NCLEXRN Exam Packset 10 LATEST Updated Questions 2023, Exams of Nursing

Download NCLEXRN Exam Packset 10 LATEST Updated Questions 2023 and more Exams Nursing in PDF only on Docsity! NCLEXRN Exam Packset 10 LATEST Updated Questions 2023 1. 1. Question The nurse should visit which of the following clients first? o A. The client with diabetes with a blood glucose of 95mg/dL o B. The client with hypertension being maintained on Lisinopril o C. The client with chest pain and a history of angina o D. The client with Raynaud’s disease Correct Answer: C. The client with chest pain and a history of angina The client with chest pain should be seen first because this could indicate a myocardial infarction. Despite many advances in treatment, acute MI still carries a mortality rate of 5-30%; the majority of deaths occur prior to arrival to the hospital. In addition, within the first year after an MI, there is an additional mortality rate of 5% to 12%. The overall prognosis depends on the extent of heart muscle damage and ejection fraction. o Option A: The client in answer A has blood glucose within normal limits. The diagnosis of T1DM is usually through a characteristic history supported by elevated serum glucose levels (fasting glucose greater than 126 mg/dL, random glucose over 200 mg/dL, or hemoglobin A1C (HbA1c exceeding 6.5%) with or without antibodies to glutamic acid decarboxylase (GAD) and insulin. o Option B: The client in this option is maintained on blood pressure medication. Pharmacological therapy consists of angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), diuretics (usually thiazides), calcium channel blockers (CCBs), and beta-blockers (BBs), which are instituted taking into account age, race, and comorbidities such as presence of renal dysfunction, LV dysfunction, heart failure, and cerebrovascular disease. JNC-8, ACC, and ESC/ ESH have their separate recommendations for pharmacological management. o Option D: The client in answer D is in no distress. In Raynaud phenomenon, blood-flow restriction occurs during cold temperatures and emotional stress. Specifically, in Raynaud phenomenon, there is vasoconstriction of the digital arteries and cutaneous arterioles. • 2. Question A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication: o A. Once per day in the morning o B. Three times per day with meals o C. Once per day at bedtime o D. Four times per day Correct Answer: B. Three times per day with meals Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body in digesting needed nutrients. Chronic, supportive therapy for patients with CF includes regular pancreatic enzymes, fat-soluble vitamins (A, D, E, K), mucolytics, bronchodilators, antibiotics, and anti- inflammatory agents. o Option A: A new class of medications known as CFTR modulator therapies is designed Correct Answer: C. Constrict the pupils Miotic eye drops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. Pilocarpine is a muscarinic acetylcholine agonist that is effective in the treatment and management of acute angle-closure glaucoma and radiation- induced xerostomia. Although not a first-line treatment for glaucoma, it is useful as an adjunct medication in the form of ophthalmic drops. o Option A: The cornea and conjunctiva can be anesthetized by drops of any of the local anesthetics. Bupivacaine, for example, is effective as an eyedrop. Bupivacaine is a potent local anesthetic with unique characteristics from the amide group of local anesthetics, first discovered in 1957. Local anesthetics are used in regional anesthesia, epidural anesthesia, spinal anesthesia, and local infiltration. Local anesthetics generally block the generation of an action potential in nerve cells by increasing the threshold for electrical excitation. o Option B: The eye doctor may dilate the pupils with a special medication called a mydriatic, so they can see the inside of the eye during a slit lamp test. Typically, mydriasis reverses within 4 to 8 hours. However, it may take 24 hours for the mydriatic effect to wear off in some individuals. Weaker strength may cause mydriasis with little cycloplegia. o Option D: Scopolamine ophthalmic is an anticholinergic agent that blocks constriction of sphincter muscle of iris and ciliary body muscle, which, in turn, results in mydriasis (dilation) and cycloplegia (paralysis of accommodation). Scopolamine competitively inhibits G-protein coupled post-ganglionic muscarinic receptors for acetylcholine and acts as a nonselective muscarinic antagonist, producing both peripheral antimuscarinic properties and central sedative, antiemetic, and amnestic effects. • 5. Question A client with a severe corneal ulcer has an order for Gentamicin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops? o A. Allow 5 minutes between the two medications. o B. The medications may be used together. o C. The medications should be separated by a cycloplegic drug. o D. The medications should not be used in the same client. Correct Answer: A. Allow 5 minutes between the two medications. When using eye drops, allow 5 minutes between the two medications. Antibiotic eye drops are prescribed by a doctor to treat bacterial eye infections. They work by killing the bacteria (microscopic organism) that entered the eye and caused the infection. o Option B: Allow 5 minutes interval before administering the next eyedrops. Take the full course, don’t stop early/without consulting your doctor, even if things seem better. Antibiotic eye drops usually help symptoms get better after three days. Call your doctor if your symptoms don’t go away. o Option C: It is not necessary to use a cycloplegic with these medications. Eye infections cause redness, tearing and drainage (yellow- green pus or watery), and can be highly contagious. A certain type of eye infection—a bacterial eye infection—may need treatment with a medicine called an antibiotic eye drop. o Option D: These medications can be used by the same client. Don’t use anyone else’s prescription. Don’t keep unused prescriptions around to use later. Ask your ophthalmologist or pharmacist if it’s OK to keep the drops in the refrigerator. When the drops are cold it might be easier to feel the drop when it hits the eye, so you can tell where it has landed. • 6. Question The client with color blindness will most likely have problems distinguishing which of the following olors? c o A. Orange o B. Violet o C. Red o D. White Correct Answer: B. Violet Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The most common forms are protanopia and deuteranopia, conditions arising from loss of function of one of the cones, leading to dichromic vision. Protanopia is the loss of L cones (red) resulting in green-blue vision only. Deuteranopia is the loss of M cones (green) resulting in red-blue vision only. o Option A: Color vision results from the combination of signals from three visual pigment types within cones: that of red, green, and blue, which correspond to cone types L, M, and S (RGB-LMS). Those colors correspond to the wavelengths of peak light absorption intensities of the modified chromophores. L cones have peak absorptions at 555 nm to 565 nm, M cones at 530 nm to 537 nm, and S cones at 415 nm to 430 nm. o Option C: Similar to above, but not as severe in its symptoms, is the condition anomalous trichromatic vision (tritanomaly), where all three cones are present but the color vision is aberrant. The two common forms, protanomaly, and deuteranomaly result in L or M cones, respectively, being replaced with a cone of intermediate spectral tuning. Both are X-linked and occur in 7% of males. o Option D: In addition to disorders of proper color recognition, many diseases in vision display phototransduction defects affecting many portions of the signal pathway and its regulation. Here, not only is color vision function lessened but scotopic (low-light, rod-associated) vision as well. • 7. Question The client with a pacemaker should be taught to: o B. 1200 o C. 1000 o D. 0700 Correct Answer: A. 1900 Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1900. If you go to the toilet too frequently ―just in case,‖ you might end up making the overactive bladder symptoms worse, because the bladder is then ―trained‖ to send a signal that you need to urinate as soon as there is only a small amount of urine in it. o Option B: It is important to go to the toilet at regular intervals so that your bladder gets used to a certain frequency. A voiding (bathroom visit) schedule can be helpful here. Bladder training programs often recommend that, once you have emptied your bladder first thing in the morning and perhaps again after breakfast, you try to keep the intervals between bathroom visits as regular as possible. o Option C: Even if you have a very strong urge to go to the bathroom, it usually only lasts a few minutes and then dies down again. You can practice not emptying your bladder as soon as you feel the need to go. Going to the bathroom calmly and at a slow pace rather than rushing to get there can help too. o Option D: You can try to wait longer between trips to the bathroom, but do so at a slow pace and without any stress. A voiding schedule can be helpful here too. You can use it to remember, for example, that you want to try to wait 5 minutes before emptying your bladder in the first few days, and then keep this up for about half a week. You can then lengthen that “waiting period” to 10, 15 and finally 20 minutes. • 9. Question Which of the following diet instructions should be given to the client with recurring urinary tract infections? o A. Increase intake of meats. o B. Avoid citrus fruits. o C. Perform peri care with hydrogen peroxide. o D. Drink a glass of cranberry juice every day. Correct Answer: D. Drink a glass of cranberry juice every day. Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria do not grow freely in acidic urine. A 2003 study that included 324 women found that frequently drinking freshly squeezed, 100% juice — especially berry juice, as well as consuming fermented dairy products like yogurt, was associated with a decreased risk of UTI occurrence o Option A: Increasing intake of meats is not associated with urinary tract infections, so answer A is . Red meat and other animal proteins have high potential renal acid loads (PRALs), meaning that they make urine more acidic. Conversely, fruits and vegetables have low PRALs, making urine less acidic. o Option B: The client does not have to avoid citrus fruits. The aforementioned study in 4,145 men and women showed that citrus juice intake was associated with a 50% reduction in lower urinary tract symptoms in men only o Option C: Peri care should be done, but hydrogen peroxide is drying. Other factors claimed to increase the chances of developing a UTI include wearing tight underwear, hot tub use, not urinating after sex, and douching, although strong evidence to support these claims is lacking. • 10. Question The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs? o A. "I will make sure I eat breakfast within 2 hours of taking my insulin." o B. "I will need to carry candy or some form of sugar with me all the time." o C. "I will eat a snack around three o'clock each afternoon." o D. "I can save my dessert from supper for a bedtime snack." Correct Answer: C. “I will eat a snack around three o’clock each afternoon.” NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. It is on the list of essential medicines of the world health organization (WHO).NPH insulin is FDA- enter the thoracic cavity. • 12. Question A client wh o delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aw are that successful breastfeeding is most dependent on the: o A. Mother’s educational level o B. Infant’s birth weight o C. Size of the mother’s breast o D. Mother’s desire to breastfeed Correct Answer: D. Mother’s desire to breastfeed Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue breastfeeding until the infant and mother have time to adapt. Breastfeeding is an important part of a newborn’s life. Breastfeeding or lactation provides total nutritional and emotional dependency of the baby on the mother. The strong emotional bonding between the mother-child dyad is needed for successfully prolong breastfeeding. o Option A: Baby and maternal factors can influence this bonding. Skin-toskin contact in the first 2 hours after birth is essential for successful initiation of lactation. The breast crawl, soon after birth, while the baby is alert will initiate the bonding, and it will be an assurance by giving comfort and calm to the mother. The breast crawl is when the baby is placed on the mother’s abdomen after birth; the baby finds its way to the breast to suckle. o Option B: Successful breastfeeding factors related to the baby include proper latching, alertness of the baby, rooting reflex, and active sucking reflex. Although lactation is a natural process, the mother needs support and education for proper positioning and latching. The ability of the baby to empty the breast will determine the subsequent milk volume. o Option C: Maternal factors like pain, anxiety, emotional instability, among others should be addressed before and after delivery. Lactation consultants or knowledgeable nurses can also be helpful with initiating of breastfeeding. • 13. Question The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physici an immediately? o A. The presence of scant bloody discharge o o B. Frequent urination C. The presence of green-tinged amniotic fluid o D. Moderate uterine contractions Correct Answer: C. The presence of green-tinged amniotic fluid Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. Amniotic fluid should be clear, or straw tinged with small vernix particles in the fluid. Brown or green staining of the fluid indicates the passage of meconium. Because the fetus swallows amniotic fluid in utero, meconium can be present in the infant’s oropharynx at delivery. During delivery, if meconium-stained amniotic fluid is noted, a neonatal resuscitation team should be promptly involved o Option A: In the third trimester, bleeding is concerning for placental abruption, placenta previa, or labor. Each of these pathologies has its entry discussing its presentation and pathophysiology. Although bleeding in pregnancy is not considered ―normal,‖ it is common, affecting about one in three pregnancies. o Option B: An increased urge to urinate can be a result of the baby’s head dropping into the pelvis. The low position of the baby’s head puts even more pressure on the urinary bladder, so many women approaching labor might feel a frequent need to urinate. o o B. Fetal bradycardia o C. Maternal hyperreflexia o D. Fetal movement Correct Answer: B. Fetal bradycardia The client receiving Pitocin should be monitored for decelerations. It is essential to monitor patient fluids (both intake and outtake) while administering oxytocin, as well as the frequency of uterine contractions, patient blood pressure, and heart rate of the unborn fetus. o Option A: Oxytocin is primarily used by the obstetrician and the labor and delivery nurses. Healthcare workers who do prescribe this hormone should be familiar with its side effects. An inappropriate dosage of oxytocin can lead to dangerous tachycardia, arrhythmias, and myocardial ischemia. High dosages of oxytocin can cause uterine rupture, hypertonicity, and spasms. o Option C: If oxytocin is given in doses too large or even slowly during 24 hours, the medication can exhibit an antidiuretic effect resulting in extreme water intoxication. This excessive dosing can result in coma, seizures, and even death in the mother. o Option D: When oxytocin is given to women who are in the first or second stages of labor, or to women to cause induction of labor, uterine rupture, as well as maternal subarachnoid hemorrhages, maternal death, o and even fetal death, can result. • 16. Question A client wit h diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding i nsulin needs during pregnancy? o A. Insulin requirements moderate as the pregnancy progresses. B.A decreased need for insulin occurs during the second trimester. o C. Elevations in human chorionic gonadotropin decrease the need for insulin. o D. Fetal development depends on adequate insulin regulation. Correct Answer: D. Fetal development depends on adequate insulin regulation. Fetal development depends on adequate nutrition and insulin regulation. Significant alterations in maternal metabolism during pregnancy ensure a continuous supply of nutrients to the fetus. Glucose is the primary energy source for the fetus. In early pregnancy, increases in maternal insulin sensitivity enable the storage of energy and nutrients. o Option A: Insulin requirements do not moderate as the pregnancy progresses. To counteract insulin resistance and achieve adequate metabolic control in late pregnancy, the dose of insulin may need to be increased. Understanding insulin requirements in o pregnant women with type 1 diabetes would help them to maintain tight glycemic control. o Option B: Insulin needs to increase during the second and third trimesters. In late pregnancy, maternal insulin resistance develops due to increases in pregnancy-related hormones, such as progesterone, human placental lactogen and prolactin, as well as inflammatory cytokines, such as tumor necrosis factor-?. These changes facilitate the supply of glucose toward the fetus. o Option C: Elevated human chorionic gonadotropin elevates insulin needs, not decreases them. Insulin dose prior to pregnancy was associated with pre- pregnancy body weight, BMI, and HbA1c levels before pregnancy and in the first trimester. Insulin dose prior to pregnancy was higher in patients with male infants than patients with female infants. • 17. Question 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 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 cardiotoxicity due to hyperkalemia or hypermagnesemia. Calcium gluconate has also been used off-label in the management of ?-blocker toxicity, calcium- channel blocker (CCB) toxicity, magnesium toxicity, and hydrofluoric acid burns. o Option D: Pardel is a dopamine receptor stimulant used to treat Parkinson’s disease. Bromocriptine is also used as an early treatment for PD to delay the onset of the use of levodopa, ultimately delaying the likely dyskinesia and motor fluctuations that occur with chronic use. • 20. Question A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should: o A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure o B. Stop the infusion of magnesium sulfate and contact the physician o C. Slow the infusion rate and turn the client on her left side o D. Administer calcium gluconate IV push and continue to monitor the blood pressure Correct Answer: A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure The client’s blood pressure and urinary output are within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8–9.6mg/dL. Magnesium levels must be monitored frequently by checking serum levels every 6 to 8 hours or clinically by following patellar reflexes or urinary output. o Option B: Do not stop the infusion. If serum concentration levels are low, a proper dose of magnesium sulfate can be given parenterally to replete low serum concentrations with recommended follow up laboratory testing. o Option C: There is no need to stop the infusion at this time or slow the rate. If patients exhibit signs and symptoms of hypermagnesemia, the recommendation is to discontinue magnesium sulfate products immediately. If the patient Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. Alpha-fetoprotein (AFP) is a plasma protein produced by the embryonic yolk sac and the fetal liver. AFP levels in serum, amniotic fluid, and urine functions as a screening test for congenital disabilities, chromosomal abnormalities, as well as some other adult occurring tumors and pathologies. o Option A: The test is not mandatory, as stated in answer A. Patients having amniocentesis must be duly counseled about the procedure, as well as, the associated risks. There is a risk of obstetric mishap following amniocentesis; a miscarriage can happen in less than 1% of cases. Some other very rare 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. o D. Fetal growth is arrested if thyroid medication is continued during pregnancy. Correct Answer: B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy. During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. During pregnancy, there are increased metabolic needs of the maternal body resulting in changes in thyroid physiology. These changes in thyroid physiology reflect in altered thyroid function tests. o Option A: There could be a need for thyroid medication during pregnancy. The serum TSH concentration is the initial and most reliable measure of thyroid function during pregnancy. As elaborated above, there are physiologic changes in TSH levels during pregnancy which warrants close monitoring of TSH levels. As per the latest American Thyroid Association (ATA) guidelines, serum TSH levels during pregnancy should be defined using population and trimester-specific based reference ranges. o Option C: The thyroid function does not slow. When population and trimester-specific normal ranges are not available, the ATA guidelines recommend reducing the lower limit of TSH by 0.4 mU/L and the upper limit by 0.5 mU/L. It would correspond to the TSH reference range of 0.1 to 4.0 mU/L during the first trimester with a gradual return of TSH towards the non-pregnant normal range during second and third trimesters. o Option D: Fetal growth is not arrested if thyroid medication is continued. There is an increase in iodine requirement during pregnancy due to an increase in maternal thyroid hormone production as well as an increase in renal iodine clearance. Along with the above two factors, there is also a fetal iodine requirement; therefore, dietary iodine requirements are higher during pregnancy. • 24. Question The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse would expect to find: o A. An apical pulse of 100 o B. An absence of tonus o C. Cyanosis of the feet and hands o D. Jaundice of the skin and sclera Correct Answer: C. Cyanosis of the feet and hands Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. Acrocyanosis is bluish discoloration around the mouth and extremities, with the remaining area pink. It is a benign finding often seen in healthy newborns and is common in the initial days of life due to initial peripheral vasoconstriction. This is managed by routine newborn care. The routine newborn care management which involves pulse oximetry and screening of congenital heart disease (CHD). o 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, you may also be given an injection of a harmless substance called a contrast agent before the scan, as this can make the images clearer. o Option D: The client should withhold voiding, not food, before an ultrasound. Avoid eating or drinking for several hours before the scan – this may be needed before a scan of your digestive system, including the liver and gallbladder. • 27. Question An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year? o A. 14 pounds o B. 16 pounds o C. 18 pounds o D. 24 pounds Correct Answer: D. 24 pounds By 1 year of age, the infant is expected to triple his birth weight. Between six months and one year, weight gain slows down a little. Most babies double their birth weight by five to six months of age and triple it by the time they are a year old. By one year, the average weight of a baby girl is approximately 19 pounds 10 ounces (8.9 kg), with boys weighing about 21 pounds 3 ounces (9.6 kg). o Option A: During the first few days of life, it’s normal for both breastfed and bottle-fed newborns to lose weight. A bottle-fed baby may lose up to 5% of his body weight, and an exclusively breastfed newborn can lose up to 10%. o Option B: On average, babies gain about one pound each month for the first six months. The average weight at six months is about 16 pounds 2 ounces (7.3 kg) for girls and 17 pounds 8 ounces (7.9 kg) for boys. o Option C: Most infants will gain about a pound over their birth weight by month one. At this age, infants are not as sleepy, they begin developing a regular feeding pattern, and they have a stronger suck during feedings. • 28. Question A pregnantclient with a history of alcohol addiction is scheduled for a nonstress test. The nonstress te st: o A. Determines the lung maturity of the fetus o B. Measures the activity of the fetus o C. Shows the effect of contractions on the fetal heart rate o D. 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 addition, the urethral meatus is usually in an abnormal location. If the infant has a complete foreskin, the hypospadias may become obvious after circumcision. • 30. Question A gravida 3 para 2 is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is: o A. Alteration in coping related to pain o B. Potential for injury related to precipitate delivery o C. Alteration in elimination related to anesthesia o D. Potential for fluid volume deficit related to NPO status Correct Answer: A. Alteration in coping related to pain Transition is the time during labor when the client loses concentration due to intense contractions. Assess nature and amount of vaginal show, cervical dilation, effacement, fetal station, and fetal descent. Cervical dilation should be approximately 1.2 cm/hr in the nullipara and 1.5 cm/hr in the multipara; vaginal show increases with a fetal descent. Choice and timing of medication is affected by the degree of dilation and contractile pattern. o Option B: Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is . Monitor uterine activity manually and/or electronically, noting frequency, duration, and intensity of contraction. The uterus is susceptible to possible rupture if a hypertonic contractile pattern develops spontaneously or in response to oxytocin administration. Placental separation and hemorrhage can also occur if contraction persists. o o Option C: Encourage periodic attempts to void, at least every 1–2 hr. Pressure of the presenting part on the bladder often reduces sensation and interferes with complete emptying. Regional anesthesia (especially in conjunction with IV fluid infusion and use of Stadol) also may contribute to voiding difficulties/bladder distension. o Option D: Monitor for signs and symptoms of excess fluid loss or shock (i.e., check BP, pulse, sensorium, skin color, and temperature). Hemorrhage associated with fluid loss greater than 500 ml may be manifested by increased pulse, decreased BP, cyanosis, disorientation, irritability, and loss of consciousness. • 31. Question The client with varicella will most likely have an order for which category of medication? 5 A. Antibiotics 6 B. Antipyretics Correct Answer: C. Antivirals Varicella is chickenpox. This herpes virus is treated with antiviral medications. In adults, infection tends to be more severe, and treatment with antiviral drugs (acyclovir or valacyclovir) is advised if they can be started within 24 to 48 hours of rash onset. In children, acyclovir decreases symptoms by one day if taken within 24 hours of the start of the rash, but it has no effect on complication rates, and it is not recommended for individuals with normal immune function. o Option A: The pharmacology behind antibiotics includes destroying the bacterial cell 5 C. Antivirals 6D. Anticoagulants o A. Avoid exercise because it fatigues the joints. 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 A client wit h acute pancreatitis is experiencing severe abdominal pain. Which of the following orders shou ld be questioned by the nurse? o A. Meperidine 100 mg IM q 4 hours PRN pain o B. Mylanta 30 ccs q 4 hours via NG o C. Cimetidine 300 mg PO q.i.d. o D. Morphine 8 mg IM q 4 hours PRN pain Correct Answer: D. Morphine 8 mg IM q 4 hours PRN pain Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphincter of Oddi. GI obstruction is another important contraindication. It is also considered by many as a contraindication to provide opioids to individuals that have a history of substance misuse, especially if a patient has had a history of abusing opioids. o Option A: Clinicians use meperidine is used for the treatment of moderate to severe pain. It has intramuscular, subcutaneous, intravenous injection, syrup, and tablet forms. In the 20th century, it was the drug of choice amongst the opioids in the management of acute pain by most of the physicians and the management of some patients with chronic pain. o Option B: Antacids are a group of drugs that have been on the market for many years. They were initially first-line defense against peptic ulcer disease; however, the discovery of proton pump inhibitors revolutionized the treatment of peptic ulcer disease. Currently, antacid use is restricted to the relief of mild intermittent gastroesophageal reflux disease (GERD) associated heartburn. o Option C: Cimetidine is ordered for pancreatitis, making answer C . Cimetidine is a gastric acid reducer used in the short-term treatment of duodenal and gastric ulcers. The drug is effective in managing gastric hypersecretion, and therefore, used for the management of reflux esophagitis disease and in the prevention of stress ulcers. With the development of proton pump inhibitors, such as omeprazole, approved for the same indications, cimetidine is available as an over the counter formulation for the prevention of heartburn or acid indigestion, along with the other H2- receptor antagonists. • 35. Question The client i s admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because: o A. Hallucinogenic drugs create both stimulant and depressant effects. o B. Hallucinogenic drugs induce a state of altered perception. o C. Hallucinogenic drugs produce severe respiratory depression. 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 A patient has been hospitalized with pneumonia and is about tobe discharged. A nurse provides discharge instructions to a patient and his family. Which misunderstanding by the family indicates the need for more detailed information? 7 A. The patient may resume normal home activities astolerated but should avoid physical exertion and get adequate rest. o B. The patient should resume a normal diet with emphasis on nutritious, healthy foods. o C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved. Correct Answer: C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved. It is always critical that patients being discharged from the hospital take prescribed medications as instructed. In the case of antibiotics, a full course must be completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection. Take antibiotics exactly as directed. Do not stop taking the medicine just because you are feeling better. The client needs to take the full course of antibiotics. o Option A: The patient should resume normal activities as tolerated, as well as a nutritious diet. Get plenty of rest and sleep. The client may feel weak and tired for a while, but the energy level will improve with time. o Option B: Healthy and nutritious food, especially those high in vitamin C, should be included in the patient’s diet to speed up recovery and prevent reinfection. To prevent dehydration, drink plenty of fluids, enough so that the urine is light yellow or clear like water. Choose water and other caffeine- free clear liquids until feeling better. If the client has kidney, heart, or liver disease and has to limit fluids, he should talk with his doctor before he increases the amount of fluids he drinks. o Option D: Continued use of the incentive spirometer after discharge will speed recovery and improve lung function. If given a spirometer to measure how well the lungs are working, use it as instructed. This can help the doctor tell how the recovery is going. 7 D. The patient should continue use of the incentive spirometer to keep airways open and free of secretions. • 38. Question A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take? o A. Restrict visiting hours and ask the family to limit visitors to two at a time. o B. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed. o C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to thefamily. o D. Contact the physician to report the unusual ritualsand activities. Correct Answer: C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family. When a family member is dying, it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. In the Vietnamese culture, it is important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the next life. When possible, allowing the family privacy for this traditional behavior is best for them and the patient. o Option A: Know the availability of support systems for the patient. If the patient’s main support is the object of perceived loss, the patient may need help in naming other 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. o B. Glucagon treats hypoglycemia resulting frominsulin overdose. o C. Glucagon treats lipoatrophy from insulin injections. o D. Glucagon prolongs the effect of insulin, allowing fewer injections. Correct Answer: B. Glucagon treats hypoglycemia resulting from insulin overdose. Glucagon is given to treat insulin overdose in an unresponsive patient. Patients with decreased levels of consciousness cannot safely consume the oral carbohydrates needed to raise their blood sugar without risk of aspiration, and obtaining IV access can be problematic in the diabetic population, which can prevent prompt administration of IV glucose. o Option A: Following Glucagon administration, the patient should respond within 15-20 minutes at which time oral carbohydrates should be given. Similar to epinephrine auto-injectors, a pre-filled glucagon injector has received approval, which injects into the patient’s thigh. Healthcare providers will most often encounter the emergency kit formulation necessitating reconstitution before injecting the medication, but the intranasal spray may be encountered with increasing frequency in hypoglycemia kits for layperson use. o Option C: Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat. Lipoatrophies are considered an adverse immunological side effect of insulin therapy, and in some cases they are mediated by a local high production of tumor necrosis factor-?, which leads to a dedifferentiation of adipocytes in the subcutaneous tissue. o Option D: Glucagon reverses rather than enhances or prolongs the effects of insulin. Glucagon is a reliable method of raising the patient’s glucose and relieving severe hypoglycemia long enough for more definitive correction of the patient’s glucose levels by mouth, particularly when IV access is unavailable to the provider or has failed. • 41. Question An infant with congestive heart failure is receiving diuretic therapy at home. Which of the following symptoms would indicate that the dosage may need to be increased? o A. Sudden weight gain o B. Decreased blood pressure o C. Slow, shallow breathing o D. Bradycardia Correct Answer: A. Sudden weight gain Weight gain is an early symptom of congestive heart failure due to accumulation of fluid. Important among these are renal retention of fluid, renin-angiotensin mediated vasoconstriction and sympathetic overactivity. Excessive fluid retention increases the cardiac output by increasing the end diastolic volume (preload), but also results in symptoms of pulmonary and systemic congestion. o Option B: Vasoconstriction (increase in afterload) tends to maintain flow to vital organs, but it is disproportionately elevated in patients with CHF and increases myocardial work. Similarly, sympathetic overactivity results in increase in contractility, which also increases myocardial requirements. An understanding of the interplay of the four principal determinants of cardiac output – preload, afterload, contractility and heart rate is essential in optimising the therapy of CHF. It is clinically useful to consider CHF in different age groups separately. o Option C: In the past, the most sensitive and specific variables for the presence of CHF (p<0.0001) were, a history of less than 3.5 oz/feed, respiratory rate greater than 50/min, an abnormal respiratory pattern, diastolic filling sounds, and hepatomegaly. Moderate to severe CHF was considered to be present when patients took less than 3 oz/feed or greater than 40 min/feed, had an abnormal respiratory pattern with a resting respiratory rate greater than 60/min, and had a diastolic filling sound and moderate hepatomegaly. o Option D: Tachycardia >150/min is common, and heart rates >180/min are abnormal even in the setting of respiratory distress and suggests CHF. Severe CHF was accompanied by a heart rate greater than 170/min, decreased perfusion, and severe hepatomegaly. Thus, the grading of the severity of CHF in infants should include an accurate description of these historical and clinical variables. • 42. Question A patient taking dilantin (Phenytoin) for a seizure disorder is experiencing breakthrough seizures. A blood sample is taken to determine the serum drug level. Which of the following would indicate a sub-therapeutic level? o C. Monitor heart rate Correct Answer: B. Monitor respiratory rate Morphine sulfate can suppress respiration and respiratory reflexes, such as cough. Patients should be monitored regularly for these effects to avoid respiratory compromise. Respiratory depression is among the more serious adverse reactions with opiate use that is especially important to monitor in the postoperative patient population. 8 Option A: Among the more common unwanted effects of morphine use is constipation. This effect occurs via stimulation of mu-opioid receptors on the myenteric plexus, which in turn inhibits gastric emptying and reduces peristalsis. Other common side effects include central nervous system depression, nausea, vomiting, and urinary retention. o Option C: Morphine can also affect the cardiovascular system and reportedly can cause flushing, bradycardia, hypotension, and syncope. It is also important to note that patients can experience pruritus, urticaria, edema, and other skin rashes. o Option D: Morphine sulfate does not significantly affect body temperature. Other reported side effects include lightheadedness, sedation, and dizziness. Patients often report nausea and vomiting, which is why in many emergency departments, morphine administration is with an antiemetic such as ondansetron. • 45. Question 8D. Monitor temperature A patient arrives at the emergency department with severe lower leg pain after a fall in a touch football game. Following routine triage, which of the following is the appropriate next step in assessment and treatment? o A. Apply heat to the painful area. o B. Apply an elastic bandage to the leg. o C. X-ray the leg. o D. Give pain medication. Correct Answer: C. X-ray the leg. Following triage, an x-ray should be performed to rule out fracture. Review follow-up and serial X-rays. Provides visual evidence of proper alignment or beginning callus formation and healing process to determine the level of activity and need for changes in or additional therapy. o Option A: Ice, not heat, should be applied to a recent sports injury. Apply cold or ice pack first 24–72 hr and as necessary. Reduces edema and hematoma formation, decreases pain sensation. Note: Length of application depends on degree of patient comfort and as long as the skin is carefully protected. o Option B: An elastic bandage may be applied. Maintain immobilization of affected part by means of bed rest, cast, splint, traction. Relieves pain and prevents bone displacement and extension of tissue injury. Elevate and support injured extremity. Promotes venous return, decreases edema, and may reduce pain. o Option D: Pain medication can be given once fracture has been excluded. Medicate before care activities. Let the patient know it is important to request medication before pain becomes severe. Promotes muscle relaxation and enhances participation. • 46. Question A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure? o A. A patient admitted for myocardial infarction without cardiac muscle damage. o B. A postoperative coronary bypass patient, recovering on schedule. o C. A patient with a history of ventricular tachycardia and syncopal episodes. o D. A patient with a history of atrial tachycardia and fatigue. refuse to complete the MRI scan and need sedation. These patients need to be well informed about the MRI scan procedure. The recommendation is that a physician has a discussion with them about the details in advance. Using Larger and opener MRI systems might be helpful in claustrophobic patients. o Option D: Psychiatric medication is not a contraindication to MRI scanning. Patients who are unable to be still or obey breathing instructions in the scanner need special attention. Some patients in pain might move during the procedure, which degrades the quality of the images, restrict the interpretation, and decrease the accuracy of the report. Some MRI sequences need to be obtained while patients hold their breath and lie motionless. • 48. Question A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed? o A. The patient is somnolent with decreased response to the family. o B. The patient suddenly complains of chest pain and shortness of breath. o C. The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs. o D. The patient has a fever, chills, and loss of appetite. Correct Answer: B. The patient suddenly complains of chest pain and shortness of breath. Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Pulmonary embolism (PE) occurs when there is a disruption to the flow of blood in the pulmonary artery or its branches by a thrombus that originated somewhere else. Chest pain is a frequent symptom and is usually caused by pleural irritation due to distal emboli causing pulmonary infarction. In central PE, chest pain may be from underlying right ventricular (RV) ischemia and needs to be differentiated from an acute coronary syndrome or aortic dissection. o Option A: The most common symptoms of PE include the following: dyspnea, pleuritic chest pain, cough, hemoptysis, presyncope, or syncope. Dyspnea may be acute and severe in central PE, whereas it is often mild and transient in small peripheral PE. o Option C: A patient with pulmonary embolism will not be sleepy or have a cough with crackles on exam. On examination, patients with PE might have tachypnea and tachycardia, which are common but nonspecific findings. Other examination findings include calf swelling, tenderness, erythema, palpable cords, pedal edema, rales, decreased breath sounds, signs of pulmonary hypertension such as elevated neck veins, loud P2 component of second heart sound, a right- sided gallop, and a right ventricular parasternal lift might be present on examination. o Option D: A patient with fever, chills, and loss of appetite may be developing pneumonia. A massive PE leads to an acute right ventricular failure, which presents as jugular venous distension, parasternal lift, third heart sound, cyanosis, and shock. If a patient with PE who has tachycardia on presentation develops sudden bradycardia or develops a new broad complex tachycardia (with right bundle branch block), providers should look for signs of right ventricular strain and possible impending shock. PE should be suspected in anyone who has hypotension with jugular venous distension wherein acute myocardial infarction, pericardial tamponade, or tension pneumothorax has been ruled out. • 49. Question A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect? o A. The patient will be admitted to the medicine unit for observation and medication. conform the patient to surroundings; put call light within reach and teach how to call for assistance; respond to call light immediately. o Option B: Monitoring for fever and requiring protective clothing are indicated to prevent infection if white blood cells are decreased. Wash hands and teach patient and SO to wash hands before contact with patients and between procedures with the patient; encourage fluid intake of 2,000 to 3,000 mL of water per day, unless contraindicated. 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. 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. 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. 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. o C. Gaucher's cells. 13D. 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 a well-defined nuclear membrane. There are one or two nucleoli, and the cytoplasm is small or moderate in amount. Lymphoblasts that grow and divide uncontrollably cause a type of cancer known as acute lymphoblastic leukemia. o Option C: Gaucher’s cells are large storage cells found in patients with Gaucher’s disease. The Gaucher cell results from the accumulation of excessive glucocerebroside in cells of the monocyte-macrophage system. It is characterized ultrastructurally by the presence of cytoplasmic inclusions which consist of tubule-like structures measuring 130 to 150 Ao in diameter. o Option D: Rieder’s cells are myeloblasts found in patients with acute myelogenous leukemia. They are abnormal myeloblasts in which the nucleus may be widely or deeply indented or may actually be a bilobate or multilobate structure; frequently observed in acute leukemia. • 55. Question A patient is about to undergo bone marrow aspiration and biopsyand expresses fear and anxiety about the procedure. Which of the following is the most effective nursing response? o A. Warn the patient to stay very still because thesmallest movement will increase her pain. o B. Encourage the family to stay in the room for the procedure. o C. Stay with the patient and focus on slow, deep breathing for relaxation. o D. Delay the procedure to allow the patient to deal with her feelings. Correct Answer: C. Stay with the patient and focus on slow, deep breathing for relaxation. Slow, deep breathing is the most effective method of reducing anxiety and stress. It reduces the level of carbon dioxide in the brain to increase calm and relaxation. Stay with the patient during panic attacks. Use short, simple directions. Encourage the client’s participation in relaxation exercises such as deep breathing, progressive muscle relaxation, guided imagery, meditation and so forth. o Option A: Warning the patient to remain still will likely increase her anxiety. Maintain a calm, non-threatening manner while working with the client. Anxiety is contagious and may be transferred from health care provider to client or vice versa. Client develops feeling of security in presence of calm staff person. o Option B: Encouraging family members to stay with the patient may make her worry about their anxiety as well as her own. Move the client to a quiet area with minimal stimuli such as a small room or seclusion area (dim lighting, few people, and so on.) Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security as compared to a large area which can make the client feel lost and panicked. o Option D: Delaying the procedure is unlikely to allay her fears. Establish and maintain a trusting relationship by listening to the client; displaying warmth, answering questions directly, offering unconditional acceptance; being available, and respecting the client’s use of personal space. • 56. Question A mother c omplains to the clinic nurse that her 2 ½-year-old son is not yet toilet trained. She is parti cularly concerned that, although he reliably uses the potty seat for bowel movements, he isn’t able to hold his urine for long periods. Which of the following statements by the nurs e is correct? o A. The child should have been trained by age 2 and may have a psychological pro blem that is responsible for his "accidents." o B. Bladder control is usually achieved before bowel control, and the child sho uld be required to sit on the potty seat until he passes urine. 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? 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 put your baby to sleep on his side or tummy. Once your baby can roll from his back t14 tummy and tummy to back, your baby can stay in the sleep position that he assumes. But always place your baby to sleep on his back. 14A. Get moderate exercise for at least 30 minutes each day. o Option C: Eye contact and verbal engagement with infants are important t15 language development. Establish a consistent bedtime routine that includes calm and enjoyable activities that you can stick with as your baby gets older. Examples include a bath and bedtime stories. The activities occurring closest to “lights out” should occur in the room where your baby sleeps. Also, avoid making bedtime feedings part of the bedtime routine after 6 months. o Option D: The best diet for infants under 4 months of age is breast milk or infant formula. The American Academy of Pediatrics recommends exclusive breastfeeding for about 6 months, and then continuing breastfeeding while introducing complementary foods until the child is 12 months old or older. This provides the child with ideal nutrition and supports growth and development. • 59. Question 15 oB. Drink 6-8 glasses of water each day. • 60. Question A child is admitted to the hospital with suspected rheumatic fever. Which of the following observations is not confirming the diagnosis? 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 rheumatic fever recall having any upper respiratory symptoms, most commonly, sore throat, in the preceding several weeks. Studies in developed countries have established that rheumatic fever followed only pharyngeal infections and that not all serotypes of group A streptococci cause rheumatic fever. o Option D: Other symptoms of rheumatic fever include fever. The average duration of an untreated ARF attack is 3 months. Chronic rheumatic fever, generally defined as disease persisting for longer than 6 months, occurs in less than 5% of cases. • 61. Question A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform? o A. Ask the patient to lie down on the exam table. o B. Draw blood for chemistry panel and arterial blood gas (ABG). o C. Send the patient for a chest x-ray. o D. Check blood pressure. Correct Answer: D. Check blood pressure. A patient with congestive heart failure and dyspnea may have pulmonary edema, which can cause severe hypertension. Therefore, taking the patient’s blood pressure should be the first action. Monitor BP and central venous pressure (CVP). Hypertension and elevated CVP suggest fluid volume excess and may reflect developing pulmonary congestion, HF. o Option A: Lying flat on the exam table would likely worsen the dyspnea, and the patient may not tolerate it. Maintain chair or bed rest in semi-Fowler’s position during acute phase. Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis. o Option B: Blood draws for chemistry and ABG will be required, but not prior to the blood pressure assessment. Investigate reports of sudden extreme dyspnea and air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom. o Option C: The patient may be sent for an xray after initial assessment. Monitor chest x-ray. Reveals changes indicative of resolution of pulmonary congestion. Maintain fluid and sodium restrictions as indicated. Reduces total body water and prevents fluid reaccumulation. • 62. Question A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct? vomiting, GI side effects, mucositis, alopecia, sterility, infertility, and infusion reactions. Furthermore, there is an increased risk of infections due to immunosuppression. o Option C: Patients undergoing chemotherapy usually need strong emotional support, and they are going through anxiety, depression, and anticipatory grief from the expected side effects of the drugs. Multidisciplinary and interprofessional interventions at various stages of their treatment regimen can promote mental health. However, it is not indicated in this stem. o Option D: The information given does not indicate that dehydration is a cause of her symptoms. Chemotherapy-induced nausea and vomiting treatment options include prochlorperazine, haloperidol, metoclopramide, lorazepam, dexamethasone, ondansetron, granisetron, dolasetron, palonosetron, dronabinol, aprepitant, fosaprepitant, netupitant. palonosetron has a longer half-life, better efficacy, and higher binding affinity than granisetron. • 64. Question A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet. Which of the following nutritional advice is appropriate? o A. The diet is providing adequate sources of iron and requires no changes. o B. The patient should add meat to her diet; a vegetarian diet is not advised. o C. The patient should use iron cookware to prepare foods, such as dark green, leafy vegetables and legumes, which are high in iron. o D. A cup of coffee or tea should be added to every meal. Correct Answer: C. The patient should use iron cookware to prepare foods, such as dark green, leafy vegetables and legumes, which are high in iron. Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly anemic. When food is prepared in iron cookware its iron content is increased. Anemia is defined as hemoglobin below two standard deviations of the mean for the age and gender of the patient. Iron is an essential component of the hemoglobin molecule. The most common cause of anemia worldwide is iron deficiency, which results in microcytic and hypochromic red cells on the peripheral smear. o Option A: The client is mildly anemic. The cause of iron-deficiency anemia varies based on age, gender, and socioeconomic status. Iron deficiency may result from insufficient iron intake, decreased absorption, or blood loss. Irondeficiency anemia is most often from blood loss, especially in older patients. o Option B: Mild anemia does not require that animal sources of iron be added to the diet. Many non-animal sources are available. Dietary sources of iron are green vegetables, red meat, and iron-fortified milk formulas. It may also be seen with low dietary intake, increased systemic requirements for iron such as in pregnancy, and decreased iron absorption such as in celiac disease. o Option D: Coffee and tea increase gastrointestinal activity and inhibit absorption of iron. The iron in food comes from two sources: animals and plants. Iron from animal sources is known as heme iron and is found in meat and fish. Iron from plants is known as nonheme iron, and is found in certain vegetables and in iron- fortified foods such as breakfast cereals. Heme iron is better absorbed by the body than non heme iron. • 65. Question A hospitali zed patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. W hich of the following is the most ac curate statement? o A. Transfusion reaction is most likely immediately after the infusion is completed. o B. PRBCs are best infused slowly through a 20g. IV catheter. o C. PRBCs should be flushed with a 5% dextrose solution. o D. A nurse should remain in the room during the first 15 minutes of infusion. Correct Answer: D. A nurse should remain in the room during the first 15 minutes of infusion. Transfusion reaction is most likely during the first 15 minutes of infusion, and a nurse should be present during this period. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Meticulously verifying patient identification beginning with type and crossmatch sample collection and labeling to double-check blood product and patient identification prior to transfusion. o Option A: Transfusion reaction typically starts in the first 15 minutes of infusion. Beginning transfusion slowly ( 1 to 2 mL/min) and and allow the physician to reach a disposition decision. That decision means discharge, admit to the observation unit or the hospital floor. o Option D: The child’s chin laceration may need to be sutured but is also non-urgent. Differentiating between levels 3,4, and 5 are determined by how many hospital resources the patient will most likely need. If the patient requires two or more hospital resources, the patient is triaged as a level 3. If the patient needs one hospital resource, the patient would be labeled a 4. If the patient does not need any hospital resources, the patient would be labeled a 5. • 67. Question A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the following symptoms would you not expect to see in this patient? o A. Numbness in hands and feet o B. Muscle cramping o C. Hypoactive bowel sounds o D. Positive Chvostek's sign Correct Answer: C. Hypoactive bowel sounds Normal serum calcium is 8.5 – 10 mg/dL. The patient is hypocalcemic. Increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds, abdominal cramping and diarrhea is an indication of hypocalcemia. Hypocalcemia is said to be present when the total serum calcium concentration is less than 8.8 mg/dl. The disorder may be acquired or inherited but its presentation can vary- from asymptomatic to life-threatening. Hypocalcemia is commonly seen in hospitalized patients and for the most part, is mild in nature and only requires supportive treatment. o Option A: Paresthesias can be perioral or otherwise. Carpopedal spasm, also referred to as Trousseau’s sign. It represents increased neuromuscular excitability which may be related to the gating function of calcium ions for ion channels at a cellular level (particularly in neurons). This manifests as a spasm of hand upon routine BP check. o Option B: Numbness in hands and feet and muscle cramps are also signs of hypocalcemia. Tetany is generally induced by a rapid decline in serum ionized calcium. Tetany is usually most dangerous and most commonly seen in the presence of respiratory alkalosis causing hypocalcemia. o Option D: Positive Chvostek’s sign refers to the sustained twitching of facial muscles following tapping in the area of the cheekbone and is a hallmark of hypocalcemia. Another manifestation of heightened neuromuscular excitability. It is the spasm of facial muscles in response to tapping the facial nerve near the angle of the jaw. • 68. Question A nurse cares for a patient who has a nasogastric tube attachedto low suction because of a suspected bowel obstruction. Which of the following arterial blood gas results might be expected in this patient? o A. pH 7.52, PCO2 54 mmHg. o B. pH 7.42, PCO2 40 mmHg. o C. pH 7.25, PCO2 25 mmHg. o D. pH 7.38, PCO2 36 mmHg. Correct Answer: A. pH 7.52, PCO2 54 mmHg. A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis. Normal range for pH range from 7.35-7.45. CO2 level has a normal range of 35 to 45 mmHg. Normal range for HCO3 is 22-26 mmol/L. The lower the number, the more acidotic the patient is. The higher the pH, the more base is in the blood sample. o Option B: This result is a normal blood gas value. Arterial blood gas analysis assesses a patient’s partial pressure of oxygen (PaO2), providing information on the oxygenation status; the partial pressure of carbon dioxide (PaCO2), providing information on the ventilation status (chronic or acute respiratory failure, and is changed by hyperventilation (rapid or deep breathing) and hypoventilation (slow or shallow breathing); and acid-base status. o Option C: This result represents respiratory acidosis. Arterial blood gas interpretation is best approached systematically. Interpretation leads to an understanding of the degree or severity of abnormalities, whether the abnormalities are acute or chronic, and if the primary disorder is metabolic or respiratory in origin. Several articles have described simplistic ways to interpret ABG results. However, the Romanski method of analysis is most simplistic for all levels of providers. This method assists with determining the presence of an acid-base disorder, its primary cause, and whether compensation is present. o Option D: This result is borderline normal with slightly low PCO2. The PaCO2 indicates whether the acidosis or alkalemia is primarily from a respiratory or metabolic acidosis/alkalosis. Paco2>40 with a pH<7.4, indicates a respiratory acidosis, and <40 and pH<7.4 indicates a respiratory alkalosis (but is often from hyperventilation from anxiety or compensation for a metabolic acidosis). • 69. Question A patient is admitted to the hospital for routine elective surgery. Included in the list of current me dications is warfarin (Coumadin) at a high dose. Concerned about the possible effects of drug, particularly in a patient scheduled for surgery, the nurse anticipates