NCLEX-RN Exam Pack Set 8 (75Questions & Answers With Explanations Updated2022), Exams of Nursing

Download NCLEX-RN Exam Pack Set 8 (75Questions & Answers With Explanations Updated2022) and more Exams Nursing in PDF only on Docsity! NCLEX-RN Exam Pack Set 8 (75 Questions & Answers With Explanations Updated 2022) 1.1. Question A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? o A. Sexual dysfunction related to radiation therapy o B. Anticipatory grieving related to terminal illness o C. Tissue integrity related to prolonged bed rest o D. Fatigue related to chemotherapy Correct Answer: A. Sexual dysfunction related to radiation therapy Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Know the importance of sex to individual, partner, and patient’s motivation for change. Because lymphomas often affect the relatively young who are in their productive years, these people may be affected more by these problems and may be less knowledgeable about the possibilities of change. o Option B: Grieving may not be an appropriate diagnosis since the client would be experiencing new milestones in his life despite his condition. Let the patient describe the problem in own words. Provides a more accurate picture of patient experience with which to develop a plan of care. o Option C: Option B is not applicable since the client is not on bed rest. Encourage the patient to share thoughts and concerns with his partner and to clarify values and impact of condition on relationship. Helps the couple begin to deal with issues that can strengthen or weaken the relationship. o Option D: Fatigue may occur during chemotherapy, but it is not the priority diagnosis. Identify pre-existing and current stress factors that may be affecting the relationship. The patient may be concerned about other issues, such as job, financial, and illness- related problems. 2. Question A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor: o A. Platelet count o B. White blood cell count o C. Potassium levels o D. Partial prothrombin time (PTT) Correct Answer: A. Platelet count Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. The laboratory tests will show low platelet count, usually <40×10^9/L for over three months. Blood film shows large platelets and tiny platelet fragments. Bone marrow examination shows an increased number of megakaryocytes. o Option B: Often associated with the CBC is a differential, which refers to the relative amounts of white blood cell types (i.e., neutrophil, lymphocyte, eosinophil, etc.) as a percentage of the total number of WBCs. Of note, if a subtype of white blood cells seems to be elevated based on the differential, the actual value of the type of white blood cells should be calculated by multiplying the percentage listed on the differential by the total number of white blood cells. o Option A: Placing the patient in Trendelenburg will increase the intracranial pressure. The most common complications are CSF leak, sinusitis, and meningitis. CSF leaks, occurring in 6 in every 100 cases, is usually prevented by a multilayer closure at the end of surgery. In the occurrence of a leak in the postoperative period, the patient is advised bed rest, and a lumbar drain is placed. If the leak does not improve in 24 hours, exploration and closure of the defect are to be done. o Option B: Coughing and deep breathing causes increase in intracranial pressure. Worsening of vision as a result of bleeding or manipulation and arterial hemorrhage are other immediate complications. A detailed study of preoperative imaging is essential to avoid catastrophes like optic nerve and carotid artery injury. o Option D: Valsalva maneuver increases the intracranial pressure. The first follow up visit is 1 week after the procedure, where postoperative day 7 serum sodium levels are reviewed to rule out occult hyponatremia. Serial nasal endoscopies are done for debridement and to assess healing. The frequency of follow-up visits is determined by nasal crusting and maintenance of nasal hygiene with irrigation. Routine early postoperative imaging is not done in most patients. 5. Question The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: o A. Measure the urinary output B. Check the vital signs o C. Encourage increased fluid intake o D. Weigh the client Correct Answer: B. Check the vital signs A large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Monitor for signs of hypovolemic shock (e.g., tachycardia, tachypnea, hypotension). Frequent assessment can detect changes early for rapid intervention. Polyuria causes decreased circulatory blood volume. o Option A: Measuring the urinary output is important, but the stem already says that the client has polyuria. Monitor intake and output. Report urine volume greater than 200 mL for each of 2 consecutive hours or 500 mL in a 2-hour period. With DI, the patient voids large urine volumes independent of the fluid intake. Urine output ranges from 2 to 3 L/day with renal DI to greater than 10 L/day with central DI. o Option C: Encouraging fluid intake will not correct the problem. Allow the patient to drink water at will. Patients with intact thirst mechanisms may maintain fluid balance by drinking huge quantities of water to compensate for the amount they urinate. Patients prefer cold or ice water. o Option D: Weighing the client is not necessary at this time. Monitor serum and urine osmolality. Urine osmolality will be decreased and serum osmolality will increase. Monitor urine-specific gravity. This may be 1.005 or less. 6. Question A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding? o A. Place the client in a sitting position with the head hyperextended B. Pack the nares tightly with gauze to apply pressure to the source of bleeding o C. Pinch the soft lower part of the nose for a minimum of 5 minutes o D. Apply ice packs to the forehead and back of the neck Correct Answer: C. Pinch the soft lower part of the nose for a minimum of 5 minutes The client should be positioned upright and leaning forward, to prevent aspiration of blood. Usual sites of external bleeding may include the bleeding in the mouth from a cut, bite, or from cutting or losing a tooth; nosebleeds for no obvious reasons; heavy bleeding from a minor cut, or bleeding from a cut that resumes after stopping for a short time. Hemophiliacs do not bleed faster or more frequently. Instead, they bleed longer due to a deficiency of clotting factor. Clients are often aware of bleeding before clinical manifestation. Bleeding can be life-threatening to these clients. o Option A: Direct pressure to the nose stops the bleeding. Apply manual or mechanical pressure if active bleeding is noted. If spontaneous or traumatic bleeding is evident, monitor vital signs. o Option B: If a pack is necessary, the nares are loosely packed. Controlling bleeding is a nursing priority. Nasal packing should be avoided, because the subsequent removal of the packing may precipitate further bleeding. o Option D: Ice packs should be applied directly to the nose as well. Assess for any signs of bruising and bleeding (note the extent of bleeding). Assess for prolonged bleeding after minor injuries. 7. Question A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is: o A. Blood pressure 8. Question A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu- Medrol). Which of the following interventions would the nurse implement? o A. Daily weights o B. Intake/output measurements o C. Sodium and potassium levels monitored o D. Glucometer readings as ordered Correct Answer: D. Glucometer readings as ordered IV glucocorticoids raise the glucose levels and often require coverage with insulin. Cortisone and prednisone replace cortisol deficits, which will promote sodium reabsorption. Fludrocortisone is a mineralocorticoid for patients who require aldosterone replacement to promote sodium and water replacement. Acute adrenal insufficiency is a medical emergency requiring immediate fluid and corticosteroid administration. If treated for adrenal crisis, the patient requires IV hydrocortisone initially; usually by the second day, administration can be converted to an oral form of replacement. o Option A: Daily weights are unnecessary. Monitor trends in weight. This provides documentation of weight loss trends. Weight loss is a common manifestation of adrenal insufficiency. o Option B: Intake/output measurements are not necessary at this time. Assess vital signs, especially noting BP and HR for orthostatic changes. A BP drop of more than 15 mm Hg when changing from supine to sitting position, with a concurrent elevation of 15 beats per min in HR, indicates reduced circulating fluids. o Option C: Sodium and potassium levels would be monitored when the client is receiving mineralocorticoids. Abnormal laboratory findings include hyperkalemia (related to aldosterone deficiency and decreased renal perfusion), hyponatremia (related to decreased aldosterone and impaired free water clearance), and increase in blood urea nitrogen (related to decreased glomerular filtration from ). 9. Question A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurse’s next action be? o A. Obtain a crash cart o B. Check the calcium level o C. Assess the dressing for drainage o D. Assess the blood pressure for hypertension Correct Answer: B. Check the calcium level The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. Evaluate reflexes periodically. Observe for neuromuscular irritability: twitching, numbness, paresthesias, positive Chvostek’s and Trousseau’s signs, seizure activity. o Option A: The crash cart would be needed in respiratory distress but would not be the next action to take. Hypocalcemia with tetany (usually transient) may occur 1–7 days postoperatively and indicates hypoparathyroidism, which can occur as a result of inadvertent trauma to or partial-to-total removal of the parathyroid gland(s) during surgery. o Option C: The drainage would occur in hemorrhage. Check dressing frequently, especially the posterior portion. If bleeding occurs, the anterior dressing may appear dry because blood pools dependently. o Option D: Hypertension occurs in a thyroid storm. Monitor vital signs noting elevated temperature, tachycardia, arrhythmias, respiratory distress, cyanosis. Manipulation of the gland during subtotal thyroidectomy may result in increased hormone release, causing thyroid storm. 10. Question A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority? o A. Impaired physical mobility related to decreased endurance o B. Hypothermia r/t decreased metabolic rate o C. Disturbed thought processes r/t interstitial edema o D. Decreased cardiac output r/t bradycardia Correct Answer: D. Decreased cardiac output r/t bradycardia The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices. Protect against coldness. Provide extra layers of clothing or extra blankets. Discourage and avoid the use of external heat sources. Monitor patient’s body temperature. o Option A: Impaired physical mobility is not applicable to a client with hypothyroidism. Promote rest. Space activities to promote rest and exercise as tolerated. Assess the client’s ability to perform activities of daily living (ADLs). The client may experience fatigue with minimal exertion due to a slow metabolic rate. This symptom hinder the client’s ability to perform daily activities (e.g., self-care, eating) o Option B: Hypothermia is correct but not a priority. Teach the expected benefits and possible side effects. The client should report symptoms such as chest pain/palpitations; these happen due to the increased metabolic and oxygen consumption. o Option C: Disturbed thought processes is not a related diagnosis. Assess the client’s appetite. Clients with hypothyroidism have decreased appetite. This opposite relationship between weight gain and decreased appetite is a manifestation found in hypothyroidism. o Option A: Wear personal protective equipment (PPE) properly. Wear gloves when providing direct care; perform hand hygiene after properly disposing of gloves. Initiate specific precautions for suspected agents as determined by CDC protocol. o Option B: Use masks, goggles, face shields to protect the mucous membranes of your eyes, mouth, and nose during procedures and in direct-care activities (e.g., suctioning secretions) that may generate splashes or sprays of blood, body fluids, secretions, and excretions. o Option C: The health care workers indicate knowledge of infection control by their actions. Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another. Wash hands with antiseptic soap and water for at least 15 seconds followed by an alcoholbased hand rub. If hands were not in contact with anyone or anything in the room, use an alcohol-based hand rub and rub until dry. Plain soap is good at reducing bacterial counts but antimicrobial soap is better, and alcohol-based hand rubs are the best. 13. Question The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective? o A. The client loses consciousness. o B. The client vomits. o C. The client’s ECG indicates tachycardia. o D. The client has a grand mal seizure. Correct Answer: D. The client has a grand mal seizure. During ECT, the client will have a grand mal seizure. This indicates completion of electroconvulsive therapy. Seizure threshold is established via trial and error via incrementally higher doses of current during the primary treatment session. Following initial dose calculation, the dose at subsequent ECT sessions for bilateral ECT is 1.5 to 2 times seizure threshold, and for right unilateral is six times the seizure threshold. During the course of ECT treatment, the seizure threshold commonly increases as the patient develops tolerance. o Option A: Once the patient is rendered unconscious, administration of a muscle relaxant follows, along with bag valve mask ventilation with 100 percent oxygen. A nerve stimulator is utilized to determine the adequacy of muscle relaxation along with the clinical assessment of plantar reflexes and fasciculations in the calves and left foot. o Option B: Physiologically, during the tonic phase of the seizure, a 15- to 20-second parasympathetic discharge occurs, which can lead to bradyarrhythmias including premature atrial and ventricular contractions, atrioventricular block, and asystole. Patients with sub convulsive seizures are at higher risk for asystole. o Option C: Paradoxically, patients with heart block or underlying arrhythmias are less likely to develop asystole. The clonic phase of the seizure correlates with a catecholamine surge that causes tachycardia and hypertension, which lasts temporally with seizure duration. Hypertension and tachycardia resolve within 10 to 20 minutes of the seizure, although some patients exhibit persistent hypertension that requires medical intervention. 14. Question The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to: o A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep o B. Scrape the skin with a piece of cardboard and bring it to the clinic o C. Obtain a stool specimen in the afternoon o D. Bring a hair sample to the clinic for evaluation Correct Answer: A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. o Option B: Pinworms do not burrow under the skin, therefore scraping the skin for examination would not reveal pinworms. Enterobius can be diagnosed through a cellophane tape test or pinworm paddle test where an adhesive tape-like material is applied to the perianal area and then examined under a microscope. o Option C: Pinworms are not usually detected in stools. Stool examination is not helpful in the diagnosis of E. vermicularis as they are only occasionally excreted in the stool usually. Sometimes analysis of the stool specimen is recommended to rule out other causes. o Option D: Taking a hair sample is inappropriate because pinworms do not live in hair. The examination might reveal characteristic ova which are 50 by 30 microns in size and have a flattened surface on one side or may reveal the worms. Female worms are around 8 to 13 mm long while male worms are 2 to 5 mm long. The examination is usually done in the early morning for higher diagnostic yield. 15. Question The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication? o Option D: Radioactive seed implants are a form of radiation therapy for prostate cancer. Permanent radioactive seed implants are a form of radiation therapy for prostate cancer. The terms “brachytherapy” or “internal radiation therapy” might also be used to describe this procedure. During the procedure, radioactive (iodine-125 or I-125) seeds are implanted into the prostate gland using ultrasound guidance. 17. Question The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? o A. The client with Cushing’s disease o B. The client with diabetes o C. The client with acromegaly o D. The client with myxedema Correct Answer: A. The client with Cushing’s disease The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immunosuppressed. High cortisol levels also cause immune disruptions; this hormone leads to a decrease in lymphocyte levels and increases the neutrophils. It causes detachment of the marginating pool of neutrophils in the bloodstream and increases the circulating neutrophil levels although there is no increased production of the neutrophils. o Option B: The client with diabetes poses no risk to other clients. Hyperglycemia alone can impair pancreatic beta-cell function and contributes to impaired insulin secretion. Consequently, there is a vicious cycle of hyperglycemia leading to the impaired metabolic state. Blood glucose levels above 180 mg/dL are often considered hyperglycemic in this context, though because of the variety of mechanisms, there is no clear cutoff point. o Option C: The client has an increase in growth hormone and poses no risk to himself or others. The common effect of the abnormal rise in growth hormone is the production of IGF-1 from the liver. The effect of IGF-1 on body tissues results in the multisystemic manifestation of acromegaly. IGF-1 also known as somatomedin C, is encoded by the IGF-1 gene on chromosome 12q23.2. o Option D: The client has hypothyroidism or myxedema and poses no risk to others or himself. Thyroid hormone influences virtually all cells in the body by activating or repressing a variety of genes after binding to thyroid hormone receptors. Ninety percent of the intracellular thyroid hormone that binds to and influences cellular function is T3, which has been converted from T4 by the removal of an iodide ion. 18. Question The nurse caring for a client in the neonatal intensive care unit administers adult- strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with: o A. Negligence o B. Tort o C. Assault o D. Malpractice Correct Answer: D. Malpractice The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. In the United States, a patient may allege medical malpractice against a clinician, which is typically defined by the failure the provide the degree of care another clinician in the same position with the same credentials would have performed that resulted in injury to the patient. o Option A: Negligence is failing to perform care for the client. a tort is a wrongful act committed. Negligence, in law, the failure to meet a standard of behaviour established to protect society against unreasonable risk. Negligence is the cornerstone of tort liability and a key factor in most personal injury and propertydamage trials. o Option B: A tort is a wrongful act committed on the client or their belongings. A tort is a civil wrong that causes harm to another person by violating a protected right. A civil wrong is an act or omission that is intentional, accidental, or negligent, other than a breach of contract. The specific rights protected give rise to the unique “elements” of each tort. Tort requires the presence of four elements that are the essential facts required to prove a civil wrong. o Option C: Assault is a violent physical or verbal attack. Assault is the intentional act of making someone fear that you will cause them harm. You do not have to actually harm them to commit assault. Threatening them verbally or pretending to hit them are both examples of assault that can occur in a nursing home. 19. Question Which assignment should not be performed by the licensed practical nurse? o A. Inserting a Foley catheter o B. Discontinuing a nasogastric tube o C. Obtaining a sputum specimen o D. Starting a blood transfusion Correct Answer: D. Starting a blood transfusion The licensed practical nurse should not be assigned to begin a blood transfusion. An LPN works under the supervision of doctors and RNs, performing duties such as taking vital signs, collecting samples, administering medication, ensuring patient comfort, and reporting the status of their patients to the nurses. o C. The RN with 10 years of experience in surgery o D. The RN with 1 year of experience in the neonatal intensive care unit Correct Answer: B. The RN with 3 years of experience in labor and delivery The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. Registered nurses need to know their rights and responsibilities when considering a patient assignment. 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 A: The nurse is a new staff to the unit hence lacking the experience needed. Most nurse-patient assignment models have focused on balancing patient acuity measures. This focus on patient acuity concentrates workload measures on direct patient care activities. While this is very important for the care of the patient, it does not necessarily take into account all of the activities comprising a nurse’s workload. o Option C: The nurse with experience in surgery does not have the same experience in labor and delivery. 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 nonpatient care activities that occur throughout a shift must be considered. o Option D: This nurse lacks sufficient experience with a postpartum client. Limitations in experience and knowledge may not require refusal of the assignment, but rather an agreement regarding supervision or a modification of the assignment to ensure patient safety. If no accommodation for limitations is considered, the nurse has an obligation to refuse an assignment for which she or he lacks education or experience. 22. Question Which information should be reported to the state Board of Nursing? o A. The facility fails to provide literature in both Spanish and English. o B. The narcotic count has been on the unit for the past 3 days. o C. The client fails to receive an itemized account of his bills and services received during his hospital stay. o D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath. Correct Answer: B. The narcotic count has been on the unit for the past 3 days. General advice from the Department of Health is that stocks of controlled drugs should be kept to the minimum required to meet the clinical needs of patients. They should be stored securely in a locked cabinet or safe to prevent unauthorised access, with the keys held in a safe place. o Option A: The Joint Commission conducts inspections with two main objectives: To evaluate the healthcare organization using TJC performance measures and standards. To educate and guide the organization’s staff in “good practices” to help improve the organization’s performance. o Option C: The Joint Commission on Accreditation of Hospitals will probably be interested in the problem in answer A. The Joint Commission offers many benefits to their members. They help members organize and strengthen their patient improvement programs and safety efforts. They raise health care consumer and community confidence in the quality of the organization’s care, services and treatment. This provides a competitive edge in the healthcare industry and a proven framework for organizational management. The Joint Commission helps to reduce risk management, liability insurance, and employee turnover costs. o Option D: The failure of the nursing assistant to care for the client with hepatitis might result in termination but is not of interest to the Joint Commission. The Joint Commission monitors and advocates for legislation that promotes better patient safety. When it comes to state legislation, The Joint Commission collaborates with patient safety authorities and state regulatory bodies to minimize unrealistic expectations and reform outdated rules. They push state regulatory bodies to rely more on private accreditation instead of mandatory state licensure inspections. 23. Question The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should: o A. Call the Board of Nursing o B. File a formal reprimand o C. Terminate the nurse o D. Charge the nurse with a tort Correct Answer: B. File a formal reprimand The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. As a rule of thumb, nurses should avoid making assumptions when they notice gaps or missing information in a patient’s treatment documentation. Healthcare professionals have exceedingly demanding schedules, but it’s always better to take the time and double-check the details than to make assumptions and be wrong. o Option A: If the behavior continues, the nurse should be reported to the Board of Nursing. Understanding these realities can add hours to the day, so the practical approach is to be strategic with efforts. Look for efficiency, work with colleagues, and use best judgment and ingenuity to find ways to get everything done while still doing it right. It’s not easy, but it’s also not impossible. o A. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis o B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm o C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury o D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain Correct Answer: B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. Cohorting of patients according to the presence or absence of specific pathogens coupled with conventional hygienic precautions can lead to a decrease in incidence and prevalence of chronic infections with these two species, wherefore patient cohorting is now an integral component of infection control in patients. o Option A: Schizophrenia is a brain disorder that probably comprises multiple etiologies. The hallmark symptom of schizophrenia is psychosis, such as experiencing auditory hallucinations (voices) and delusions (fixed false beliefs). Impaired cognition or a disturbance in information processing is an underappreciated symptom that interferes with dayto-day life. Hospitalizations are usually brief and are typically oriented towards crisis management or symptom stabilization. o Option C: The goals of care are for the child and their loved ones are to be free of complicated grieving and to have access to adequate resources to allow for the natural grieving process. It is important for them to verbalize and express their true feelings and seek the help and support of others. Having privacy from other patients would be most appropriate. o Option D: This group of clients needs to be placed in separate rooms due to the serious nature of their injuries. The client with chest pain should be placed in a private room to allow him to rest. Promote expression of feelings and fears. Let the patient/SO know these are normal reactions. Verbalization of concerns reduces tension, verifies the level of coping, and facilitates dealing with feelings. The presence of negative self-talk can increase the level of anxiety and may contribute to the exacerbation of angina attacks. 26. Question The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eye drops, the nurse should recognize that it is essential to consider which of the following? o A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops. o B. The child should be allowed to instill his own eye drops. o C. The mother should be allowed to instill the eyedrops. o D. If the eye is clear from any redness or edema, the eye drops should be held. Correct Answer: A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops. Before instilling eye drops, the nurse should cleanse the area with water. Cleanse the eyelids and lashes with cotton balls or gauze pledgets moistened with normal saline or water. This prevents debris to be carried into the eye when the conjunctival sac is exposed. o Option B: A 6-year-old child is not developmentally ready to instill his own eye drops. An ophthalmic assistant, technician, nurse or physician instills eye drops during a routine eye examination or during treatment for ocular disease. o Option C: Although the mother of the child can instill the eye drops, the area must be cleansed before administration. Use each cotton ball or pledget for only one stroke, moving from the inner to the outer canthus of the eye. o Option D: Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered, so answer D is . Allow the prescribed number of drops to fall in the lower conjunctival sac but do not allow to fall onto the cornea. Release the lower lid after the drops are instilled. Instruct the patient to close eyes slowly, move the eye and not to squeeze or rub. 27. Question The nurse is discussing meal planning with the mother of a 2year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction? o A. "It is okay to give my child white grape juice for breakfast." o B. "My child can have a grilled cheese sandwich for lunch." o C. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch." o D. "For a snack, my child can have ice cream." Correct Answer: C. “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.” Remember the ABCs (airway, breathing, circulation) when answering this question. A hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. It is important to avoid foods that may cause choking like slippery foods such as whole grapes; large pieces of meat, poultry, and hot dogs; candy, and cough drops. o Option A: A white grape juice does not pose a risk for aspiration. The toddler years are full of exploring and discovery. The best thing you can do is offer your toddler a variety of foods from each food group with different tastes, textures, and colors. The hearing aid should be stored in a warm, dry place. Proper maintenance and care will extend the life of your hearing aid. Make it a habit to keep hearing aids away from heat and moisture. Avoid using hairspray or other hair care products while wearing hearing aids. When it’s exposed to moisture it can cause serious damage. Although hearing aids are now being made to be water resistant it’s recommended that they are removed when showering or swimming. If they do come in contact with water, dry them immediately with a towel. Never attempt to dry them with a hair drier or other heated device, since the high heat can damage them. o Option A: It should be cleaned daily but should not be moldy. Clean hearing aids as instructed. Earwax and ear drainage can damage a hearing aid. Turn off hearing aids when they are not in use. Always take the hearing aids out before having a shower, taking a bath or going swimming. It’s best to leave the hearing aids out of humid environments like the bathroom, as moisture can damage the electronic components in the hearing aid. o Option C: A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aid. A whistling sound can be caused by a hearing aid that does not fit or work well or is clogged by earwax or fluid. When cleaning your hearing aids, use a dry, soft cloth. Hearing aid care products are available through audiologists and audiometrists. They will also check for ear wax build up and the general working order of the hearing aid. o Option D: Changing the batteries weekly is not necessary. Replace dead batteries immediately. Keep replacement batteries and small aids away from children and pets. Also when changing out batteries, remember to clean the battery contacts in the devices. This can be done by gently wiping them down with a dry cotton swab. If the battery contacts on the devices are dirty, it can create a poor connection and lower performance. 30. Question A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: o A. Body image disturbance o B. Impaired verbal communication o C. Risk for aspiration o D. Pain Correct Answer: C. Risk for aspiration Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Place the child prone or side-lying position. Promotes drainage of blood and unswallowed saliva from the mouth that can potentially be aspirated. o Option A: Does not apply for a child who has undergone a tonsillectomy. Assess for signs and symptoms of inadequate oxygenation. Early signs of hypoxia include confusion, irritability, headaches, pallor, tachycardia, and tachypnea. o Option B: Observe the child for nonverbal indications of pain such as crying, grimacing, irritability. Provides additional information about pain. The child may find discomfort in speaking. o Option D: Although these nursing diagnoses might be appropriate for this child, risk for aspiration should have the highest priority. Apply an ice collar on the neck or encourage the child to eat popsicles. Cold promotes vasoconstriction and decreases swelling that contributes to pain. 31. Question A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal? o A. High fever o B. Nonproductive cough C. Rhinitis D. Vomiting and diarrhea Correct Answer: A. High fever If the child has bacterial pneumonia, a high fever is usually present. Increased temperature (usually more than 38 C or 100.4 F) or fever with tachycardia and/or chills and sweats is a major clinical finding. Physical findings also vary from patient to patient and mainly depend on the severity of lung consolidation, the type of organism, the extent of the infection, host factors, and existence or nonexistence of pleural effusion. o Option B: Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough. The presence of a productive cough is the most common and significant presenting symptom. The lower respiratory tract is not sterile, and it always is exposed to environmental pathogens. Invasion and propagation of the above- mentioned bacteria into lung parenchyma at alveolar level causes bacterial pneumonia, and the body’s inflammatory response against it causes the clinical syndrome of pneumonia. o Option C: Rhinitis is often seen with viral pneumonia. Features in the history of bacterial pneumonia may vary from indolent to fulminant. Clinical manifestation includes both constitutional findings and findings due to damage to the lung and related tissue. o Option D: Vomiting and diarrhea are usually not seen with pneumonia. Atypical pneumonia presents with pulmonary and extrapulmonary manifestations, such as Legionella pneumonia, often presents with altered mentation and gastrointestinal symptoms. 32. Question The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available? o A. Intravenous access supplies o A. Ham sandwich on whole-wheat toast o B. Spaghetti and meatballs o C. Hamburger with ketchup o D. Cheese omelet Correct Answer: D. Cheese omelet The child with celiac disease should be on a gluten-free diet. When a child has celiac disease, gluten causes the immune system to damage or destroy villi. Villi are the tiny, fingerlike tubules that line the small intestine. The villi’s job is to get food nutrients to the blood through the walls of the small intestine. If villi are destroyed, the child may become malnourished, no matter how much he eats. This is because they aren’t able to absorb nutrients. Complications of the disorder include anemia, seizures, joint pain, thinning bones, and cancer. o Option A: Be careful of corn and rice products. These don’t contain gluten, but they can sometimes be contaminated with wheat gluten if they’re produced in factories that also manufacture wheat products. Look for such a warning on the package label. o Option B: Avoid all products with barley, rye, triticale (a cross between wheat and rye), farina, graham flour, semolina, and any other kind of flour, including selfrising and durum, not labeled gluten-free. o Option C: Substitute potato, rice, soy, amaranth, quinoa, buckwheat, or bean flour for wheat flour. You can also use sorghum, chickpea or Bengal gram, arrowroot, and corn flour, as well as tapioca starch extract. These act as thickeners and leavening agents. 35. Question The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first? A. Notify the physician B. Recheck the O2 saturation level in 15 minutes C. Apply oxygen by masko D. Assess the pulse Correct Answer: C. Apply oxygen by mask Remember the ABCs (airway, breathing, circulation) when answering this question. Administer oxygen first to increase the O2 saturation level. Provide humidified oxygen as ordered. Administering humidified oxygen prevents drying out the airways, decreases convective moisture losses, and improves compliance. o Option A: Monitor vital signs and cardiac rhythm. Tachycardia, dysrhythmias, and changes in BP can reflect the effect of systemic hypoxemia on cardiac function. Auscultate breath sounds, noting areas of decreased airflow and adventitious sounds. Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm or retained secretions. Scattered moist crackles may indicate interstitial fluid or cardiac decompensation. o Option B: The normal oxygen saturation for a child is 92%–100%. Monitor O2 saturation and titrate oxygen to maintain Sp02 between 88% to 92%. Pulse oximetry reading of 87% below may indicate the need for oxygen administration while a pulse oximetry reading of 92% or higher may require oxygen titration. o Option D: Before assessing the pulse, oxygen should be applied to increase the oxygen saturation. Monitor vital signs and cardiac rhythm. Tachycardia, dysrhythmias, and changes in BP can reflect the effect of systemic hypoxemia on cardiac function. 36. Question A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy? A. Fetal heart tones 160bpm B. A moderate amount of straw-colored fluid C. A small amount of greenish fluido D. A small segment of the umbilical cord Correct Answer: B. A moderate amount of straw-colored fluid An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Successful rupture of membranes most commonly is determined by the immediate return of amniotic fluid from the vagina. This fluid usually is clear and odorless. o Option A: Fetal heart tones of 160 indicate tachycardia. Monitoring of the fetal heart rate as well as uterine activity can be easily obtained via external monitoring systems. However, in certain circumstances, more direct evaluation of the fetal heart rate or uterine activity is required during labor. o Option C: Greenish fluid is indicative of meconium. In certain circumstances, the fluid may either contain meconium or may be blood-tinged. It is important to note the color of the fluid at the time of rupture. o Option D: If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord and would need to be reported immediately. Typically, following artificial rupture of membranes, the practitioner should not immediately remove their hand from the vagina because it is at this point that the highest risk of potential cord prolapse can occur and will be noted as the amniotic fluid continues to drain. After the immediate flow of amniotic fluid ceases, and there is no palpable cord in the vagina, the vaginal hand then can be removed. 37. Question The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make? A. "We have a name picked out for the baby." B. "I need to push when I have a contraction." emergency cesarean section. Emergency cesarean section should be performed within 5 to 30 minutes depending on the circumstances. 39. Question In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect: o A. A painless delivery o B. Cervical effacement o C. Infrequent contractions o D. Progressive cervical dilation Correct Answer: D. Progressive cervical dilation The expected effect of Pitocin is cervical dilation. Oxytocin is indicated and approved by the FDA for two specific time frames in the obstetric world: antepartum and postpartum. In the antepartum period, exogenous oxytocin is FDA-approved for strengthening uterine contractions with the aim of successful vaginal delivery of the fetus. o Option A: Pitocin causes more intense contractions, which can increase the pain. When oxytocin is released, it stimulates uterine contractions, and these uterine contractions, in turn, cause more oxytocin to be released; this is what causes the increase in both the intensity and frequency of contractions and enables a mother to carry out vaginal delivery completely. o Option B: Cervical effacement is caused by pressure on the presenting part. During the later stages of pregnancy, the fetus’s head drops into the pelvis, pushing it against the cervix. This process stretches the cervix, causing it to thin and shorten. Measurement of effacement is usually in percentages. For example, when the cervix is 100% effaced, it means that it is completely thinned and shortened. o Option C: Infrequent contractions is opposite the action of Pitocin. Exogenous oxytocin causes the same response in the female reproductive system as that of endogenous oxytocin. Both types of oxytocin stimulate uterine contractions in the myometrium by causing Gprotein coupled receptors to stimulate a rise in intracellular calcium in uterine myofibrils. 40. Question A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time? o A. Anticipate the need for a Caesarean section o B. Apply the fetal heart monitor o C. Place the client in Genupectoral position o D. Perform an ultrasound exam Correct Answer: B. Apply the fetal heart monitor Applying a fetal heart monitor is the correct action at this time. Fetal heart sounds are heard high in the abdomen in breech presentation. Be certain to monitor the FHR and uterine contractions continuously to detect fetal distress early and provide prompt intervention. o Option A: In a breech birth, the birth of the head is the most dangerous part because a loop of umbilical cord that has passed down alongside the head may be compressed. Intracranial hemorrhage is another danger of breech birth because of the pressure changes that has occurred spontaneously. There is no need to prepare for a Caesarean section because vaginal delivery is still possible. o Option C: It is unnecessary to place the client in Genupectoral position (knee-chest). An infant born from a frank breech position usually extends his or her legs continuously during the first 2 or 3 days of life, so be sure to point out to the parents that this is normal. o Option D: There is no need for an ultrasound based on the finding. An anesthesiologist and a pediatrician should be immediately available for all vaginal breech deliveries. A pediatrician is needed because of the higher prevalence of neonatal depression and the increased risk for unrecognized fetal anomalies. An anesthesiologist may be needed if intrapartum complications develop and the patient requires general anesthesia. 41. Question A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is: o A. The cervix is closed. o B. The membranes are still intact. o C. The fetal heart tones are within normal limits. o D. The contractions are intense enough for insertion of an internal monitor. Correct Answer: B. The membranes are still intact. The nurse decides to apply an external monitor because the membranes are intact. The test is used to determine if a fetus is at risk for intrauterine death or neonatal complications, usually secondary to high-risk pregnancies or suspected fetal hypoxemia. The frequency of use is based on clinical judgment, but is common because it is non-invasive and presents a low maternal and fetal risk; however, the test does not hold predictive value and only indicates fetal hypoxia at time of the test. o Option A: The cervix is dilated enough to use an internal monitor, if necessary. Fetal heart rate is monitored using the Doppler ultrasound transducer, and the tocodynamometer is applied to detect uterine contractions or fetal movement. Fetal activity may be recorded by the patient using an event marker or noted by the staff performing the test. o Option C: An internal monitor can be applied if the client is at 0-station. The Non-Stress Test (NST) is an assessment tool used from 32 weeks of gestation to term to evaluate fetal health through the use of This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Late decelerations are one of the precarious decelerations among the three types of fetal heart rate decelerations during labor. They are caused by decreased blood flow to the placenta and can signify an impending fetal acidemia. o Option A: Has no relation to the readings. The primary etiology of a late declaration is found to be uteroplacental insufficiency. Decreased blood flow to the placenta causes a reduced amount of blood and oxygen to the fetus. o Option B: Compressed umbilical cord results in a variable deceleration. The central pathophysiology behind late deceleration involves uterine contraction constricting blood vessels in the wall of the uterus which decreases blood flow through the intervillous space of the placenta, reducing diffusion of oxygen into fetal capillaries causing decreased fetal PO2. o Option C: A vagal response is indicative of an early deceleration. When fetal PO2 decreases, chemoreceptors initiate an autonomic response in the fetus causing intense vasoconstriction with increased blood pressure. The elevated blood pressure is perceived by the baroreceptors which ultimately stimulate the parasympathetic system to decrease the fetal heart rate, causing late deceleration. 44. Question The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to: o A. Notify her doctor o B. Start an IV o C. Reposition the client o D. Readjust the monitor Correct Answer: C. Reposition the client The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Initial management of recurrent variable decelerations should have a target of relieving potential cord compression. Maternal repositioning is a reasonable first maneuver. Variable decelerations can be seen resulting from fetal movement if the fetus is premature. o Option A: Notifying the physician might be necessary but not before turning the client to her side. Recurrent variable decelerations during labor require evaluation. Initial evaluation includes characterization of the decelerations themselves, including their frequency, depth, and duration. It is also important to assess the uterine contraction pattern and the other fetal heart tracing characteristics. o Option B: Starting an IV is not necessary at this time. In specific clinical scenarios that may result in concerning variable decelerations, management should be directed by the etiology of those decelerations. If a patient is having uterine tachysystole, reducing the number of contractions by decreasing oxytocin or administration of a betaagonist may be appropriate. o Option D: Readjusting the fetal monitor is inappropriate since there is no data to indicate that the monitor has been applied ly. Electronic fetal monitoring is utilized in approximately 85% of live births in the United States, making it the most common procedure in obstetrics. This frequency represents an increase since 1980 when its use was about only 45% of women in labor. Intermittent, variable decelerations, defined as decelerations occurring with less than half of contractions, are the most common fetal heart rate abnormality that takes place in labor. 45. Question Which of the following is a characteristic of a reassuring fetal heart rate pattern? o A. A fetal heart rate of 170–180 bpm o B. A baseline variability of 25–35 bpm o C. Ominous periodic changes o D. Acceleration of FHR with fetal movements Correct Answer: D. Acceleration of FHR with fetal movements Accelerations with movement are normal. Accelerations are transient increases in the FHR. They are usually associated with fetal movement, vaginal examinations, uterine contractions, umbilical vein compression, fetal scalp stimulation or even external acoustic stimulation. The presence of accelerations is considered a reassuring sign of fetal well-being. o Option A: The average fetal heart rate is between 110 and 160 beats per minute. The normal FHR range is between 120 and 160 beats per minute (bpm). The baseline rate is interpreted as changed if the alteration persists for more than 15 minutes. Prematurity, maternal anxiety and maternal fever may increase the baseline rate, while fetal maturity decreases the baseline rate. o Option B: Baseline variability is defined as fluctuations in the fetal heart rate of more than 2 cycles per minute. Marked variability is at >25 BPM. The FHR is under constant variation from the baseline. This variability reflects a healthy nervous system, chemoreceptors, baroreceptors and cardiac responsiveness. Prematurity decreases variability; therefore, there is little rate fluctuation before 28 weeks. Variability should be normal after 32 weeks. o Option C: If there are ominous periodic changes, it would indicate an abnormality in the fetal heart rate pattern. Fetal hypoxia, congenital heart anomalies and fetal tachycardia also cause decreased variability. Beat-to-beat or short-term variability is the oscillation of the FHR around the baseline in amplitude of 5 to 10 bpm. Long-term variability is a somewhat slower oscillation in heart rate and has a frequency of three to 10 cycles per minute and an amplitude of 10 to 25 bpm. o Option A: Estrogen levels are high at the beginning of ovulation. At about day 14 in the menstrual cycle, a sudden surge in luteinizing hormone causes the ovary to release its egg. The egg begins its five- day travel through a narrow, hollow structure called the fallopian tube to the uterus. As the egg is traveling through the fallopian tube, the level of progesterone, another hormone, rises, which helps prepare the uterine lining for pregnancy. o Option C: The endometrial lining is thick, not thin. The blastocyst then attaches itself to the lining of the uterus (the endometrium). This attachment process is called implantation. Release of the hormones estrogen and progesterone causes the endometrium to thicken, which provides the nutrients the blastocyst needs to grow and eventually develop into a baby. o Option D: The progesterone levels are high, not low. As cells continue to divide — some developing into the baby, others forming the nourishment and oxygen supply structure called the placenta — hormones are released that signal the body that a baby is growing inside the uterus. These hormones also signal the uterus to maintain its lining rather than shedding it. 48. Question A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the: o A. Age of the client o B. Frequency of intercourse o C. Regularity of the menses o D. Range of the client’s temperature Correct Answer: C. Regularity of the menses The success of the rhythm method of birth control is dependent on the client’s menses being regular. Women are only fertile (an egg is present) for a few days each month. Women using the rhythm method monitor their body and analyze their past menstrual cycles to try to determine when their fertile days are. They can then either choose to not have sex during those days, or can use a “barrier” form of birth control, such as condoms or spermicide. o Option A: The rhythm method is not dependent on the age of the client. The rhythm method works best for women whose cycles are consistent because it is easier to predict when she ovulates (releases an egg from her ovaries). o Option B: Rhythm method is not successful when based entirely on the frequency of intercourse. Most women will have a period 14 to 16 days after ovulation, regardless of the length of their overall cycle. Counting backward from the day their period begins can be a good way to know when they ovulated. o Option D: Basal temperature method relies on the client’s temperature during ovulation period. The basal body temperature method is a method of natural family planning that requires only the purchase of a very accurate thermometer. The method, which calls for tracking the woman’s body temperature on a daily basis, helps to determine which days of the month she is fertile. 49. Question A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes? o A. Intrauterine device o B. Oral contraceptives o C. Diaphragm o D. Contraceptive sponge Correct Answer: C. Diaphragm The best method of birth control for the client with diabetes is the diaphragm. The diaphragm is a birth control (contraceptive) device that prevents sperm from entering the uterus. The diaphragm is a small, reusable rubber or silicone cup with a flexible rim that covers the cervix. Before sex, the diaphragm is inserted deep into the vagina so that part of the rim fits snugly behind the pubic bone. The diaphragm is effective at preventing pregnancy only when used with spermicide. o Option A: Permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided. Fibrinolytic activity is due in part to prostaglandin synthetase activation which was thought to be required for the efficacy of the copper IUD. Its absence was thought to be a possible reason why copper IUDs were less effective in diabetics (and in nondiabetics who became pregnant). o Option B: Oral contraceptives tend to elevate blood glucose levels. Choice of contraception should be made on the preference of the woman and individual risk factors identified such as the presence of vascular, nephropathy, neuropathy, or retinal disease. Choosing a safe and reliable method of contraception for a woman with DM needs careful consideration and practitioners need to make reference to the WHO Medical Eligibility Criteria for Contraceptive Use. o Option C: Contraceptive sponges are not good at preventing pregnancy. The contraceptive sponge is a type of birth control (contraceptive) that prevents sperm from entering the uterus. It is soft and diskshaped, and made of polyurethane foam. The contraceptive sponge contains spermicide, which blocks or kills sperm. 50. Question The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? o A. Painless vaginal bleeding o B. Abdominal cramping o A. Respiratory alkalosis without dehydration o B. Metabolic acidosis with dehydration o C. Respiratory acidosis without dehydration o D. Metabolic alkalosis with dehydration Correct Answer: B. Metabolic acidosis with dehydration The client with hyperemesis has persistent nausea and vomiting. With vomiting comes dehydration. When the client is dehydrated, she will have metabolic acidosis. In severe cases of hyperemesis, complications include vitamin deficiency, dehydration, and malnutrition, if not treated appropriately. Wernicke’s encephalopathy, caused by vitamin-B1 deficiency, can lead to death and permanent disability if it goes untreated. o Option A: Electrolyte abnormalities such as hypokalemia can also cause significant morbidity and mortality. Additionally, patients with hyperemesis may have higher rates of depression and anxiety during pregnancy. Electrolytes should be replaced as needed. Severe refractory cases of hyperemesis gravidarum may respond to intravenous or intramuscular chlorpromazine 25 to 50 mg or methylprednisolone 16 mg every 8 hours, orally or intravenously. o Option C: A vomiting pregnant client will ultimately develop dehydration. Additionally, there have been case reports of injuries secondary to forceful and frequent vomiting, including esophageal rupture and pneumothorax. Initial treatment should begin with non- pharmacologic interventions such as switching the patient’s prenatal vitamins to folic acid supplementation only, using ginger supplementation (250 mg orally 4 times daily) as needed, and by applying acupressure wristbands. o Option D: The client will not be in alkalosis with persistent vomiting. There is no single accepted definition for hyperemesis gravidarum. However, it generally refers to extreme cases of nausea and vomiting during pregnancy. It is a clinical diagnosis. The criteria for diagnosis include vomiting that causes significant dehydration (as evidenced by ketonuria or electrolyte abnormalities) and weight loss (the most commonly cited marker for this is the loss of at least five percent of the patient’s pre- pregnancy weight) in the setting of pregnancy without any other underlying pathological cause for vomiting. 53. Question A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is: o A. Elevated human chorionic gonadotropin o B. The presence of fetal heart tones o C. Uterine enlargement o D. Breast enlargement and tenderness Correct Answer: B. The presence of fetal heart tones The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in answers A, C, and D are subjective and might be related to other medical conditions. Fetal heart tones can be appreciated between six and eight weeks of gestation. Between eight and ten weeks of gestation, important information about the pregnancy can be obtained by the provider, including placental location, fetal position and anatomy, amniotic fluid volume, and maternal anatomy, including dimensions of the cervix and uterus. o Option A: It is important to note that an elevated beta-HCG level is not definitive of a normal or viable pregnancy. Conditions that result in elevated beta-HCG levels must be considered, including ectopic and heterotopic pregnancy; miscarriage; and the presence of abnormal germ cell, placental, and embryonal tissues. o Option C: Uterine enlargement may be related to a hydatidiform mole. The list of early pregnancy complications is vast, including ectopic pregnancy, heterotopic pregnancy, molar pregnancy, and miscarriage. The provider needs to visualize an intrauterine pregnancy for reasons discussed in prior sections. o Option D: Breast enlargement and tenderness is often present before menses or with the use of oral contraceptives. Early in pregnancy hormonal changes might make your breasts sensitive and sore. The discomfort will likely decrease after a few weeks as your body adjusts to hormonal changes. 54. Question The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be: o A. Hypoglycemic, small for gestational age o B. Hyperglycemic, large for gestational age o C. Hypoglycemic, large for gestational age o D. Hyperglycemic, small for gestational age Correct Answer: C. Hypoglycemic, large for gestational age The infant of a diabetic mother is usually large for gestational age. After birth, glucose levels fall rapidly due to the absence of glucose from the mother. Hypoglycemia is caused by hyperinsulinemia due to hyperplasia of fetal pancreatic beta cells consequent to maternal-fetal hyperglycemia. Because the continuous supply of glucose is stopped after birth, the neonate develops hypoglycemia because of insufficient substrate. o Option A: The infant will not be small for gestational age. Fetal macrosomia (>90th percentile for gestational age or >4000 g in the term infant) occurs in 15-45% of diabetic pregnancies. It is most commonly observed as a consequence of maternal hyperglycemia. When macrosomia is present, the infant appears puffy, fat, ruddy, and often hypotonic. Correct Answer: B. Positive HIV Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The best way to prevent transmission of HIV to an infant through breast milk is to not breastfeed. In the United States, where mothers have access to clean water and affordable replacement feeding (infant formula), the CDC and the American Academy of Pediatrics recommend that HIV- infected mothers completely avoid breastfeeding their infants, regardless of ART and maternal viral load. o Option A: Among women who had gestational diabetes, breastfeeding was associated with a lower rate of type 2 diabetes for up to 2 years after childbirth. The results suggest that breastfeeding after gestational diabetes may have lasting effects that reduce a woman’s chance of developing type 2 diabetes. o Option C: More children breastfed and longer duration of breastfeeding were associated with a lower risk of hypertension in postmenopausal women, and the degree of obesity and insulin resistance moderated the breastfeeding-hypertension association. o Option D: The client with thyroid disease can be allowed to breastfeed. Some breastfeeding mothers with hypothyroidism struggle to make a full milk supply. Thyroid hormones play a role in normal breast development and helping breasts to make milk. When not enough thyroid hormones are made, a mother’s milk supply may be affected. 57. Question A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to: o A. Assess the fetal heart tones o B. Check for cervical dilation o C. Check for firmness of the uterus o D. Obtain a detailed history Correct Answer: A. Assess the fetal heart tones The symptoms of painless vaginal bleeding are consistent with placenta previa. Assess fetal heart sounds so the mother would be aware of the health of her baby. Assess any bleeding or spotting that might occur to give adequate measures. Most cases are diagnosed early on in pregnancy via sonography and others may present to the emergency room with painless vaginal bleeding in the second or third trimester of pregnancy. o Option B: Cervical check for dilation is contraindicated because this can increase the bleeding. A patient presenting with vaginal bleeding in the second or third trimester should receive a transabdominal sonogram before a digital examination. If there is a concern for placenta previa, then a transvaginal sonogram should be performed to confirm the location of the placenta. o Option C: Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones. Painless vaginal bleeding during the second or third trimester of pregnancy is the usual presentation. The bleeding may be provoked from intercourse, vaginal examinations, labor, and at times there may be no identifiable cause. On speculum examination, there may be minimal bleeding to active bleeding. o Option D: A detailed history can be done later. The relationship between advanced maternal age and placenta previa may be confounded by higher parity and a higher probability of previous uterine procedures or fertility treatment. However, it may also represent an altered hormonal or implantation environment. 58. Question A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when: o A. Her contractions are 2 minutes apart. o B. She has back pain and a bloody discharge. o C. She experiences abdominal pain and frequent urination. o D. Her contractions are 5 minutes apart. Correct Answer: D. Her contractions are 5 minutes apart. The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. True labor consists of contractions at regular intervals. As labor progresses, these contractions become stronger, and the time between each contraction decreases. o Option A: She should not wait until the contractions are every 2 minutes. The first stage of labor is divided into two phases, which are defined by the degree of cervical dilation. The latent phase is during the dilation from 0 to 6 cm, while the active phase starts from 6 cm to full cervical dilation of 10 cm. o Option B: The woman should not wait until she has a bloody discharge. It is essential to call the healthcare provider at any time if there is bright red vaginal bleeding; continuous leaking of fluid or wetness, or if your water breaks (can be felt as a “gushing” of fluid); strong contractions every five minutes for one hour; and contractions that the woman is unable to “walk through”. o Option C: Has a vague answer and can be related to a urinary tract infection. The way a contraction feels is different for each woman and might feel different from one pregnancy to the next. Labor contractions cause discomfort or a dull ache in your back and lower abdomen, along with pressure in the pelvis. Some women might also feel pain in their sides and thighs. Some women describe contractions as strong menstrual cramps, while others describe them as strong waves that feel like diarrhea cramps. 59. Question The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy? o Option D: These durations are too late to provide antibody protection. RhoGam can also be given during pregnancy. Hemolytic disease can be prevented in women who are not already sensitized. Rh immunoglobulin (RhoGAM) is a prescription medicine given by intramuscular injection that stops an Rhnegative mother from making antibodies that attack Rh-positive red cells. 61. Question After the physician performs an amniotomy, the nurse’s first action should be to assess the: o A. Degree of cervical dilation o B. Fetal heart tones o C. Client’s vital signs o D. Client’s level of discomfort Correct Answer: B. Fetal heart tones When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. The nurse plays a vital role during the procedure in monitoring the mother as well as the fetus, she also notes the color of the draining amniotic fluid and documents the findings in the medical chart. o Option A: Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. The two most commonly used devices are (1) an approximately 10- inch rod with a hook on the end of the rod or (2) a finger cot with a hook on the end of the cot. With either device, the practitioner assesses cervical dilation through the performance of a sterile digital exam. o Option C: After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. The nurse also monitors the fetal heart rate via continuous electronic fetal monitoring and communicates the findings to the provider. o Option D: After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort. The nurse needs to frequently change underpads. One of the most crucial roles of the nurse is to educate the woman about the amniotomy procedure and address the patient’s concerns at all times. 62. Question A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor? o A. Active o B. Latent C. Transition o o D. Early Correct Answer: A. Active The active phase of labor occurs when the client is dilated 4–7cm. Active labor with more rapid cervical dilation generally starts around 6 centimeters of dilation. During the active phase, the cervix typically dilates at a rate of 1.2 to 1.5 centimeters per hour. Multiparas, or women with a history of prior vaginal delivery, tend to demonstrate more rapid cervical dilation. The absence of cervical change for greater than 4 hours in the presence of adequate contractions or six hours with inadequate contractions is considered the arrest of labor and may warrant clinical intervention. o Option B: The latent phase is commonly defined as the 0 to 6 cm, while the active phase commences from 6 cm to full cervical dilation. The presenting fetal part also begins the process of engagement into the pelvis during the first stage. Throughout the first stage of labor, serial cervical exams are done to determine the position of the fetus, cervical dilation, and cervical effacement. o Option C: The transition phase of labor is 8–10cm in dilation. The second stage of labor commences with complete cervical dilation to 10 centimeters and ends with the delivery of the neonate. This was also defined as the pelvic division phase by Friedman. After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts. o Option D: The latent or early phase of labor is from 1cm to 3cm in dilation. During the latent phase, the cervix dilates slowly to approximately 6 centimeters. The latent phase is generally considerably longer and less predictable with regard to the rate of cervical change than is observed in the active phase. A normal latent phase can last up to 20 hours and 14 hours in nulliparous and multiparous women respectively, without being considered prolonged. 63. Question A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include: o A. Teaching the mother to provide tactile stimulation o B. Wrapping the newborn snugly in a blanket o C. Placing the newborn in the infant seat o D. Initiating an early infant-stimulation program Correct Answer: B. Wrapping the newborn snugly in a blanket The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Nonpharmacological care, like rooming-in and control of environmental factors, is the first clinical management strategy and should continue even after discharge from the hospital. Breastfeeding should be strongly encouraged unless there is maternal polysubstance abuse or maternal medical contraindication. o A. Administer a prescribed antibiotic o B. Wash her hands for 2 minutes before care o C. Wear a mask when providing care o D. Ask the client to cover her mouth when she coughs Correct Answer: B. Wash her hands for 2 minutes before care The best way to prevent postoperative wound infection is hand washing. Up to 60% of SSI can be prevented. Prevention of postoperative wound infection is done by good general hygiene, operative sterility and effective barriers against transmission of infections, before, during and after surgery. o Option A: Use of prescribed antibiotics will treat infection, not prevent infections. The prophylaxis should only cover the current operating time and start at the beginning of anaesthesia (1A). The prophylaxis should reach high enough tissue doses before incision (1A). Short half-life preparations (e.g. cefalotin) must be followed up with a new dose if prolonged operating time. o Option C: Perform good hand hygiene throughout your stay. If bedridden, ask for wipes for hand disinfection. Ask visitors to carry out hand hygiene on arrival and when they leave the hospital. Ask health professionals to carry out hand hygiene if this fails— before and after your examination. o Option D: Asking the client to cover her mouth are good practices but will not prevent wound infections. Ensure the eradication of infections, urinary tract infections, skin infections, and other local infections prior to admission. Check the dental status, especially before larger elective interventions with implants and the like. Postpone surgery, if possible, until the infection is cleared. 66. Question The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit? o A. Pain o B. Misalignment o C. Cool extremity o D. Absence of pedal pulses Correct Answer: B. Misalignment The client with a hip fracture will most likely have a misalignment. Most hip fractures can be diagnosed, or at least suspected, from history alone. Classically a fall leads to a painful hip with an associated inability to walk. Clinicians should explore potentially sinister causes of the fall, such as syncope, stroke, or myocardial infarction. o Option A: Pain is a prominent feature in all fractures. The physical examination will demonstrate pain, immobility, and potentially a deformed limb. The degree of deformity seen is dependent on both the anatomical configuration of the fracture and the degree of displacement. The classically described presentation is a shortened and externally rotated limb due to the unopposed pull of the iliopsoas muscle that attaches to the lesser trochanter. o Option C: Coolness of the extremities is indicative of compartment syndrome. Further examination often reveals pain on any, or all, of the following: palpation in the groin or greater trochanter, axial loading of the hip, and ‘pin rolling of the leg. It is recommended that a cognitive assessment be performed in all patients presenting with hip fractures. Ideally, this should be done both on admission and post-operatively. The aim of this is to recognize patients with underlying dementia or those who are developing an acute delirium, both of which are associated with a poorer prognosis. o Option D: The absence of pulses is indicative of peripheral vascular disease. A full primary trauma and secondary trauma assessment should be performed to assess the patient for other injuries. It is always useful to assess the patient’s cardiovascular and respiratory status prior to undergoing surgery. Specific examinations to identify the cause of the fall should also be considered. 67. Question The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to: o A. Lack of exercise o B. Hormonal disturbances o C. Lack of calcium o D. Genetic predisposition Correct Answer: B. Hormonal disturbances After menopause, women lack hormones necessary to absorb and utilize calcium. Primary osteoporosis is related to the aging process in conjunction with decreasing sex hormones. The bones have deterioration in microarchitecture leading to loss of bone mineral density and increased risk of a fracture. Osteoporosis is defined as low bone mineral density caused by altered bone microstructure ultimately predisposing patients to low-impact, fragility fractures. Osteoporotic fractures lead to a significant decrease in quality of life, with increased morbidity, mortality, and disability. o Option A: Risk factors for osteoporosis include increasing age, body weight less than 128 pounds, smoking, family history of osteoporosis, white or Asian race, early menopause, low levels of physical activity and a personal history of a fracture from a groundlevel fall or minor trauma after the age of forty. Patients afflicted with conditions affecting overall mobility level, such as spinal cord injuries (SCI), can experience rapid deterioration of bone mineral density levels within the first 2 weeks following these debilitating injuries. Correct Answer: A. Utilizes a Steinman pin Balanced skeletal traction uses pins and screws. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur. For some types of femur fractures, a pin is placed in the child’s broken bone and the pin is connected to the weights. This is called “balanced skeletal traction.” The weights keep the parts of the bone in the proper place so the bone can heal well. o Option B: Only the affected leg is in traction. Weights, ropes and pulleys are used to balance and hold the leg up for best healing. The equipment cradles the leg to help the child relax and feel more comfortable while the ends of the bones are healing together. o Option C: Kirschner wires are used to stabilize small bones such as fingers and toes. The nurses will also check the skin around the pin for these signs: redness, flaking, and blisters. These are signs of skin breakdown and irritation. o Option D: Buck’s traction is not used for fractured hips. For people with hip fractures, traction involves either using tapes (skin traction) or pins (skeletal traction) attached to the injured leg and connected to weights via a pulley. The application of traction before surgery is thought to relieve pain and make the subsequent surgery easier. 70. Question The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the: o A. Serum collection (Davol) drain o B. Client’s pain C. Nutritional status o D. Immobilizer o Correct Answer: A. Serum collection (Davol) drain Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. Maintain patency of drainage devices when present. Note characteristics of wound drainage. Reduces the risk of infection by preventing the accumulation of blood and secretions in the joint space (medium for bacterial growth). Purulent, non serous, odorous drainage is indicative of infection, and continuous drainage from incision may reflect developing skin tract, which can potentiate the infectious process. o Option B: The client’s pain should be assessed, but this is not life- threatening. Provide comfort measures (frequent repositioning, back rub) and diversional activities. Encourage stress management techniques (progressive relaxation, guided imagery, visualization, meditation). Provide Therapeutic Touch as appropriate. Reduces muscle tension, refocuses attention, promotes a sense of control, and may enhance coping abilities in the management of discomfort or pain, which can persist for an extended period. o Option C: When the client is in less danger, the nutritional status should be assessed. Encourage intake of a balanced diet, including roughage and adequate fluids. Enhances healing and feeling of general well-being. Promotes bowel and bladder function during a period of altered activity. o Option D: An immobilizer is unnecessary in this case. Demonstrate and assist with transfer techniques and use of mobility aids, e.g., trapeze, walker. Facilitates self-care and patient’s independence. Proper transfer techniques prevent shearing abrasions of skin and fall. 71. Question Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates an understanding of the nurse’s teaching? o A. "I must flush the tube with water after feedings and clamp the tube." o B. "I must check placement four times per day." C. "I will report to the doctor any signs of indigestion." o o D. "If my father is unable to swallow, I will discontinue the feeding and call the clinic." Correct Answer: A. “I must flush the tube with water after feedings and clamp the tube.” The client’s family member should be taught to flush the tube after each feeding and clamp the tube. PEG stands for percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus. o Option B: A dressing will be placed on the PEG site following the procedure. This dressing is usually removed after one or two days. After that you should clean the site once a day with diluted soap and water and keep the site dry between cleansings. No special dressing or covering is needed. o Option C: The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client. Complications can occur with the PEG placement. Possible complications include pain at the PEG site, leakage of stomach contents around the tube site, and dislodgement or malfunction of the tube. Possible complications include infection of the PEG site, aspiration (inhalation of gastric contents into the lungs), bleeding and perforation (an unwanted hole in the bowel wall). o Option D: Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopic gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing. 72. Question The nurse is assessing the client with a total knee replacement 2 hours postoperative. Which information requires notification of the doctor? make their way into children’s mouths as a result of normal childhood exploratory hand-to-mouth behavior. o Option D: Having several siblings is unrelated to the stem. A variety of occupations and hobbies may expose adults to lead, and working parents may inadvertently bring lead home where they can expose their children second-hand. Some of the highest risk occupations and hobbies include metal welding, battery manufacturing, and recycling, shipbuilding and shipbreaking, firing range use or instruction as well as bullet salvaging, lead smelting and refining, painting and construction work, and pipefitting and plumbing. 74. Question A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living? o A. High-seat commode o B. Recliner C. TENS unit o D. Abduction o pillow Correct Answer: A. High-seat commode The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. There is also equipment available for patients to help them follow their newly prescribed hip precautions. Some patients purchase raised toilet seats and chairs to prevent them from bending at the hip more than 90 degrees. o Option B: The recliner is good because it prevents 90° flexion but not daily activities. Sock aids and dressing sticks are often used to make dressing and changing clothing easier for the patient. Reachers or “pinchers” can also be used by a patient following a total hip arthroplasty to help them grab items from the ground and other areas without breaking the hip precautions. o Option C: A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management. Compliance with hip precautions can be challenging for patients to follow. Many activities that were once simple to perform are instantly complicated. Activities of daily living can be significantly affected. Examples of activities of daily living include bathing, grooming, dressing, toileting, and transferring. Lack of independence can leave patients very upset and disheartened further affecting the rate of compliance. o Option D: An abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis. There are also environmental modifications that can help prevent hip dislocations; these include removing all tripping hazards from home, moving around the layout of home furniture so that there are fewer turns, and installing grab rails around the house. 75. Question An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should: o A. Administer oxygen via nasal cannula o B. Have narcan (naloxone) available o C. Prepare to administer blood products o D. Prepare to do cardio resuscitation Correct Answer: B. Have narcan (naloxone) available Narcan is the antidote for narcotic overdose. Naloxone is indicated for the treatment of opioid toxicity, specifically to reverse respiratory depression from opioid use. It is useful in accidental or intentional overdose and acute or chronic toxicity. Common opioid overdoses treated with naloxone include heroin, fentanyl, carfentanil, hydrocodone, oxycodone, methadone, and others. o Option A: If hypoxia occurs, the client should have oxygen administered by mask, not cannula. The incidence of naloxone-induced noncardiogenic pulmonary edema is estimated to be between 0.2% and 3.6% of patients who have received naloxone and are transported to the emergency department. Symptoms include persistent hypoxia, despite the resolution of respiratory depression secondary to acute overdose. Patients may also have a cough productive of the classic “pink, frothy sputum” indicative of pulmonary edema. o Option C: In chronic opioid users, naloxone requires slow administration to individuals who are dependent on opioids. All patients who have responded to naloxone should be continuously monitored for at least six to 12 hours since some opioids (methadone, fentanyl, buprenorphine) have a much longer half-life than naloxone. o Option D: There is no data to support cardiac resuscitation in this case. The patient should have vital signs, including pulse oximetry, monitored until obtaining a full recovery. Even after reversing respiratory depression, the patient must be monitored for at least six to 12 hours because the patient may have ingested the longer- acting opioids, which will continue to exert their effects after excretion of the naloxone. Any patient that requires IV naloxone of doses more than 5 mg should be admitted.