NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+, Exams of Nursing

Download NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ and more Exams Nursing in PDF only on Docsity! NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 1 | 124 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. NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 2 | 124 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 NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 5 | 124 o Option B: Because only a small portion of the retina, the fovea, is actually employed for distinct vision, it is vitally important that the motor apparatus governing the direction of gaze be extremely precise in its operation, and rapid. o Option D: The lens works much like a camera lens, bending and focusing light t1 produce a clear image. The crystalline lens is a convex lens that creates an inverted image focused on the retina. The brain flips the 1 A. Anesthetize the cornea NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 6 | 124 image back t2 normal t3 create what you see around you. In a process called accommodation, the elasticity of the crystalline lens allows you t4 focus on images at far distances and near with minimal disruption. • 4. Question A client who has glaucoma is to have miotic eye drops instilled in both eyes. The nurse knows that the purpose of the medication is to: 2 B. Dilate the pupils 3 C. Constrict the pupils 4 D. Paralyze the muscles of accommodation NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 7 | 124 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 NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 10 | 124 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 The client with a pacemaker should be taught to: o A. Report ankle edema o B. Check his blood pressure daily o C. Refrain from using a microwave oven o D. Monitor his pulse rate Correct Answer: D. Monitor his pulse rate The client with a pacemaker should be taught to count and record his pulse rate. Pacemakers are adjustable artificial electrical pulse generators, frequently emitting a pulse with a duration between 0.5 and 25 milliseconds with an output of 0.1 to 15 volts, at a frequency up to 300 times per minute. The cardiologist or pacemaker technologist will be able to interrogate and control the pacing rate, the pulse width, and the voltage, whether the device is temporary or permanent. o Option A: Ankle edema is a sign of right-sided congestive NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 11 | 124 heart failure. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. The pacing and CRT are associated with complications. The majority of complications NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 12 | 124 occur in the hospital or during the first 6 months. Lead complications are the main reason for the re- implantation of the pacemaker and CRT devices. Other complications include, but are not limited to infections, hematoma formation, pericardial effusion or tamponade, pneumothorax, coronary sinus dissection, or perforation. Some old pacemakers are not MRI safe. o Option B: Checking the blood pressure daily is not necessary for these clients. Patients who eventually require permanent pacemaker implantation often present with symptoms of dizziness, lightheadedness, fatigue, syncope, or lack of exercise tolerance. Frequently, these symptoms arise from bradyarrhythmias and patients will have sinus node dysfunction or atrioventricular (AV) conduction defects. o Option C: The client with a pacemaker can use a microwave oven, but he should stand about 5 feet from the oven while it is operating. There are some areas where the indications for a pacemaker are clear, but there are few areas where clinical judgment and expertise plays a greater role. Although the guidelines attempt to define practices that meet the needs of most patients, the ultimate decision for the patient should be based on the particular patient presenting the scenario, clinician judgment, and discussion with the patient about risks and benefits of the procedure. • 8. Question The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after: NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 15 | 124 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? NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 16 | 124 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 NCLEX RN Exam Pack Set 100.QUESTIONS AND ANSWERS LATEST UPDATE 2024.ASSURED A+ P a g e 17 | 124 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 meticulous monitoring, including fasting blood glucose, and changes in HbA1c values. • 11. Question The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes? o A. The tube will allow for equalization of the lung expansion. o B. Chest tubes serve as a method of draining blood and serous fluid and assist in re inflating the lungs. o C. Chest tubes relieve pain associated with a collapsed lung. o D. Chest tubes assist with cardiac function by stabilizing lung expansion. Correct Answer: B. Chest tubes serve as a method of draining blood and serous fluid and assist in re inflating the lungs. 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 P a g e 21 | 124 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 o P a g e 22 | 124 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 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 t he 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 P a g e 25 | 124 rupture, as well as maternal subarachnoid hemorrhages, maternal death, 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. o P a g e 26 | 124 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 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. o P a g e 27 | 124 • 17. Question P a g e 30 | 124 o C. Turner’s syndrome o D. Pathological jaundice Correct Answer: A. Down syndrome The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations. The risk of chromosome abnormalities is higher. Babies born to older mothers have a higher risk of certain chromosome problems, such as Down syndrome. o Option B: Risk factors for respiratory distress syndrome include prematurity, maternal diabetes, cesarean delivery, and asphyxia. The mother will more likely have a low birth weight baby and a premature birth. Premature babies, especially those born earliest, often have complicated medical problems. o Option C: Turner’s syndrome is a genetic disorder. Turner syndrome results from a deletion or the non- functioning of one X chromosome in females. About half of the population with Turner syndrome have monosomy X (45,XO). The other 50% of the population has a mosaic chromosomal component (45,X with mosaicism). Option D: Premature infants are at most risk for pathological jaundice because they develop higher levels of bilirubin. The risk of pregnancy loss — by miscarriage and stillbirth — increases as you get older, perhaps due to pre-existing medical conditions or fetal chromosomal abnormalities. Research suggests that the decrease in the quality of your eggs, combined with an increased risk of chronic medical conditions such as high blood pressure and diabetes, could increase your risk of miscarriage. Ask your health care provider about monitoring your baby’s well-being during the last weeks of pregnancy. • 19. Question P a g e 31 | 124 A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with: o A. Magnesium sulfate 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 P a g e 32 | 124 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 P a g e 35 | 124 through a family to determine which individuals are carriers and which individuals are likely become impacted. o Option A: To have an affected newborn, the parents must be carriers. The easiest way to determine the inheritance pattern of a disorder in a family is by looking at a pedigree. Autosomal recessive diseases typically affect both females and males equally. Autosomal recessive patterns manifest by skipping generations as the affected are usually children of unaffected carriers. o Option B: Both parents must be carriers. The most common situation of an autosomal recessive disease occurs when the parents are each carrier or heterozygous (Dd). Children of carrier parents have a 25% chance of inheriting the disorder. This value is obtained by using the Punnett square model used in genetics. o Option D: The parents might have affected children. Each parent has a 50% chance of passing on the disease allele. Using the multiplication rule of probability, there is a 50% chance that the father passes on his disease allele and a 50% chance that the mother passes on her disease allele; 50% x 50% = 25%. So with the mating of carrier parents, there is a 25% chance that the child will be affected, a 50% chance that the child would be a carrier, and 25% chance that they would be homozygous dominant and unaffected. • 22. Question A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein . The nurse should explain that the doctor has recommended the test: o A. Because it is a state law o B. To detect cardiovascular defects o C. Because of her age o D. To detect neurological defects P a g e 36 | 124 complications of amniocentesis are preterm labor, infection (amnionitis), iatrogenic trauma, or injury to the developing fetus or mother. o Option B: It does not indicate cardiovascular defects. Maternal blood AFP levels often as part of triple (AFP, Estriol, and hCG) or quadruple (AFP, implies Estriol, hCG and Inhibin A) screening test for birth defects. Levels are usually interpreted for age, race, weight, and gestational age. The elevated levels imply a significant risk of having birth defects, hence, further evaluation may be required to assess the level of risk. o Option C: The mother’s age has no bearing on the need for the test, so answer C is . A significant number of patients with elevated maternal AFP do not develop birth defects, but there may be an increased risk of obstetric complications like premature rupture of membrane, placenta accreta, increta, and packet. • 23. Question A client wit h hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that: o A. There is no need to take thyroid medication because the fetus’s thyroid pro duces a thyroid-stimulating hormone. 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. P a g e 37 | 124 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 P a g e 40 | 124 Correct Answer: A. Supplemental oxygen Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. The supply of extra oxygen with oxygen therapy may be beneficial for some patients with sickle cell disease. But the use of oxygen therapy in sickle cell disease is controversial because high levels of oxygen are known to suppress the formation of new red blood cells. Oxygen therapy is, therefore, only recommended when oxygen levels drop below a critical threshold. o Option B: Fluids are increased, not decreased. Vaso- occlusive crisis is treated with vigorous intravenous hydration and analgesics. Intravenous fluids should be of sufficient quantity to correct dehydration and to replace continuing loss, both insensible and due to fever. Normal saline and 5% dextrose in saline may be used. Treatment must be in an inpatient setting. o Option C: Blood transfusions are usually not required. Transfusions are not needed for the usual anemia or episodes of pain associated with SCD. Urgent replacement of blood is often required for sudden, severe anemia due to acute splenic sequestration, parvovirus B19 infection, or hyperhemolytic crisis. Transfusions are helpful in acute chest syndrome, perioperatively, and during pregnancy. o Option D: The client can deliver vaginally. Although activity is unrestricted, patients may not be able to tolerate vigorous exercise or exertion. Patients with avascular necrosis of the femur may not be able to tolerate weightbearing and may be restricted to bed rest. Patients with chronic leg ulcers may need to restrict activity that involves raising the legs. • 26. Question A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes: P a g e 41 | 124 o A. Increasing fluid intake o B. Limiting ambulation o C. Administering an enema o D. Withholding food for 8 hours Correct Answer: A. Increasing fluid intake Before ultrasonography, the client should be taught to drink plenty of fluids and not void. Drink water and do not go to the toilet until after the scan – this may be needed before a scan of the unborn baby or the pelvic area. A full bladder is very important for the ultrasound exam. Empty the bladder 90 minutes before exam time, then consume one 8ounce glasses of fluid (water, milk, coffee, etc.) about an hour before exam time. o Option B: There is no restriction for ambulation before ultrasound. Most ultrasound scans last between 15 and 45 minutes. They usually take place in a hospital radiology department and are performed either by a radiologist or a sonographer. o Option C: Enema is not necessary during an ultrasound. In some cases, P a g e 42 | 124 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 P a g e 45 | 124 amniocentesis to determine the risk of the neonate developing respiratory distress syndrome (RDS). o Option C: An oxytocin challenge test shows the effect of contractions on fetal heart rate. The oxytocin challenge test (OCT) is a form of antenatal fetal monitoring that is being utilized by obstetricians to assess fetal well-being. Uterine contractions may lower the fetal oxygen supply by decreasing the blood circulation in the intervillous spaces of the placenta. o Option D: Nonstress test does not measure neurological well-being of the fetus. Advances in technology over the past decade have enabled researchers to investigate directly the functional development of the fetal brain through two emerging techniques: functional magnetic resonance imaging (fMRI) and fetal magnetoencephalography (MEG). • 29. Question A full-term male has hypospadias. Which statement describes hypospadias? o A. The urethral opening is absent. o B. The urethra opens on the dorsal side of the penis. o C. The penis is shorter than usual. P a g e 46 | 124 o D. The urethral meatus opens on the underside of the penis. Correct Answer: D. The urethral meatus opens on the underside of the penis. Hypospadias is a congenital abnormality in which the urethral meatus is on the underside of the penis. Hypospadias is an anatomical congenital malformation of the male external genitalia. It is characterized by abnormal development of the urethral fold and the ventral foreskin of the penis that causes abnormal positioning of the urethral opening. o Option A: Urethral agenesis is the absence of the urethral opening. Urethral atresia is a rare urethral malformation, which is not compatible with life unless the urachus open in the umbilicus, an alternative communication between the bladder and rectum exists in a form of congenital fistula, or a prenatal placement of a vesico-amniotic shunt established. Terminal renal failure and multiple reconstructive operations have to be expected in the course of the disease. o Option B: The urethral opening is located ventrally, not dorsally, in hypospadias. In hypospadias, the external urethral meatus may present various degrees of malpositioning and may be found with associated penile curvature. Depending on the location of the defect, patients may have an additional genitourinary malformation. o Option C: Penis shorter than usual is not a characteristic of a patient with hypospadias. Key features include a glandular groove and a dorsal hood of the foreskin but in almost all cases the prepuce is incomplete ventrally. In P a g e 47 | 124 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. P a g e 50 | 124 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 o D. Verapamil Correct Answer: B. Ampicillin P a g e 51 | 124 There is no indication for an antibiotic such as Ampicillin. Penicillins had been very effective against S. aureus; in the past, however, S. aureus has become capable of exhibiting resistance against them by producing a penicillin hydrolyzing enzyme – penicillinase. After that, subsequent efforts to overcome this issue and extend the antimicrobial coverage of penicillins, ampicillin was developed. It is also resistant to acid so that it can be administered orally. o Option A: Nitroglycerin is a vasodilatory drug used primarily to provide relief from anginal chest pain. Nitroglycerin has been FDA approved since 2000 and was first sold by Pfizer under the brand name Nitrostat. It is currently FDA approved for the acute relief of an attack or acute prophylaxis of angina pectoris secondary to coronary artery disease. o Option C: B-adrenoceptor antagonists, including propranolol, have been advised to be used for the treatment of heart failure, atrial fibrillation, and coronary artery disease. Furthermore, they have demonstrated to improve mortality and morbidity in those with hypertension that is complicated with heart failure, angina, or any history of previous myocardial infarctions. o Option D: Clients with chest pain can be treated with nitroglycerin, a beta-blocker such as propranolol, or Verapamil. Given as initial treatment in patients with: (1) Non-ST elevation acute coronary syndrome(NSTE- ACS, (2) continuing or frequently recurring ischemia and are unable to use beta-blockers (e.g., contraindication, suffered from unacceptable adverse effects, beta-blockers were insufficient for treatment). • 33. Question Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis? o A. Avoid exercise because it fatigues the joints. P a g e 52 | 124 o B. Take prescribed anti-inflammatory medications with meals. o C. Alternate hot and cold packs to affected joints. o D. Avoid weight-bearing activity. Correct Answer: B. Take prescribed anti-inflammatory medications with meals. Anti-inflammatory drugs should be taken with meals to avoid stomach upset. Disease- modifying, anti-rheumatic drugs (DMARDs) are initiated as soon as the diagnosis of rheumatoid arthritis is made. Traditional or conventional DMARD include methotrexate, leflunomide, sulfasalazine, hydroxychloroquine. Biologic DMARDs include TNF (tumor necrosis factor): Adalimumab, Etanercept, Infliximab, Golilumab, Certolizumab. And non-TNF inhibitors: Tocilizumab (Interleukin-6 inhibitor), Abatacept (inhibits T-cell costimulation), Rituximab (anti-B cell). o Option A: Clients with rheumatoid arthritis should exercise, but not to the point of pain. The patient should enroll in an exercise program to recover joint function. An occupational therapy consult can help the patient manage daily living activities. o Option C: Alternating hot and cold is not necessary, especially because warm, moist soaks are more useful in decreasing pain. Provide a variety of comfort measures (eg, application of heat or cold; massage, position changes, rest; foam mattress, supportive pillow, splints; relaxation techniques, diversional activities). o Option D: Weight-bearing activities such as walking are useful but are 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 P a g e 55 | 124 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 P a g e 56 | 124 side effects of LSD is the flashback. Flashbacks can be induced by stress or fatigue and by using other drugs. Often a flashback of a ―bad trip‖ can occur without warning, even if the patient was not currently under the influence of LSD. o Option D: They do produce psychological dependence rather than physical dependence. Daily ingestion is almost impossible because it produces an absurd ―good trip‖ or high, making abuse of LSD difficult. The dependence on LSD, therefore, is not from physical effects or cravings but psychological dependence or need. • 36. Question A patient arrives at the emergency department complaining of midsternal chest pain. Which of the following nursing actions should take priority? o A. A complete history with emphasis on preceding events. o B. An electrocardiogram. o C. Careful assessment of vital signs. o D. Chest exam with auscultation. P a g e 57 | 124 Correct Answer: C. Careful assessment of vital signs. The priority nursing action for a patient arriving at the ED in distress is always an assessment of vital signs. This indicates the extent of the physical compromise and provides a baseline by which to plan further assessment and treatment. Monitor vital signs every 5 min during the initial anginal attack. Blood pressure may initially rise because of sympathetic stimulation, then fall if cardiac output is compromised. Tachycardia also develops in response to sympathetic stimulation and may be sustained as a compensatory response if cardiac output falls. o Option A: A thorough medical history, including the onset of symptoms, will be necessary. Identify precipitating events, if any: frequency, duration, intensity, and location of the pain. Helps differentiate this chest pain, and aids in evaluating possible progression to unstable angina. o Option B: It is likely that an electrocardiogram will be performed as well, but this is not the first priority. Monitor heart rate and rhythm. Patients with unstable angina have an increased risk of acute life-threatening dysrhythmias, which occur in response to ischemic changes and/or stress. o Option D: Similarly, chest exams with auscultation may offer useful information after vital signs are assessed. Observe for associated symptoms: dyspnea, nausea, and vomiting, dizziness, palpitations, desire to micturate. Decreased cardiac output (which may occur during an ischemic myocardial episodes) stimulates sympathetic and parasympathetic nervous systems, causing a variety of vague sensations that the patient may not identify as related to the anginal episode. • 37. Question P a g e 60 | 124 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 charge nurse 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. P a g e 61 | 124 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. The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. o Option B: A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. Nurse- patient assignments are typically allocated based on estimated direct patient care requirements with little consideration for other activities that must be completed throughout a shift. In an effort to improve upon previous assignment methodologies, new measures and metrics were considered in this study to reduce and balance demands placed on nurses through the assignment of P a g e 62 | 124 required activities. o Option C: The unstable patient requires staff that can immediately identify symptoms and respond appropriately. In most hospitals, a unit charge nurse is responsible for the shift assignment of patients to nurses based on experience and past practices. The nurse-patient assignment process is also often a manual process in which the charge nurse must sort through multiple decision criteria in a limited amount of time. o Option D: A postoperative patient also requires close monitoring and cardiac experience. Balancing workload among nurses on a hospital unit is important for the satisfaction and safety of nurses and patients. To balance nurse workloads, direct patient care activities, indirect patient care activities, and non- patient care activities that occur throughout a shift must be considered. • 40. Question A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct? o A. Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after injection. P a g e 65 | 124 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? o A. 15 mcg/mL. o B. 4 mcg/mL. o C. 10 mcg/dL. o D. 5 mcg/dL. • 43. Question P a g e 66 | 124 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 Option A: Tinnitus is associated with aspirin overdose, not acetaminophen. Acetaminophen has an elimination half-life of 2 hours, but can be as long as 17 hours in patients with hepatic dysfunction. It is metabolized by the liver, where it is conjugated to nontoxic, water-soluble metabolites that are excreted in the urine. P a g e 67 | 124 o Option B: In the third stage (72 hours to 96 hours), liver dysfunction is significant with renal failure, coagulopathies, metabolic acidosis, and encephalopathy. Gastrointestinal (GI) symptoms reappear, and death is most common at this stage. The fourth stage (4 days to 3 weeks) is marked by recovery. o Option C: Diarrhea and hypertension are not associated with acetaminophen. The diagnosis of acetaminophen toxicity is based on serum levels of the drug, even if there are no symptoms. Other laboratory studies needed include liver function tests (LFTs) and coagulation profile (PT/INR). If the ingestion is severe, LFTs can rise within 8 to 12 hours of ingestion. Normally LFTS remain elevated in the second stage at 18 to 72 hours. • 44. Question A nurse is caring for a cancer patient receiving subcutaneous morphine sulfate for pain. Which of the following nursing actions is most important in the care of this patient? o A. Monitor urine output o B. Monitor respiratory rate o C. Monitor heart rate P a g e 70 | 124 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. P a g e 71 | 124 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 P a g e 72 | 124 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). • 47. Question A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient? o A. The patient is allergic to shellfish. o B. The patient has a pacemaker. o C. The patient suffers from claustrophobia. o D. The patient takes antipsychotic medication. P a g e 75 | 124 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. P a g e 76 | 124 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 P a g e 77 | 124 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. 9 A. Monitor for fever every 4 hours. P a g e 80 | 124 o Option C: Transfusion of red cells is indicated for severe anemia. Prehospital care focuses on the ABCs (airway, breathing, circulation), which include providing oxygen, controlling severe hemorrhage, and initiating intravenous (IV) fluids to maintain hemodynamic stability; airway control may be necessary for a large intracranial hemorrhage. • 51. Question A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family me mbers about infectious precautions. Which of the following statements by family members in dicates that the family needs more education? o A. We will bring in books and magazines for entertainment. o B. We will bring in personal care items for comfort. o C. We will bring in fresh flowers to brighten the room. o D. We will bring in family pictures and get well cards. P a g e 81 | 124 Correct Answer: C. We will bring in fresh flowers to brighten the room. 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. P a g e 82 | 124 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. P a g e 85 | 124 o Option D: Weight loss occurs early in the disease. Four features characterize Hodgkin lymphomas. They commonly arise in the cervical lymph nodes; the disease is more common in young adults; there are scattered large mononuclear Hodgkin and multinucleated cells (Reed-Sternberg) intermixed in a background of a mixture of non-neoplastic inflammatory cells; finally, T lymphocytes are often observed surrounding the characteristic neoplastic cells. • 54. Question The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find? 13 A. Reed-Sternberg cells. o B. Lymphoblastic cells. 13 D. Rieder's cells Correct Answer: A. Reed-Sternberg cells A definitive diagnosis of Hodgkin’s disease is made if Reed- Sternberg cells are found on pathologic examination of the excised lymph node. Four features characterize Hodgkin lymphomas. They commonly arise in the cervical lymph nodes; the disease is more common in young adults; there are scattered large mononuclear Hodgkin and multinucleated cells (Reed- Sternberg) intermixed in a background of a mixture of non- neoplastic inflammatory cells; finally, T lymphocytes are often observed surrounding the characteristic neoplastic cells. o Option B: Lymphoblasts are immature cells found in the bone marrow of patients with acute lymphoblastic leukemia. Lymphoblast is an immature white blood cell that gives rise to a type of immune cell known as a lymphocyte. The nucleus contains moderately fine chromatin (readily stainable nuclear material) and has P a g e 86 | 124 o C. Gaucher's cells. P a g e 87 | 124 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 P a g e 90 | 124 • 57. Question The mother of a 14-month-old child reports to the nurse that her child will not fall asleep at night without a bottle of milk in the crib and often wakes during the night asking for another. Which of the following instructions by the nurse is correct? o A. Allow the child to have the bottle at bedtime, but withhold the one later in the night. o B. Put juice in the bottle instead of milk. o C. Give only a bottle of water at bedtime. o D. Do not allow bottles in the crib. P a g e 91 | 124 Correct Answer: C. Give only a bottle of water at bedtime. Babies and toddlers should not fall asleep with bottles containing liquid other than plain water due to the risk of dental decay. Wean one ounce a night. Let’s say the child takes three 4 oz bottles a night. Take the last bottle and reduce it by an oz on night one. On night 2, reduce bottle 2 by 1 oz. On night 3 reduce Bottle #1 by 1 oz. When a bottle gets down to 2 oz, substitute a bottle of water. After this step, get rid of the bottle. Don’t ever wake up the child if they sleep through a feeding– that is the goal. o Option A: If they skip a feeding one night but wake up the following night for that feeding, it is OK to give them the scheduled bottle. Limit the water bottles to 2 oz, simply to reduce the amount of urine produced and wet diapers to deal with. If the child doesn’t want the water, that is fine. But don’t give in and give the milk. o Option B: Sugars in juice remain in the mouth during sleep and cause caries, even in teeth that have not yet erupted. Make slow incremental changes over time. These changes are relatively easy to make and the child will tolerate them well. o Option D: The child could have a bottle of water in the crib with close supervision. Bottle fed infants typically can wean off night feeding by 6 months of age. Breast fed infants tend to take longer, up to a year of age. The American Academy of Pediatrics recommends exclusive breastfeeding for six months, with the addition of complementary foods continuing up to a year, or longer “as desired by mother and infant”. It’s important to note that night weaning can lead to weaning altogether. • 58. Question Which of the following actions is not appropriate in the care of a 2-month-old infant? P a g e 92 | 124 o A. Place the infant on her back for naps and bedtime. 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 P a g e 95 | 124 not contraindicated medically. Sufficient fluid is needed to keep the fecal mass soft. But take note of some patients or older patients having cardiovascular limitations requiring less fluid intake. o Option C: Assist the patient to take at least 20 g of dietary fiber (e.g. raw fruits, fresh vegetable, whole grains) per day. Fiber adds bulk to the stool and makes defecation easier because it passes through the intestine essentially unchanged. o Option D: Laxatives should be used as a last resort and should not be taken regularly. Over time, laxatives can desensitize the bowel and worsen constipation. The use of laxatives or enemas is indicated for short- term management of constipation. o Option E: Protein-rich foods could cause constipation. A balanced diet that comprises adequate fiber, fresh fruits, vegetables, and grains. Twenty grams of fiber per day is suggested. A regular period for elimination and an adequate time for defection. Successful bowel training relies on routine. Facilitating regular time prevents the bowel from emptying sporadically. • 60. Question A child is admitted to the hospital with suspected rheumatic fever. Which of the following observations is not confirming the diagnosis? P a g e 96 | 124 o A. A reddened rash visible over the trunk and extremities. o B. A history of sore throat that was self-limited in the past month. o C. A negative antistreptolysin O titer. o D. An unexplained fever. Correct Answer: C. A negative antistreptolysin O titer. Rheumatic fever is caused by an untreated group A B hemolytic Streptococcus infection in the previous 2-6 weeks, confirmed by a positive antistreptolysin O titer. ASO is a test used to detect streptococcal antibodies directed against streptococcal lysin O. An elevated titer is proof of a previous streptococcal infection. It is usually more elevated after a pharyngeal than skin infection, while the ADB is typically elevated regardless of the site of the infection. o Option A: Rheumatic fever is characterized by a red rash over the 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 P a g e 97 | 124 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.