o Option D: The client is not treated with anticoagulants as stated in answer D. Anticoagulants derive their effect by acting at different sites of the coagulation cascade. Some act directly by enzyme inhibition, while others indirectly, by binding to antithrombin or by preventing their synthesis from the liver (vitamin K dependent factors). • 32. Question A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question? o A. Nitroglycerin o B. Ampicillin o C. Propranolol not the best answer for the stem. Encourage independence in mobility and assist as needed: Allow ample time for activity; provide rest period after activity; reinforce principles of joint protection and work simplification. • 34. Question A client wit h acute pancreatitis is experiencing severe abdominal pain. Which of the following orders shou ld be questioned by the nurse? o A. Meperidine 100 mg IM q 4 hours PRN pain o B. Mylanta 30 ccs q 4 hours via NG o C. Cimetidine 300 mg PO q.i.d. o D. Morphine 8 mg IM q 4 hours PRN pain Correct Answer: D. Morphine 8 mg IM q 4 hours PRN pain Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphincter of Oddi. GI obstruction is another important contraindication. It is also considered by many as a contraindication to provide opioids to individuals that have a history of substance misuse, especially if a patient has had a history of abusing opioids. o Option A: Clinicians use meperidine is used for the treatment of moderate to severe pain. It has intramuscular, subcutaneous, intravenous injection, syrup, and tablet forms. In the 20th century, it was the drug of choice amongst the opioids in the management of acute pain by most of the physicians and the management of some patients with chronic pain. o Option B: Antacids are a group of drugs that have been on the market for many years. They were initially first-line defense against peptic ulcer disease; however, the discovery of proton pump inhibitors revolutionized the treatment of peptic ulcer disease. Currently, antacid use is restricted to the relief of mild intermittent gastroesophageal reflux disease (GERD) associated heartburn. o Option C: Cimetidine is ordered for pancreatitis, making answer C . Cimetidine is a gastric acid reducer used in the short-term treatment of duodenal and gastric ulcers. The drug is effective in managing gastric hypersecretion, and therefore, used for the management of reflux esophagitis disease and in the prevention of stress ulcers. With the development of proton pump inhibitors, such as omeprazole, approved for the same indications, cimetidine is available as an over the counter formulation for the prevention of heartburn or acid indigestion, along with the other H2- receptor antagonists. • 35. Question The client i s admitted to the chemical dependence unit with an order for continuous observatio n . The nurse is aware that the doctor has ordered continuous observation because: o A. Hallucinogenic drugs create both stimulant and depressant effects. o B. Hallucinogenic drugs induce a state of altered perception. o C. Hallucinogenic drugs produce severe respiratory depression. o D. Hallucinogenic drugs induce rapid physical dependence. Correct Answer: B. Hallucinogenic drugs induce a state of altered perception. Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Adverse effects are extremely subjective, with significant variability and unpredictability. One patient may experience a positive effect filled with bright hallucinations, sights and sensations, increased awareness owing to mind expansion, and marked euphoria. The positive spectrum of effects is colloquially called a ―good trip.‖ o Option A: Another patient may experience the total opposite that is filled with increased anxiety becoming panic, fear, depression, despair, and disappointment. The negative spectrum is colloquially called a ―bad trip.‖ One patient can experience both the positive and negative spectrum at different times of use. o Option C: Hallucinogenic drugs don’t create both stimulant and depressant effects or produce severe respiratory depression. One of the more disturbing 7 A. The patient may resume normal home activities astolerated but should avoid physical exertion and get adequate rest. o B. The patient should resume a normal diet with emphasis on nutritious, healthy foods. o C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved. Correct Answer: C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved. It is always critical that patients being discharged from the hospital take prescribed medications as instructed. In the case of antibiotics, a full course must be completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection. Take antibiotics exactly as directed. Do not stop taking the medicine just because you are feeling better. The client needs to take the full course of antibiotics. o Option A: The patient should resume normal activities as tolerated, as well as a nutritious diet. Get plenty of rest and sleep. The client may feel weak and tired for a while, but the energy level will improve with time. o Option B: Healthy and nutritious food, especially those high in vitamin C, should be included in the patient’s diet to speed up recovery and prevent reinfection. To prevent dehydration, drink plenty of fluids, enough so that the urine is light yellow or clear like water. Choose water and other caffeine- free clear liquids until feeling better. If the client has kidney, heart, or liver disease and has to limit fluids, he should talk with his doctor before he increases the amount of fluids he drinks. o Option D: Continued use of the incentive spirometer after discharge will speed recovery and improve lung function. If given a spirometer to measure how well the lungs are working, use it as instructed. This can help the doctor tell how the recovery is going. 7 D. The patient should continue use of the incentive spirometer to keep airways open and free of secretions. • 38. Question A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take? o A. Restrict visiting hours and ask the family to limit visitors to two at a time. o B. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed. o C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to thefamily. o D. Contact the physician to report the unusual ritualsand activities. Correct Answer: C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family. When a family member is dying, it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. In the Vietnamese culture, it is important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the next life. When possible, allowing the family privacy for this traditional behavior is best for them and the patient. o Option A: Know the availability of support systems for the patient. If the patient’s main support is the object of perceived loss, the patient may need help in naming other sources of support. Communicate therapeutically with patient and family members and allow them to verbalize feelings. o Option B: Support the patient and significant others share mutual fears, concerns, plans, and hopes for each other. Keeping secrets won’t do any help during this time. These times of stress can be used as an opportunity for growth and family development. o Option D: Initiate a process that provides additional support and resources. The patient and family may benefit from spiritual support resources. Strengthen the patient’s efforts to go on with his or her life and normal routine. Allow the patient and family to feel that they are enabled to do this by supporting them. • 39. Question The chargenurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery? o A. A one-week postoperative coronary bypass patient, who is being eva luated for placement of a pacemaker prior to discharge. o B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and scheduled for an angiogram. o C. A patient with unstable angina being closely monitored for pain and medication titration. o D. A postoperative valve replacement patient who was recently admitted to the unit because all surgical beds were filled. Correct Answer: A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. o Option C: Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat. Lipoatrophies are considered an adverse immunological side effect of insulin therapy, and in some cases they are mediated by a local high production of tumor necrosis factor-?, which leads to a dedifferentiation of adipocytes in the subcutaneous tissue. o Option D: Glucagon reverses rather than enhances or prolongs the effects of insulin. Glucagon is a reliable method of raising the patient’s glucose and relieving severe hypoglycemia long enough for more definitive correction of the patient’s glucose levels by mouth, particularly when IV access is unavailable to the provider or has failed. • 41. Question An infant with congestive heart failure is receiving diuretic therapy at home. Which of the following symptoms would indicate that the dosage may need to be increased? o A. Sudden weight gain o B. Decreased blood pressure o C. Slow, shallow breathing o D. Bradycardia Correct Answer: A. Sudden weight gain Weight gain is an early symptom of congestive heart failure due to accumulation of fluid. Important among these are renal retention of fluid, renin-angiotensin mediated vasoconstriction and sympathetic overactivity. Excessive fluid retention increases the cardiac output by increasing the end diastolic volume (preload), but also results in symptoms of pulmonary and systemic congestion. o Option B: Vasoconstriction (increase in afterload) tends to maintain flow to vital organs, but it is disproportionately elevated in patients with CHF and increases myocardial work. Similarly, sympathetic overactivity results in increase in contractility, which also increases myocardial requirements. An understanding of the interplay of the four principal determinants of cardiac output – preload, afterload, contractility and heart rate is essential in optimising the therapy of CHF. It is clinically useful to consider CHF in different age groups separately. o Option C: In the past, the most sensitive and specific variables for the presence of CHF (p<0.0001) were, a history of less than 3.5 oz/feed, respiratory rate greater than 50/min, an abnormal respiratory pattern, diastolic filling sounds, and hepatomegaly. Moderate to severe CHF was considered to be present when patients took less than 3 oz/feed or greater than 40 min/feed, had an abnormal respiratory pattern with a resting respiratory rate greater than 60/min, and had a diastolic filling sound and moderate hepatomegaly. o Option D: Tachycardia >150/min is common, and heart rates >180/min are abnormal even in the setting of respiratory distress and suggests CHF. Severe CHF was accompanied by a heart rate greater than 170/min, decreased perfusion, and severe hepatomegaly. Thus, the grading of the severity of CHF in infants should include an accurate description of these historical and clinical variables. • 42. Question A patient taking dilantin (Phenytoin) for a seizure disorder is experiencing breakthrough seizures. A blood sample is taken to determine the serum drug level. Which of the following would indicate a sub-therapeutic level? A patient arrives at the emergency department complaining of back pain. He reports taking at least 3 acetaminophen tablets every three hours for the past week without relief. Which of the following symptoms suggests acetaminophen toxicity? o A. Tinnitus o B. Diarrhea o C. Hypertension o D. Hepatic damage Correct Answer: D. Hepatic damage Acetaminophen in even moderately large doses can cause serious liver damage that may result in death. Immediate evaluation of liver function is indicated with consideration of N- acetylcysteine administration as an antidote. Acetaminophen is rapidly absorbed from the gastrointestinal (GI) tract and reaches therapeutic levels in 30 minutes to 2 hours. Overdose levels peak at 4 hours unless other factors could delay gastric emptying, such as a coingestion of an agent that slows gastric motility, or if the acetaminophen is in an extendedrelease form. o A. 15 mcg/mL. o B. 4 mcg/mL. o C. 10 mcg/dL. o D. 5 mcg/dL. • 43. Question A patient arrives at the emergency department with severe lower leg pain after a fall in a touch football game. Following routine triage, which of the following is the appropriate next step in assessment and treatment? o A. Apply heat to the painful area. o B. Apply an elastic bandage to the leg. o C. X-ray the leg. o D. Give pain medication. Correct Answer: C. X-ray the leg. Following triage, an x-ray should be performed to rule out fracture. Review follow-up and serial X-rays. Provides visual evidence of proper alignment or beginning callus formation and healing process to determine the level of activity and need for changes in or additional therapy. o Option A: Ice, not heat, should be applied to a recent sports injury. Apply cold or ice pack first 24–72 hr and as necessary. Reduces edema and hematoma formation, decreases pain sensation. Note: Length of application depends on degree of patient comfort and as long as the skin is carefully protected. o Option B: An elastic bandage may be applied. Maintain immobilization of affected part by means of bed rest, cast, splint, traction. Relieves pain and prevents bone displacement and extension of tissue injury. Elevate and support injured extremity. Promotes venous return, decreases edema, and may reduce pain. o Option D: Pain medication can be given once fracture has been excluded. Medicate before care activities. Let the patient know it is important to request medication before pain becomes severe. Promotes muscle relaxation and enhances participation. • 46. Question A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure? o A. A patient admitted for myocardial infarction without cardiac muscle damage. o B. A postoperative coronary bypass patient, recovering on schedule. o C. A patient with a history of ventricular tachycardia and syncopal episodes. o D. A patient with a history of atrial tachycardia and fatigue. Correct Answer: C. A patient with a history of ventricular tachycardia and syncopal episodes. An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary in a patient with significant ventricular symptoms, such as tachycardia resulting in syncope. Indications are usually secondary where the patient has already suffered and survived cardiac arrest due to ventricular fibrillation/ventricular tachycardia, or primary when the patient is at high risk of sudden cardiac death due to VF/ VT but has never had any such event. o Option A: A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate. ICD is a state of the art device that treats arrhythmias specifically those of ventricular origin like ventricular tachycardia and fibrillation. It has become the first line of defense in patients who are at high risk for sudden cardiac death (SCD) and has shown consistent survival benefit in cardiac arrest survivors (SCA), in patients with Heart failure and severe systolic dysfunction (left ventricular ejection fraction-LVEF less than or equal to 35%) as well as in patients with hypertrophic cardiomyopathy (HCM). o Option B: A patient recovering well from coronary bypass would not need the device. ICD is essentially a pacemaker with the ability to recognize abnormally fast cardiac rhythm and provide immediate treatment which can be in the form of overdrive pacing called anti- tachycardia Pacing (ATP) or shock therapy which could be synchronized or unsynchronized, depending on the recognized rhythm and the pre- programmed rhythm detection algorithm. o Option D: Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort. Secondary prophylaxis usually involves the event of cardiac arrest due to ventricular fibrillation (VF) or hemodynamically unstable, also known as pulseless, ventricular tachycardia (VT). Adequate workup and exclusion of reversible causes should be done first before deciding to put the device in, as is endorsed by the guidelines laid down by Heart Rhythm Society (HRS) and American College of Cardiology (ACC). branches by a thrombus that originated somewhere else. Chest pain is a frequent symptom and is usually caused by pleural irritation due to distal emboli causing pulmonary infarction. In central PE, chest pain may be from underlying right ventricular (RV) ischemia and needs to be differentiated from an acute coronary syndrome or aortic dissection. o Option A: The most common symptoms of PE include the following: dyspnea, pleuritic chest pain, cough, hemoptysis, presyncope, or syncope. Dyspnea may be acute and severe in central PE, whereas it is often mild and transient in small peripheral PE. o Option C: A patient with pulmonary embolism will not be sleepy or have a cough with crackles on exam. On examination, patients with PE might have tachypnea and tachycardia, which are common but nonspecific findings. Other examination findings include calf swelling, tenderness, erythema, palpable cords, pedal edema, rales, decreased breath sounds, signs of pulmonary hypertension such as elevated neck veins, loud P2 component of second heart sound, a right- sided gallop, and a right ventricular parasternal lift might be present on examination. o Option D: A patient with fever, chills, and loss of appetite may be developing pneumonia. A massive PE leads to an acute right ventricular failure, which presents as jugular venous distension, parasternal lift, third heart sound, cyanosis, and shock. If a patient with PE who has tachycardia on presentation develops sudden bradycardia or develops a new broad complex tachycardia (with right bundle branch block), providers should look for signs of right ventricular strain and possible impending shock. PE should be suspected in anyone who has hypotension with jugular venous distension wherein acute myocardial infarction, pericardial tamponade, or tension pneumothorax has been ruled out. • 49. Question A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect? o A. The patient will be admitted to the medicine unit for observation and medication. o B. The patient will be admitted to the day surgery unit for sclerotherapy. o C. The patient will be admitted to the surgical unit and resection will be scheduled. o D. The patient will be discharged home to follow-up withhis cardiologist in 24 hours. Correct Answer: C. The patient will be admitted to the surgical unit and resection will be scheduled. A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should be resected as soon as possible. Abdominal aortic aneurysm (AAA) is a life-threatening condition which requires monitoring or treatment depending upon the size of the aneurysm and/or symptomatology. AAA may be detected incidentally or at the time of rupture. An arterial aneurysm is defined as a permanent localized dilatation of the vessel at least 150% compared to a relative normal adjacent diameter of that artery o Option A: The patient should be admitted but not in the medicine unit. Rupture of an abdominal aortic aneurysm is life- threatening. These patients may present in shock often with diffuse abdominal pain and distension. However, the presentation of patients with this type of ruptured aneurysm can vary from subtle t9quite dramatic. Most patients with a ruptured abdominal aortic aneurysm die before hospital arrival. o Option B: The patient should undergo resection instead of sclerotherapy. Open surgical repair via transabdominal or retroperitoneal approach has been the gold standard. Endovascular repair from a femoral arterial approach is now applied for a majority of repairs, especially in older and higher risk patients. Endovascular therapy is recommended in patients wh10are not candidates for open surgery. This includes patients with severe heart disease, and/or other comorbidities that preclude open repair. 9A. Monitor for fever every 4 hours. During induction chemotherapy, the leukemia patient is severely immunocompromised and at risk of serious infection. Fresh flowers, fruit, and plants can carry microbes and should be avoided. Teach proper hand washing using antibacterial soap before and after each care activity. Hand washing and hand hygiene lessen the risk of cross- contamination. Note: Methicillin- resistant Staphylococcus aureus (MRSA) is most commonly transmitted bacteria via direct contact with health care workers who are unable to wash hands between client contacts. o Option A: Books and magazines can be brought to the patient, but they should be disinfected. Encourage the client to cover their mouth and nose with a tissue when coughing or sneezing. Place in a private room if indicated. Wear a mask when providing direct as appropriate. Appropriate behaviors, personal protective equipment, and isolation prevent the spread of infection via airborne droplets. o Option B: Personal items can be cleaned with antimicrobials before being brought into the room to minimize the risk of contamination. Body substance isolation should be used for all infectious clients. Wound and linen isolation and hand washing may be all that is required for draining wounds. Clients with diseases transmitted through air may also need airborne and droplet precautions. o Option D: The pictures should be disinfected before given to the client. Note temperature trends and observe for shaking chills and profuse diaphoresis. Fever [101°F-105°F (38.5°C-40°C)] is the result of endotoxin effect on the hypothalamus and pyrogen- released endorphins. Hypothermia lower than 96°F (36°C) is a grave sign reflecting advancing shock state, decreased tissue perfusion, and failure of the body’s ability to mount a febrile response. Chills often precede temperature spikes in the presence of generalized infection. • 52. Question A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient? o A. 3-10 years. o B. 25-35 years. o C. 45-55 years. o D. over 60 years. Correct Answer: A. 3-10 years. The peak incidence of ALL is at 4 years (range 3-10). It is uncommon after the mid-teen years. It is diagnosed in about 4000 people in the United States each year with the majority being under the age of 18. It is the most common malignancy of childhood. The peak age of diagnosis is between two and ten years of age. o Option B: ALL is uncommon during young adulthood. Acute Lymphocytic Leukemia is more common in children with Trisomy 21 (Down syndrome), neurofibromatosis type 1, Bloom syndrome, and ataxia telangiectasia. All are common in children between two and three years of age. o Option C: The peak incidence of chronic myelogenous leukemia (CML) is 4555 years. Prognosis is diminished in children when diagnosed in infants less than one year of age and in adults. It is more favorable for children. Association of the MLL gene in children at 11q23 chromosome is associated with poor prognosis. o Option D: The peak incidence of acute myelogenous leukemia (AML) occurs at 60 years. Two-thirds of cases of chronic lymphocytic leukemia (CLL) occur after 60 years. Lymphocytic Leukemia is a disease with low incidence overall in population studies. The incidence of Acute Lymphocytic Leukemia is about 3.3 cases per 100,000 children. Survival rates for ALL have improved dramatically since the 1980s, with a current five-year overall survival rate estimated at greater than 85 percent. • 53. Question A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin’s disease. Which of the following symptoms istypical of Hodgkin’s disease? o A. Painful cervical lymph nodes. o B. Night sweats and fatigue. o C. Nausea and vomiting. o D. Weight gain. Correct Answer: B. Night sweats and fatigue. Symptoms of Hodgkin’s disease include night sweats, fatigue, weakness, and a well-defined nuclear membrane. There are one or two nucleoli, and the cytoplasm is small or moderate in amount. Lymphoblasts that grow and divide uncontrollably cause a type of cancer known as acute lymphoblastic leukemia. o Option C: Gaucher’s cells are large storage cells found in patients with Gaucher’s disease. The Gaucher cell results from the accumulation of excessive glucocerebroside in cells of the monocyte-macrophage system. It is characterized ultrastructurally by the presence of cytoplasmic inclusions which consist of tubule-like structures measuring 130 to 150 Ao in diameter. o Option D: Rieder’s cells are myeloblasts found in patients with acute myelogenous leukemia. They are abnormal myeloblasts in which the nucleus may be widely or deeply indented or may actually be a bilobate or multilobate structure; frequently observed in acute leukemia. • 55. Question A patient is about to undergo bone marrow aspiration and biopsyand expresses fear and anxiety about the procedure. Which of the following is the most effective nursing response? o A. Warn the patient to stay very still because thesmallest movement will increase her pain. o B. Encourage the family to stay in the room for the procedure. o C. Stay with the patient and focus on slow, deep breathing for relaxation. o D. Delay the procedure to allow the patient to deal with her feelings. Correct Answer: C. Stay with the patient and focus on slow, deep breathing for relaxation. Slow, deep breathing is the most effective method of reducing anxiety and stress. It reduces the level of carbon dioxide in the brain to increase calm and relaxation. Stay with the patient during panic attacks. Use short, simple directions. Encourage the client’s participation in relaxation exercises such as deep breathing, progressive muscle relaxation, guided imagery, meditation and so forth. o Option A: Warning the patient to remain still will likely increase her anxiety. Maintain a calm, non-threatening manner while working with the client. Anxiety is contagious and may be transferred from health care provider to client or vice versa. Client develops feeling of security in presence of calm staff person. o Option B: Encouraging family members to stay with the patient may make her worry about their anxiety as well as her own. Move the client to a quiet area with minimal stimuli such as a small room or seclusion area (dim lighting, few people, and so on.) Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security as compared to a large area which can make the client feel lost and panicked. o Option D: Delaying the procedure is unlikely to allay her fears. Establish and maintain a trusting relationship by listening to the client; displaying warmth, answering questions directly, offering unconditional acceptance; being available, and respecting the client’s use of personal space. • 56. Question A mother c omplains to the clinic nurse that her 2 ½-year-old son is not yet toilet trained. She is parti cularly concerned that, although he reliably uses the potty seat for bowel movements, he isn’t able to hold his urine for long periods. Which of the following statements by the nurs e is correct? o A. The child should have been trained by age 2 and may have a psychological pro blem that is responsible for his "accidents." o B. Bladder control is usually achieved before bowel control, and the child sho uld be required to sit on the potty seat until he passes urine. o C. Bowel control is usually achieved before bladder control, and the average age for completion of toilet training varies widely from 24 to 36 months. o D. The child should be told "no" each time he wets so that he learns the behavior is unacceptable. Correct Answer: C. Bowel control is usually achieved before bladder control, and the average age for completion of toilet training varies widely from 24 to 36 months. Toddlers typically learn bowel control before bladder control, with boys often taking longer to complete toilet training than girls. Readiness to begin toilet training depends on the individual child. In general, starting before age 2 (24 months) is not recommended. The readiness skills and physical development the child needs occur between age 18 months and 2.5 years. o Option A: Many children are not trained until 36 months and this should not cause concern. Later training is rarely caused by psychological factors and is much more commonly related to individual developmental maturity. Timing is important. Toilet training should not be started when the child is feeling ill or when the child is experiencing any major life changes such as moving, new siblings, new school, or new child-care situation. o Option B: Bowel control is first achieved before bladder control. Start a routine with regular reminders beginning with one time a day—after breakfast or maybe at bath time when the child is already undressed. Watch for behavior, grimaces, or poses that may signal the need for a bowel movement, and ask the child if he or she needs to go. o Option D: Reprimanding the child will not speed the process and may be confusing. Accidents are common and should be expected in the training process. Praise the child whenever he or she tells you that he/she needs to go and when the child tells you without being reminded. o B. Allow the infant to cry for 5 minutes before responding if she wakes during the night as she may fall back asleep. o C. Talk to the infant frequently and make eye contact to encourage language development. o D. Wait until at least 4 months to add infant cereals andstrained fruits to the diet. Correct Answer: B. Allow the infant to cry for 5 minutes before responding if she wakes during the night as she may fall back asleep. Infants under 6 months may not be able to sleep for long periods because their stomachs are too small to hold adequate nourishment to take them through the night. After 6 months, it may be helpful to let babies put themselves back to sleep after waking during the night, but not prior to 6 months. By 6 months of age, most babies are physiologically capable of sleeping through the night and no longer require nighttime feedings. However, 25%-50% continue to awaken during the night. When it comes to waking during the night, the most important point to understand is that all babies wake briefly between four and six times. Babies who are able to soothe themselves back to sleep (“self-soothers”) awaken briefly and go right back to sleep. o Option A: Infants should always be placed on their backs to sleep. Research has shown a dramatic decrease in sudden infant death syndrome (SIDS) with back sleeping. Babies should always sleep Alone, on their Backs, in a Crib. Place your baby on his or her back for every sleep, night time and nap time. Do not put your baby to sleep on his side or tummy. Once your baby can roll from his back t14 tummy and tummy to back, your baby can stay in the sleep position that he assumes. But always place your baby to sleep on his back. 14A. Get moderate exercise for at least 30 minutes each day. o Option C: Eye contact and verbal engagement with infants are important t15 language development. Establish a consistent bedtime routine that includes calm and enjoyable activities that you can stick with as your baby gets older. Examples include a bath and bedtime stories. The activities occurring closest to “lights out” should occur in the room where your baby sleeps. Also, avoid making bedtime feedings part of the bedtime routine after 6 months. o Option D: The best diet for infants under 4 months of age is breast milk or infant formula. The American Academy of Pediatrics recommends exclusive breastfeeding for about 6 months, and then continuing breastfeeding while introducing complementary foods until the child is 12 months old or older. This provides the child with ideal nutrition and supports growth and development. • 59. Question 15 o B. Drink 6-8 glasses of water each day. An older patient asks a nurse t16 recommend strategies t1718 prevent constipation. Which of the following suggestions would be helpful? Note: More than one answer may be correct. Select all that apply. 16C. Eat a diet high in fiber. 17 D. Take a mild laxative if you don't have a bowel movement every day. 18E. Eat a protein-rich diet. trunk and extremities. The individual lesions of erythema marginatum are evanescent, moving over the skin in serpiginous patterns. Likened to smoke rings, they have a tendency to advance at the margins while clearing in the center. o Option B: Although estimates vary, only 35%-60% of patients with rheumatic fever recall having any upper respiratory symptoms, most commonly, sore throat, in the preceding several weeks. Studies in developed countries have established that rheumatic fever followed only pharyngeal infections and that not all serotypes of group A streptococci cause rheumatic fever. o Option D: Other symptoms of rheumatic fever include fever. The average duration of an untreated ARF attack is 3 months. Chronic rheumatic fever, generally defined as disease persisting for longer than 6 months, occurs in less than 5% of cases. • 61. Question A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform? o A. Ask the patient to lie down on the exam table. o B. Draw blood for chemistry panel and arterial blood gas (ABG). o C. Send the patient for a chest x-ray. o D. Check blood pressure. Correct Answer: D. Check blood pressure. A patient with congestive heart failure and dyspnea may have pulmonary edema, which can cause severe hypertension. Therefore, taking the patient’s blood pressure should be the first action. Monitor BP and central venous pressure (CVP). Hypertension and elevated CVP suggest fluid volume excess and may reflect developing pulmonary congestion, HF. o Option A: Lying flat on the exam table would likely worsen the dyspnea, and the patient may not tolerate it. Maintain chair or bed rest in semi-Fowler’s position during acute phase. Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis. o Option B: Blood draws for chemistry and ABG will be required, but not prior to the blood pressure assessment. Investigate reports of sudden extreme dyspnea and air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom. o Option C: The patient may be sent for an xray after initial assessment. Monitor chest x-ray. Reveals changes indicative of resolution of pulmonary congestion. Maintain fluid and sodium restrictions as indicated. Reduces total body water and prevents fluid reaccumulation. • 62. Question A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct? o A. "Stop taking the nitroglycerin and see if the headaches improve." o B. "Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain." o C. "Headaches are a frequent side effect of nitroglycerine because it causes vasodilation." o D. "The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation." Correct Answer: C. “Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.” Nitroglycerin is a potent vasodilator and often produces unwanted effects such as headache, dizziness, and hypotension. Headaches can be severe, throbbing, and persistent and may occur immediately after use. Many of these adverse effects are secondary to the hypotensive effects of nitroglycerin. Patients may report symptoms of orthostatic hypotension which manifest as dizziness, weakness, palpitations, and vertigo. Profound hypotension may occur in patients with preload-dependent conditions. o Option A: Patients should be counseled, and the dose titrated, to minimize these effects. The patient should not stop the medication. No currently known antagonist is available to counteract the effect of nitroglycerin. Since the effects are related to venodilation and relative arterial hypovolemia, efforts to increase central fluid volume have proven to be effective. o o Option B: Nitroglycerine does not cause bleeding in the brain. Some patients can be more sensitive to the hypotension caused by nitrates, Correct Answer: C. The patient should use iron cookware to prepare foods, such as dark green, leafy vegetables and legumes, which are high in iron. Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly anemic. When food is prepared in iron cookware its iron content is increased. Anemia is defined as hemoglobin below two standard deviations of the mean for the age and gender of the patient. Iron is an essential component of the hemoglobin molecule. The most common cause of anemia worldwide is iron deficiency, which results in microcytic and hypochromic red cells on the peripheral smear. o Option A: The client is mildly anemic. The cause of iron-deficiency anemia varies based on age, gender, and socioeconomic status. Iron deficiency may result from insufficient iron intake, decreased absorption, or blood loss. Irondeficiency anemia is most often from blood loss, especially in older patients. o Option B: Mild anemia does not require that animal sources of iron be added to the diet. Many non-animal sources are available. Dietary sources of iron are green vegetables, red meat, and iron-fortified milk formulas. It may also be seen with low dietary intake, increased systemic requirements for iron such as in pregnancy, and decreased iron absorption such as in celiac disease. o Option D: Coffee and tea increase gastrointestinal activity and inhibit absorption of iron. The iron in food comes from two sources: animals and plants. Iron from animal sources is known as heme iron and is found in meat and fish. Iron from plants is known as nonheme iron, and is found in certain vegetables and in iron- fortified foods such as breakfast cereals. Heme iron is better absorbed by the body than non heme iron. • 65. Question A hospitali zed patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. W hich of the following is the most ac curate statement? o A. Transfusion reaction is most likely immediately after the infusion is completed. o B. PRBCs are best infused slowly through a 20g. IV catheter. o C. PRBCs should be flushed with a 5% dextrose solution. o D. A nurse should remain in the room during the first 15 minutes of infusion. Correct Answer: D. A nurse should remain in the room during the first 15 minutes of infusion. Transfusion reaction is most likely during the first 15 minutes of infusion, and a nurse should be present during this period. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Meticulously verifying patient identification beginning with type and crossmatch sample collection and labeling to double-check blood product and patient identification prior to transfusion. o Option A: Transfusion reaction typically starts in the first 15 minutes of infusion. Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion). o Option B: PRBCs should be infused through a 19g or larger IV catheter to avoid slow flow, which can cause clotting. Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures. o Option C: PRBCs must be flushed with 0.45% normal saline solution. Other intravenous solutions will hemolyze the cells. Upon detection of any signs or symptoms of reaction, stop the transfusion immediately and notify the physician. Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion. • 66. Question Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority? o A. A patient with low-grade fever, headache, and myalgias for the past 72 hours. o B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident. commonly seen in hospitalized patients and for the most part, is mild in nature and only requires supportive treatment. o Option A: Paresthesias can be perioral or otherwise. Carpopedal spasm, also referred to as Trousseau’s sign. It represents increased neuromuscular excitability which may be related to the gating function of calcium ions for ion channels at a cellular level (particularly in neurons). This manifests as a spasm of hand upon routine BP check. o Option B: Numbness in hands and feet and muscle cramps are also signs of hypocalcemia. Tetany is generally induced by a rapid decline in serum ionized calcium. Tetany is usually most dangerous and most commonly seen in the presence of respiratory alkalosis causing hypocalcemia. o Option D: Positive Chvostek’s sign refers to the sustained twitching of facial muscles following tapping in the area of the cheekbone and is a hallmark of hypocalcemia. Another manifestation of heightened neuromuscular excitability. It is the spasm of facial muscles in response to tapping the facial nerve near the angle of the jaw. • 68. Question A nurse cares for a patient who has a nasogastric tube attachedto low suction because of a suspected bowel obstruction. Which of the following arterial blood gas results might be expected in this patient? o A. pH 7.52, PCO2 54 mmHg. o B. pH 7.42, PCO2 40 mmHg. o C. pH 7.25, PCO2 25 mmHg. o D. pH 7.38, PCO2 36 mmHg. Correct Answer: A. pH 7.52, PCO2 54 mmHg. A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis. Normal range for pH range from 7.35-7.45. CO2 level has a normal range of 35 to 45 mmHg. Normal range for HCO3 is 22-26 mmol/L. The lower the number, the more acidotic the patient is. The higher the pH, the more base is in the blood sample. o Option B: This result is a normal blood gas value. Arterial blood gas analysis assesses a patient’s partial pressure of oxygen (PaO2), providing information on the oxygenation status; the partial pressure of carbon dioxide (PaCO2), providing information on the ventilation status (chronic or acute respiratory failure, and is changed by hyperventilation (rapid or deep breathing) and hypoventilation (slow or shallow breathing); and acid-base status. o Option C: This result represents respiratory acidosis. Arterial blood gas interpretation is best approached systematically. Interpretation leads to an understanding of the degree or severity of abnormalities, whether the abnormalities are acute or chronic, and if the primary disorder is metabolic or respiratory in origin. Several articles have described simplistic ways to interpret ABG results. However, the Romanski method of analysis is most simplistic for all levels of providers. This method assists with determining the presence of an acid-base disorder, its primary cause, and whether compensation is present. o Option D: This result is borderline normal with slightly low PCO2. The PaCO2 indicates whether the acidosis or alkalemia is primarily from a respiratory or metabolic acidosis/alkalosis. Paco2>40 with a pH<7.4, indicates a respiratory acidosis, and <40 and pH<7.4 indicates a respiratory alkalosis (but is often from hyperventilation from anxiety or compensation for a metabolic acidosis). • 69. Question A patient is admitted to the hospital for routine elective surgery. Included in the list of current me dications is warfarin (Coumadin) at a high dose. Concerned about the possible effects of drug, particularly in a patient scheduled for surgery, the nurse anticipates the which of the following actions? o A. Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) level. o B. Administer vitamin K. o C. Draw a blood sample for type and crossmatch and request blood from the blood bank. o D. Cancel the surgery after the patient reports stopping the Coumadin one week previously. Correct Answer: A. Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) level. The effect of Coumadin is to inhibit clotting. The next step is to check the PT and INR to determine the patient’s anticoagulation status and risk of bleeding. Patients receiving treatment with warfarin should have close monitoring to ensure the safety and efficacy of the medication. Periodic blood testing is the recommendation to assess the patient’s prothrombin time (PT) and the international normalized ratio (INR). o Option B: Vitamin K is an antidote to Coumadin and may be used in a patient who is at imminent risk of dangerous bleeding. When managing warfarin toxicity, the initial step would be to discontinue warfarin and then administer vitamin K (phytonadione). The vitamin K may administration can be either via the oral, intravenous, or subcutaneous route. However, the