Question #1
A patient with a history angina pectoris brought by to the Emergency Department complaining of severe chest pain. The patient informs the nurse that he did not take nitroglycerine tablet.
Which of the following assessment findings must concern the nurses MOST before administering nitroglycerine?
- A . Heart rate of 90 bpm
- B . Blood sugar of 12 mmol/L
- C . Blood pressure of 190/110 mmHg
- D . Blood pressure of 80/60 mmHg
Correct Answer: D
D
Explanation:
Patient History: The patient has angina pectoris, which means they have episodes of chest pain due to reduced blood flow to the heart muscle. Nitroglycerin is a common medication used to relieve this pain by dilating blood vessels.
Nitroglycerin Mechanism: Nitroglycerin works by relaxing and widening blood vessels, which decreases the workload on the heart and increases blood flow to the heart muscle. This process typically lowers blood pressure.
Assessment Concerns:
Heart rate of 90 bpm: This is within the normal range and does not typically contraindicate the use of nitroglycerin.
Blood sugar of 12 mmol/L: Elevated blood sugar is concerning but not directly affected by nitroglycerin administration.
Blood pressure of 190/110 mmHg: This is high and nitroglycerin can help reduce it. High blood pressure is often treated with nitroglycerin.
Blood pressure of 80/60 mmHg: This is hypotension (low blood pressure). Since nitroglycerin lowers blood pressure further, administering it to a patient with already low blood pressure can lead to severe hypotension, which is life-threatening.
Conclusion: The most concerning finding is the low blood pressure (80/60 mmHg) because administering nitroglycerin in this situation can further lower the blood pressure to dangerous levels.
Reference: NCLEX-RN review guides, pharmacology textbooks, clinical guidelines on the management of angina pectoris and nitroglycerin use.
D
Explanation:
Patient History: The patient has angina pectoris, which means they have episodes of chest pain due to reduced blood flow to the heart muscle. Nitroglycerin is a common medication used to relieve this pain by dilating blood vessels.
Nitroglycerin Mechanism: Nitroglycerin works by relaxing and widening blood vessels, which decreases the workload on the heart and increases blood flow to the heart muscle. This process typically lowers blood pressure.
Assessment Concerns:
Heart rate of 90 bpm: This is within the normal range and does not typically contraindicate the use of nitroglycerin.
Blood sugar of 12 mmol/L: Elevated blood sugar is concerning but not directly affected by nitroglycerin administration.
Blood pressure of 190/110 mmHg: This is high and nitroglycerin can help reduce it. High blood pressure is often treated with nitroglycerin.
Blood pressure of 80/60 mmHg: This is hypotension (low blood pressure). Since nitroglycerin lowers blood pressure further, administering it to a patient with already low blood pressure can lead to severe hypotension, which is life-threatening.
Conclusion: The most concerning finding is the low blood pressure (80/60 mmHg) because administering nitroglycerin in this situation can further lower the blood pressure to dangerous levels.
Reference: NCLEX-RN review guides, pharmacology textbooks, clinical guidelines on the management of angina pectoris and nitroglycerin use.
Question #2
A circulating nurse is caring for a patient who is undergoing to laparotomy under a general anesthesia in the Operating Room.
What is the PRIORITY nursing diagnosis the circulating nurse would include in the care plan?
- A . Risk for anxiety related to surgery
- B . Risk for bleeding related to surgery
- C . Risk for injury related to positioning
- D . Risk for infection related to surgical incision
Correct Answer: C
C
Explanation:
Role of Circulating Nurse: The circulating nurse manages the overall environment of the operating room, ensuring safety and coordination among the surgical team. They are responsible for maintaining patient safety, including correct positioning.
Prioritizing Safety:
Risk for anxiety: While relevant, managing anxiety is typically addressed preoperatively and postoperatively, not the immediate intraoperative period.
Risk for bleeding: While bleeding is a concern, it is primarily monitored and managed by the surgical team.
Risk for injury related to positioning: During surgery, improper positioning can lead to nerve damage, pressure sores, and musculoskeletal injuries. The circulating nurse must ensure that the patient is correctly positioned to avoid these injuries.
Risk for infection: Preventing infection is crucial, but the sterile field and surgical techniques primarily address this risk.
Conclusion: The highest priority for the circulating nurse is to ensure the patient is correctly positioned to prevent any injury related to positioning, as this is a direct and immediate responsibility during the surgical procedure.
Reference: Surgical nursing textbooks, NCLEX-RN review guides, AORN (Association of periOperative Registered Nurses) guidelines.
C
Explanation:
Role of Circulating Nurse: The circulating nurse manages the overall environment of the operating room, ensuring safety and coordination among the surgical team. They are responsible for maintaining patient safety, including correct positioning.
Prioritizing Safety:
Risk for anxiety: While relevant, managing anxiety is typically addressed preoperatively and postoperatively, not the immediate intraoperative period.
Risk for bleeding: While bleeding is a concern, it is primarily monitored and managed by the surgical team.
Risk for injury related to positioning: During surgery, improper positioning can lead to nerve damage, pressure sores, and musculoskeletal injuries. The circulating nurse must ensure that the patient is correctly positioned to avoid these injuries.
Risk for infection: Preventing infection is crucial, but the sterile field and surgical techniques primarily address this risk.
Conclusion: The highest priority for the circulating nurse is to ensure the patient is correctly positioned to prevent any injury related to positioning, as this is a direct and immediate responsibility during the surgical procedure.
Reference: Surgical nursing textbooks, NCLEX-RN review guides, AORN (Association of periOperative Registered Nurses) guidelines.
Question #3
A nurse is providing health education and instructions to a woman who has been diagnosed with mastitis.
Which of the following statements if made by the woman indicates a need for further teaching?
- A . "1 need to stop breastfeeding until this condition resolves."
- B . "Analgesia will help me to alleviate some of the discomfort."
- C . "1 need to take antibiotics and 1 will feel better in 24-48 hours."
- D . "Warm compression to the breasts before feeding may be useful."
Correct Answer: A
A
Explanation:
Understanding Mastitis: Mastitis is an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. It often occurs in breastfeeding women.
Appropriate Management:
Continue Breastfeeding: It is generally recommended to continue breastfeeding or pumping to relieve milk stasis and prevent further complications.
Analgesia: Pain relief medications (analgesia) can help manage discomfort associated with mastitis.
Antibiotics: Antibiotics are often prescribed, and improvement is typically seen within 24-48 hours. Warm Compression: Applying warm compresses before breastfeeding can help alleviate pain and improve milk flow.
Incorrect Belief: The statement "I need to stop breastfeeding until this condition resolves" indicates a misunderstanding. Stopping breastfeeding can worsen the condition due to milk stasis and increased engorgement.
Conclusion: The statement indicates a need for further teaching as continuing breastfeeding is crucial for managing and resolving mastitis.
Reference: Maternal and child nursing textbooks, NCLEX-RN review guides, clinical guidelines on breastfeeding and mastitis management.
A
Explanation:
Understanding Mastitis: Mastitis is an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. It often occurs in breastfeeding women.
Appropriate Management:
Continue Breastfeeding: It is generally recommended to continue breastfeeding or pumping to relieve milk stasis and prevent further complications.
Analgesia: Pain relief medications (analgesia) can help manage discomfort associated with mastitis.
Antibiotics: Antibiotics are often prescribed, and improvement is typically seen within 24-48 hours. Warm Compression: Applying warm compresses before breastfeeding can help alleviate pain and improve milk flow.
Incorrect Belief: The statement "I need to stop breastfeeding until this condition resolves" indicates a misunderstanding. Stopping breastfeeding can worsen the condition due to milk stasis and increased engorgement.
Conclusion: The statement indicates a need for further teaching as continuing breastfeeding is crucial for managing and resolving mastitis.
Reference: Maternal and child nursing textbooks, NCLEX-RN review guides, clinical guidelines on breastfeeding and mastitis management.
Question #4
A nurse is preparing to collect a throat culture for a middle-aged male patient.
The nurse is aware that the swabbing should be collected from:
- A . Uvula and soft palate
- B . Any site of oral cavity mucosa
- C . Tongue and right or left buccal mucosa
- D . Mucosa of oropharynx and tonsillar region
Correct Answer: D
D
Explanation:
Purpose of Throat Culture: A throat culture is performed to detect the presence of pathogens (like bacteria) that cause infections such as strep throat. Correct Technique:
Uvula and Soft Palate: These are not the primary sites for collecting throat cultures.
Any site of Oral Cavity Mucosa: This is too broad and non-specific.
Tongue and Buccal Mucosa: These sites are not typically infected in throat infections and do not provide accurate culture results.
Oropharynx and Tonsillar Region: The mucosa of the oropharynx and tonsillar region is the most common site of infection in throat infections, making it the appropriate site for swabbing. Procedure: The nurse should gently swab the oropharynx and tonsillar area, avoiding the tongue and other parts of the oral cavity to avoid contamination and ensure accurate results.
Conclusion: The correct site for collecting a throat culture is the mucosa of the oropharynx and tonsillar region, ensuring the detection of the causative pathogens.
Reference: Clinical nursing skills textbooks, NCLEX-RN review guides, guidelines for throat culture collection.
D
Explanation:
Purpose of Throat Culture: A throat culture is performed to detect the presence of pathogens (like bacteria) that cause infections such as strep throat. Correct Technique:
Uvula and Soft Palate: These are not the primary sites for collecting throat cultures.
Any site of Oral Cavity Mucosa: This is too broad and non-specific.
Tongue and Buccal Mucosa: These sites are not typically infected in throat infections and do not provide accurate culture results.
Oropharynx and Tonsillar Region: The mucosa of the oropharynx and tonsillar region is the most common site of infection in throat infections, making it the appropriate site for swabbing. Procedure: The nurse should gently swab the oropharynx and tonsillar area, avoiding the tongue and other parts of the oral cavity to avoid contamination and ensure accurate results.
Conclusion: The correct site for collecting a throat culture is the mucosa of the oropharynx and tonsillar region, ensuring the detection of the causative pathogens.
Reference: Clinical nursing skills textbooks, NCLEX-RN review guides, guidelines for throat culture collection.
Question #5
The aim of outcome research in nursing is to:
- A . Explore and investigate nursing clinical interventions
- B . Focus on the perception and of nursing professional
- C . Assess and documents the effectiveness of health care services
- D . Analyze the cause and effect relationship based on nursing actions
Correct Answer: C
C
Explanation:
Outcome research in nursing focuses on understanding the results of health care practices and interventions. It aims to evaluate how effective these practices are in improving patient outcomes. This type of research is crucial for ensuring that the care provided is evidence-based and leads to the best possible health results for patients.
For example, if a new wound care protocol is introduced, outcome research would measure whether patients heal faster or have fewer infections compared to the previous method. This helps in determining the effectiveness of the new protocol.
Reference: Polit,
D. F., & Beck,
C. T. (2017). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Wolters Kluwer Health.
C
Explanation:
Outcome research in nursing focuses on understanding the results of health care practices and interventions. It aims to evaluate how effective these practices are in improving patient outcomes. This type of research is crucial for ensuring that the care provided is evidence-based and leads to the best possible health results for patients.
For example, if a new wound care protocol is introduced, outcome research would measure whether patients heal faster or have fewer infections compared to the previous method. This helps in determining the effectiveness of the new protocol.
Reference: Polit,
D. F., & Beck,
C. T. (2017). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Wolters Kluwer Health.
Question #6
A nurse is caring for an adult client with cancer who is complaining of acute pain.
The MOST appropriate pain assessment would be:
- A . The client’s pain rating
- B . Nonverbal cues from the client
- C . The nurses’ impression of the client’s pain
- D . Pain relief after appropriate nursing intervention
Correct Answer: A
A
Explanation:
The most appropriate way to assess pain is by asking the client to rate their pain. Pain is a subjective experience, meaning only the person experiencing it can accurately describe its intensity and quality. This is often done using a numerical scale (0-10) where the patient rates their pain, with 0 being no pain and 10 being the worst pain imaginable.
Nonverbal cues and the nurse’s impression can provide additional information, but they are not as reliable as the patient’s self-report. Pain relief after interventions helps evaluate the effectiveness of the pain management but does not assess the initial pain level.
Reference: McCaffery, M., & Pasero, C. (1999). Pain: Clinical Manual. Mosby.
A
Explanation:
The most appropriate way to assess pain is by asking the client to rate their pain. Pain is a subjective experience, meaning only the person experiencing it can accurately describe its intensity and quality. This is often done using a numerical scale (0-10) where the patient rates their pain, with 0 being no pain and 10 being the worst pain imaginable.
Nonverbal cues and the nurse’s impression can provide additional information, but they are not as reliable as the patient’s self-report. Pain relief after interventions helps evaluate the effectiveness of the pain management but does not assess the initial pain level.
Reference: McCaffery, M., & Pasero, C. (1999). Pain: Clinical Manual. Mosby.
Question #7
A client with schizophrenia is placed on chlorpromazine 50 mg PO bid, and Benztropine 2 mg PO bid
PRN.
Which of the following nursing assessment findings would indicate a need to administer Benztropine?
- A . Client is agitated severely
- B . Client complains of a sore throat
- C . Client expresses suicidal thoughts
- D . Client develops muscle spasm and tremors
Correct Answer: D
D
Explanation:
Chlorpromazine is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), such as muscle spasms and tremors. Benztropine is an anticholinergic medication often prescribed to manage these side effects.
If a client on chlorpromazine develops muscle spasms and tremors, it indicates EPS, and administering Benztropine would help alleviate these symptoms. The other options, such as severe agitation, sore throat, or suicidal thoughts, are not directly related to the need for Benztropine.
Reference: Stahl, S. M. (2013). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. Cambridge University Press.
D
Explanation:
Chlorpromazine is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), such as muscle spasms and tremors. Benztropine is an anticholinergic medication often prescribed to manage these side effects.
If a client on chlorpromazine develops muscle spasms and tremors, it indicates EPS, and administering Benztropine would help alleviate these symptoms. The other options, such as severe agitation, sore throat, or suicidal thoughts, are not directly related to the need for Benztropine.
Reference: Stahl, S. M. (2013). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. Cambridge University Press.
Question #8
A nurse is visiting an Asian family and found that both parents have cardiac problems. The nurse is aware of Asian genetic predisposition to cardiovascular diseases.
The nurse assessment falls below which of the following cultural assessment category?
- A . Bio-cultural factors
- B . Socio-cultural practices
- C . Ethnic/racial background
- D . Cultural dietary practices
Correct Answer: A
A
Explanation:
When assessing the health of a family, considering their genetic predispositions to certain conditions falls under the category of bio-cultural factors. These factors include genetic traits, physical characteristics, and biological variations that can influence health. In this case, the nurse’s awareness of the genetic predisposition of Asian individuals to cardiovascular diseases helps in understanding the family’s health risks.
Reference: Spector, R.
E. (2017). Cultural Diversity in Health and Illness. Pearson.
A
Explanation:
When assessing the health of a family, considering their genetic predispositions to certain conditions falls under the category of bio-cultural factors. These factors include genetic traits, physical characteristics, and biological variations that can influence health. In this case, the nurse’s awareness of the genetic predisposition of Asian individuals to cardiovascular diseases helps in understanding the family’s health risks.
Reference: Spector, R.
E. (2017). Cultural Diversity in Health and Illness. Pearson.
Question #9
A woman presents to the clinic with signs and symptoms of menopause. The doctor advised to start hormonal replacement therapy. The woman enquired about the adverse effects of this therapy.
Which of the following is an adverse effects of the hormonal replacement therapy?
- A . Osteoporosis
- B . Atherosclerosis
- C . Endometrial cancer
- D . Cerebrovascular accident
Correct Answer: C
C
Explanation:
Hormone replacement therapy (HRT) can have several adverse effects. One significant risk associated with HRT, especially if estrogen is given without progesterone to women with an intact uterus, is the increased risk of endometrial cancer. Estrogen stimulates the lining of the uterus, and without the balancing effect of progesterone, this can lead to endometrial hyperplasia and potentially cancer.
Other risks include breast cancer, blood clots, and stroke, but endometrial cancer is a specific concern with unopposed estrogen therapy.
Reference: Goodman, N. F., et al. (2011). American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocrine Practice, 17(6), 1-25.
C
Explanation:
Hormone replacement therapy (HRT) can have several adverse effects. One significant risk associated with HRT, especially if estrogen is given without progesterone to women with an intact uterus, is the increased risk of endometrial cancer. Estrogen stimulates the lining of the uterus, and without the balancing effect of progesterone, this can lead to endometrial hyperplasia and potentially cancer.
Other risks include breast cancer, blood clots, and stroke, but endometrial cancer is a specific concern with unopposed estrogen therapy.
Reference: Goodman, N. F., et al. (2011). American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocrine Practice, 17(6), 1-25.
Question #10
A nurse understands that patient with blood transfusion reaction is at risk to develop which of the following types of jaundice?
- A . Hepatocellular
- B . Obstructive
- C . Hemolytic
- D . Chronic
Correct Answer: C
C
Explanation:
A blood transfusion reaction can lead to hemolytic jaundice. This type of jaundice occurs when there is an excessive breakdown of red blood cells, leading to an increase in bilirubin production.
Hemolytic reactions during a blood transfusion cause the destruction of the transfused red blood cells, releasing large amounts of hemoglobin into the bloodstream, which is then converted to bilirubin, resulting in jaundice.
Reference: American Association of Blood Banks (AABB). (2017). Technical Manual, 19th Edition. AABB Press.
C
Explanation:
A blood transfusion reaction can lead to hemolytic jaundice. This type of jaundice occurs when there is an excessive breakdown of red blood cells, leading to an increase in bilirubin production.
Hemolytic reactions during a blood transfusion cause the destruction of the transfused red blood cells, releasing large amounts of hemoglobin into the bloodstream, which is then converted to bilirubin, resulting in jaundice.
Reference: American Association of Blood Banks (AABB). (2017). Technical Manual, 19th Edition. AABB Press.
Question #11
A nurse is caring for a patient who is admitted into the surgical ward and was diagnosed with perforated appendix and is shifted to operation room for appendectomy.
The nurse understands that this procedure is classified as:
- A . Urgent
- B . Emergent
- C . Elective
- D . Required
Correct Answer: B
B
Explanation:
A perforated appendix is a medical emergency requiring immediate surgical intervention to prevent complications such as peritonitis and sepsis. Therefore, an appendectomy in this context is classified as an emergent procedure. Emergent surgeries are those that need to be performed without delay to preserve the patient’s life or health.
Reference: Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
B
Explanation:
A perforated appendix is a medical emergency requiring immediate surgical intervention to prevent complications such as peritonitis and sepsis. Therefore, an appendectomy in this context is classified as an emergent procedure. Emergent surgeries are those that need to be performed without delay to preserve the patient’s life or health.
Reference: Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
Question #12
Which of the following is an appropriate role of the parents in the teenage-stage of family developmental tasks?
- A . Coping with the energy depletion
- B . Releasing young adults into work
- C . Balancing freedom with responsibility
- D . Preparing themselves for different roles
Correct Answer: C
C
Explanation:
During the teenage stage of family development, parents play a crucial role in helping their adolescents balance freedom with responsibility. This includes setting appropriate boundaries, providing guidance, and encouraging independence while ensuring that teenagers understand and meet their responsibilities. It is a critical period where parental support and oversight help teens develop into responsible adults.
Reference: Hockenberry, M. J., & Wilson, D. (2018). Wong’s Nursing Care of Infants and Children. Elsevier.
C
Explanation:
During the teenage stage of family development, parents play a crucial role in helping their adolescents balance freedom with responsibility. This includes setting appropriate boundaries, providing guidance, and encouraging independence while ensuring that teenagers understand and meet their responsibilities. It is a critical period where parental support and oversight help teens develop into responsible adults.
Reference: Hockenberry, M. J., & Wilson, D. (2018). Wong’s Nursing Care of Infants and Children. Elsevier.
Question #13
A nurse is caring for a patient with bacterial meningitis who develops high-grade fever and nasal discharge.
Which of the following is the FIRST nursing intervention for this patient?
- A . Control elevated body temperature
- B . Assist with getting rest in a quiet dark room
- C . Encourage patient to stay hydrated with adequate oral intake
- D . Follow infection precautions for 24 hours after starting antibiotic treatment
Correct Answer: D
D
Explanation:
The first nursing intervention for a patient with bacterial meningitis who develops a high-grade fever and nasal discharge is to follow infection precautions. This is crucial to prevent the spread of the infection to others. Bacterial meningitis is highly contagious, and infection control measures such as isolation and wearing protective gear should be implemented immediately upon diagnosis and continued for at least 24 hours after starting antibiotic treatment.
Reference: Centers for Disease Control and Prevention (CDC). (2018). Bacterial Meningitis. Retrieved from CDC website.
D
Explanation:
The first nursing intervention for a patient with bacterial meningitis who develops a high-grade fever and nasal discharge is to follow infection precautions. This is crucial to prevent the spread of the infection to others. Bacterial meningitis is highly contagious, and infection control measures such as isolation and wearing protective gear should be implemented immediately upon diagnosis and continued for at least 24 hours after starting antibiotic treatment.
Reference: Centers for Disease Control and Prevention (CDC). (2018). Bacterial Meningitis. Retrieved from CDC website.
Question #14
A nurse must be aware that keeping an aggressive patient in a seclusion or restraint requires an order from the doctor.
The renewal of such order for a patient aged 19 years old must be done:
- A . Every 1 hour
- B . Every 2 hours
- C . Every 4 hours
- D . Every 7 hours
Correct Answer: C
C
Explanation:
When a patient aged 19 years old is placed in seclusion or restraint, the renewal of the order must be done every 4 hours. This requirement is based on the guidelines provided by the Joint Commission and the Centers for Medicare & Medicaid Services (CMS), which regulate the use of seclusion and restraints in healthcare settings.
Initial Order: The use of seclusion or restraint must be ordered by a licensed independent practitioner (LIP), such as a physician.
Time Limits: For adults aged 18 and older, the order must be renewed every 4 hours.
Renewal Process: This renewal must involve an assessment of the patient’s condition and the need for continued seclusion or restraint.
Documentation: The rationale for using seclusion or restraint and the patient’s response to the intervention must be documented thoroughly in the patient’s medical record.
Reference: The Joint Commission: Standards for Behavioral Health Care
Centers for Medicare & Medicaid Services (CMS): Conditions of Participation for Hospitals, 42 CFR 482.13(e)
C
Explanation:
When a patient aged 19 years old is placed in seclusion or restraint, the renewal of the order must be done every 4 hours. This requirement is based on the guidelines provided by the Joint Commission and the Centers for Medicare & Medicaid Services (CMS), which regulate the use of seclusion and restraints in healthcare settings.
Initial Order: The use of seclusion or restraint must be ordered by a licensed independent practitioner (LIP), such as a physician.
Time Limits: For adults aged 18 and older, the order must be renewed every 4 hours.
Renewal Process: This renewal must involve an assessment of the patient’s condition and the need for continued seclusion or restraint.
Documentation: The rationale for using seclusion or restraint and the patient’s response to the intervention must be documented thoroughly in the patient’s medical record.
Reference: The Joint Commission: Standards for Behavioral Health Care
Centers for Medicare & Medicaid Services (CMS): Conditions of Participation for Hospitals, 42 CFR 482.13(e)
Question #15
The unit in-charge is following up an incident report for a patient who fell down from the bed to be written by the nurse.
Which of the following actions if done by the nurse needs to be corrected?
- A . Writing the incident report immediately
- B . Investigating the root cause of the incidence
- C . Writing the incident report by the assigned nurse
- D . Documenting the incident report in patient’s record
Correct Answer: D
D
Explanation:
When an incident such as a patient fall occurs, specific protocols must be followed to ensure proper documentation and quality improvement processes.
Writing the Incident Report Immediately: The nurse should document the incident as soon as possible to ensure accurate details are captured.
Investigating the Root Cause of the Incident: This is essential to prevent future occurrences and improve patient safety. It involves a thorough analysis of the factors that led to the incident. Writing the Incident Report by the Assigned Nurse: The nurse who witnessed or discovered the incident is typically responsible for documenting it, ensuring first-hand accuracy.
Documenting the Incident Report in Patient’s Record: This is incorrect. Incident reports are meant for
internal use to track and analyze incidents and should not be included in the patient’s medical
record. Including it in the patient’s record can potentially compromise confidentiality and affect the
patient’s care.
Reference: The Joint Commission: Sentinel Event Policy and Procedures
National Patient Safety Foundation: Guidelines for Incident Reporting
D
Explanation:
When an incident such as a patient fall occurs, specific protocols must be followed to ensure proper documentation and quality improvement processes.
Writing the Incident Report Immediately: The nurse should document the incident as soon as possible to ensure accurate details are captured.
Investigating the Root Cause of the Incident: This is essential to prevent future occurrences and improve patient safety. It involves a thorough analysis of the factors that led to the incident. Writing the Incident Report by the Assigned Nurse: The nurse who witnessed or discovered the incident is typically responsible for documenting it, ensuring first-hand accuracy.
Documenting the Incident Report in Patient’s Record: This is incorrect. Incident reports are meant for
internal use to track and analyze incidents and should not be included in the patient’s medical
record. Including it in the patient’s record can potentially compromise confidentiality and affect the
patient’s care.
Reference: The Joint Commission: Sentinel Event Policy and Procedures
National Patient Safety Foundation: Guidelines for Incident Reporting
Question #16
A head nurse of an intensive care unit wants to ensure that the staff are performing Basic Life Support (BLS) based on latest American Heart Association’s guidelines.
What will be the head nurse’s BEST action?
- A . Review the BLS policy periodically
- B . Perform regular mocks on BLS in the unit
- C . Send staff to renew BLS certification every three years
- D . Monitor the staff performing BLS during the actual scene
Correct Answer: B
B
Explanation:
Ensuring that staff perform Basic Life Support (BLS) according to the latest American Heart Association (AHA) guidelines involves several strategies, but performing regular mock drills is the best approach.
Reviewing the BLS Policy Periodically: While this is important, it alone does not ensure that staff are up-to-date or proficient in BLS techniques.
Performing Regular Mocks on BLS in the Unit: Regular mock drills provide hands-on practice and allow staff to apply the latest guidelines in a simulated environment. This helps in retaining skills and identifying any gaps in knowledge or performance.
Sending Staff to Renew BLS Certification Every Three Years: Certification renewal is necessary, but practical skills can degrade over time if not regularly practiced.
Monitoring the Staff Performing BLS During the Actual Scene: This is reactive rather than proactive and does not provide an opportunity for practice and improvement without the pressure of a real-life situation.
Reference: American Heart Association (AHA): Guidelines for CPR and ECC
National Institutes of Health (NIH): Effective Training Strategies in Healthcare
B
Explanation:
Ensuring that staff perform Basic Life Support (BLS) according to the latest American Heart Association (AHA) guidelines involves several strategies, but performing regular mock drills is the best approach.
Reviewing the BLS Policy Periodically: While this is important, it alone does not ensure that staff are up-to-date or proficient in BLS techniques.
Performing Regular Mocks on BLS in the Unit: Regular mock drills provide hands-on practice and allow staff to apply the latest guidelines in a simulated environment. This helps in retaining skills and identifying any gaps in knowledge or performance.
Sending Staff to Renew BLS Certification Every Three Years: Certification renewal is necessary, but practical skills can degrade over time if not regularly practiced.
Monitoring the Staff Performing BLS During the Actual Scene: This is reactive rather than proactive and does not provide an opportunity for practice and improvement without the pressure of a real-life situation.
Reference: American Heart Association (AHA): Guidelines for CPR and ECC
National Institutes of Health (NIH): Effective Training Strategies in Healthcare
Question #17
A nursing instructor teaching a group of nursing students about the recommended diet for a patient with a myocardial infarction.
Which of the following points will be included in the teaching?
- A . Low fat and cholesterol
- B . High intake of red meat
- C . Low intake of dark chocolate
D Low protein and high carbohydrates
Correct Answer: A
A
Explanation:
When teaching nursing students about the recommended diet for a patient with a myocardial infarction, it’s crucial to emphasize a diet low in fat and cholesterol. This helps in reducing the risk of further cardiovascular complications.
Low Fat and Cholesterol: Foods low in saturated fat and cholesterol are recommended to prevent the build-up of plaque in the arteries and reduce the risk of another heart attack.
Avoiding Red Meat: High intake of red meat is discouraged because it is often high in saturated fat and cholesterol.
Dark Chocolate Intake: While some dark chocolate in moderation can have health benefits due to its antioxidant properties, the emphasis should be on a balanced diet.
Protein and Carbohydrates: Protein is essential for recovery, but the focus should be on lean sources. Carbohydrates should come from whole grains and other healthy sources rather than simple sugars.
Reference: American Heart Association (AHA): Dietary Recommendations for Cardiovascular Health National Institutes of Health (NIH): Heart-Healthy Eating
A
Explanation:
When teaching nursing students about the recommended diet for a patient with a myocardial infarction, it’s crucial to emphasize a diet low in fat and cholesterol. This helps in reducing the risk of further cardiovascular complications.
Low Fat and Cholesterol: Foods low in saturated fat and cholesterol are recommended to prevent the build-up of plaque in the arteries and reduce the risk of another heart attack.
Avoiding Red Meat: High intake of red meat is discouraged because it is often high in saturated fat and cholesterol.
Dark Chocolate Intake: While some dark chocolate in moderation can have health benefits due to its antioxidant properties, the emphasis should be on a balanced diet.
Protein and Carbohydrates: Protein is essential for recovery, but the focus should be on lean sources. Carbohydrates should come from whole grains and other healthy sources rather than simple sugars.
Reference: American Heart Association (AHA): Dietary Recommendations for Cardiovascular Health National Institutes of Health (NIH): Heart-Healthy Eating
Question #18
A nurse is performing a chest physical assessment on a client with asthma.
Which of the following lung sounds the nurse expects to hear?
- A . Stridor
- B . Crackles
- C . Wheezes
- D . D. Diminished
Correct Answer: C
C
Explanation:
In a chest physical assessment of a client with asthma, the nurse expects to hear wheezes. Wheezes: These are high-pitched, musical sounds heard during expiration (and sometimes inspiration) caused by narrowing or obstruction of the airways.
Stridor: This is a high-pitched sound usually heard on inspiration, typically associated with upper airway obstruction, not asthma.
Crackles: These are popping sounds heard during inspiration, often associated with conditions like pneumonia or heart failure, not typical for asthma.
Diminished Lung Sounds: This can occur in severe asthma but is less common compared to wheezes.
Reference: American Thoracic Society: Asthma Diagnosis and Monitoring National Institute of Allergy and Infectious Diseases (NIAID): Asthma Symptoms and Diagnosis
C
Explanation:
In a chest physical assessment of a client with asthma, the nurse expects to hear wheezes. Wheezes: These are high-pitched, musical sounds heard during expiration (and sometimes inspiration) caused by narrowing or obstruction of the airways.
Stridor: This is a high-pitched sound usually heard on inspiration, typically associated with upper airway obstruction, not asthma.
Crackles: These are popping sounds heard during inspiration, often associated with conditions like pneumonia or heart failure, not typical for asthma.
Diminished Lung Sounds: This can occur in severe asthma but is less common compared to wheezes.
Reference: American Thoracic Society: Asthma Diagnosis and Monitoring National Institute of Allergy and Infectious Diseases (NIAID): Asthma Symptoms and Diagnosis
Question #19
A nurse is aiming to utilize an evidence based process to improve pain management for patients with cancer.
The initial step the nurse should start with is:
- A . Selecting the study design
- B . Obtaining the ethical approval
- C . Writing an answerable question
- D . Formulating Hypothesis statement
Correct Answer: C
C
Explanation:
The initial step in an evidence-based process to improve pain management for patients with cancer is to write an answerable question.
Writing an Answerable Question : This is often done using the PICO (Patient/Problem, Intervention, Comparison, Outcome) format to clearly define the clinical issue and guide the research.
Selecting the Study Design: This comes after formulating the question and involves choosing an appropriate methodology to answer it.
Obtaining Ethical Approval: This is essential for conducting research but comes after defining the question and designing the study.
Formulating Hypothesis Statement: This is part of the research design and planning, following the creation of an answerable question.
Reference: Melnyk,
B. M., & Fineout-Overholt,
E. (2015). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice.
National Institutes of Health (NIH): Evidence-Based Practice Resources
C
Explanation:
The initial step in an evidence-based process to improve pain management for patients with cancer is to write an answerable question.
Writing an Answerable Question : This is often done using the PICO (Patient/Problem, Intervention, Comparison, Outcome) format to clearly define the clinical issue and guide the research.
Selecting the Study Design: This comes after formulating the question and involves choosing an appropriate methodology to answer it.
Obtaining Ethical Approval: This is essential for conducting research but comes after defining the question and designing the study.
Formulating Hypothesis Statement: This is part of the research design and planning, following the creation of an answerable question.
Reference: Melnyk,
B. M., & Fineout-Overholt,
E. (2015). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice.
National Institutes of Health (NIH): Evidence-Based Practice Resources
Question #20
A mother of a newborn is diagnosed with breast cancer, the surgeon recommended to carry out an emergency operation.
According to Freud’s theory, which stage of newborn development is being affected?
- A . Oral stage
- B . Anal stage
- C . Phallic stage
- D . Latent stage
Correct Answer: A
A
Explanation:
According to Freud’s theory of psychosexual development, the stage affected in a newborn is the oral stage.
Oral Stage: This stage occurs from birth to about 18 months of age, where the infant’s pleasure centers on the mouth through activities like sucking and biting.
Anal Stage: This stage follows the oral stage, from 18 months to 3 years, focusing on bowel and bladder control.
Phallic Stage: This occurs from 3 to 6 years, focusing on the genitals and the differences between males and females.
Latent Stage: This stage occurs from 6 years to puberty, characterized by dormant sexual feelings and a focus on social and intellectual skills.
Reference: Freud, S. (1905). Three Essays on the Theory of Sexuality. National Institutes of Health (NIH): Child Development Theories
A
Explanation:
According to Freud’s theory of psychosexual development, the stage affected in a newborn is the oral stage.
Oral Stage: This stage occurs from birth to about 18 months of age, where the infant’s pleasure centers on the mouth through activities like sucking and biting.
Anal Stage: This stage follows the oral stage, from 18 months to 3 years, focusing on bowel and bladder control.
Phallic Stage: This occurs from 3 to 6 years, focusing on the genitals and the differences between males and females.
Latent Stage: This stage occurs from 6 years to puberty, characterized by dormant sexual feelings and a focus on social and intellectual skills.
Reference: Freud, S. (1905). Three Essays on the Theory of Sexuality. National Institutes of Health (NIH): Child Development Theories
Question #21
A staff nurse was entering patient’s clinical notes in the computer, and had to leave to attend an immediate call without completion of recording. Another nurse used the account of the previous nurse to enter her notes.
Which of the following BEST describes the ethical issue that was committed?
- A . Negligence
- B . Malpractice
- C . Breach of privacy
- D . Breach of confidentiality
Correct Answer: D
D
Explanation:
The situation describes a breach of confidentiality, which occurs when private patient information is accessed or disclosed without proper authorization.
Negligence: This refers to the failure to provide the standard of care that a reasonably prudent person would provide in a similar situation, but it doesn’t specifically address unauthorized access to patient information.
Malpractice: This is a type of negligence by a professional, which results in harm to the patient, and usually involves direct patient care rather than record-keeping issues.
Breach of Privacy: This involves the inappropriate disclosure of private information. In this case,
using someone else’s account does not directly disclose patient information to unauthorized parties.
Breach of Confidentiality: This specifically addresses the unauthorized access or use of patient information, which is exactly what happened when another nurse used the first nurse’s account to enter notes.
Reference: Health Insurance Portability and Accountability Act (HIPAA) Guidelines American Nurses Association (ANA): Code of Ethics for Nurses with Interpretive Statements
D
Explanation:
The situation describes a breach of confidentiality, which occurs when private patient information is accessed or disclosed without proper authorization.
Negligence: This refers to the failure to provide the standard of care that a reasonably prudent person would provide in a similar situation, but it doesn’t specifically address unauthorized access to patient information.
Malpractice: This is a type of negligence by a professional, which results in harm to the patient, and usually involves direct patient care rather than record-keeping issues.
Breach of Privacy: This involves the inappropriate disclosure of private information. In this case,
using someone else’s account does not directly disclose patient information to unauthorized parties.
Breach of Confidentiality: This specifically addresses the unauthorized access or use of patient information, which is exactly what happened when another nurse used the first nurse’s account to enter notes.
Reference: Health Insurance Portability and Accountability Act (HIPAA) Guidelines American Nurses Association (ANA): Code of Ethics for Nurses with Interpretive Statements
Question #22
The nurse assesses a patient with Chronic Renal Failure notes crackles in the lung bases, elevated blood pressure, and weight gain of 1 kg in one day.
Based on these finding, which of the following nursing diagnoses is the MOST appropriate for this patient?
- A . Increased cardiac output related to fluid overload
- B . Ineffective tissue perfusion related to interrupted arterial blood flow
- C . Imbalance nutrition more than body requirements related to dietary excess
- D . Excess fluid volume related to the kidney’s inability to maintain fluid balance
Correct Answer: D
D
Explanation:
The patient’s symptoms―crackles in the lung bases, elevated blood pressure, and rapid weight gain―are indicative of fluid overload, which is a common issue in chronic renal failure due to the kidneys’ inability to excrete excess fluid.
Increased Cardiac Output Related to Fluid Overload: Increased cardiac output would not typically result from fluid overload; rather, fluid overload can lead to decreased cardiac output due to strain on the heart.
Ineffective Tissue Perfusion Related to Interrupted Arterial Blood Flow: This diagnosis does not directly correlate with the symptoms of fluid overload observed in this patient.
Imbalanced Nutrition More Than Body Requirements Related to Dietary Excess: This diagnosis is not relevant to the observed symptoms, which are more clearly related to fluid retention rather than dietary intake.
Excess Fluid Volume Related to the Kidney’s Inability to Maintain Fluid Balance: This is the most appropriate nursing diagnosis as it directly addresses the kidney’s failure to regulate fluid balance, leading to the observed clinical signs.
Reference: National Kidney Foundation: Clinical Practice Guidelines for Chronic Kidney Disease Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
D
Explanation:
The patient’s symptoms―crackles in the lung bases, elevated blood pressure, and rapid weight gain―are indicative of fluid overload, which is a common issue in chronic renal failure due to the kidneys’ inability to excrete excess fluid.
Increased Cardiac Output Related to Fluid Overload: Increased cardiac output would not typically result from fluid overload; rather, fluid overload can lead to decreased cardiac output due to strain on the heart.
Ineffective Tissue Perfusion Related to Interrupted Arterial Blood Flow: This diagnosis does not directly correlate with the symptoms of fluid overload observed in this patient.
Imbalanced Nutrition More Than Body Requirements Related to Dietary Excess: This diagnosis is not relevant to the observed symptoms, which are more clearly related to fluid retention rather than dietary intake.
Excess Fluid Volume Related to the Kidney’s Inability to Maintain Fluid Balance: This is the most appropriate nursing diagnosis as it directly addresses the kidney’s failure to regulate fluid balance, leading to the observed clinical signs.
Reference: National Kidney Foundation: Clinical Practice Guidelines for Chronic Kidney Disease Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Question #23
A nurse is seeking best evidence to educate the parents on the use of olive oil for skin care of newborns.
Which of the following is the BEST evidence to consider?
- A . Studies that explored the experience of using olive oil
- B . Studies that considered pediatrician opinion on using olive oil
- C . Studies that assessed parent’s perception on the use of olive oil
- D . Studies that compared the use of olive oil versus manufactured baby oils
Correct Answer: D
D
Explanation:
The best evidence for educating parents on the use of olive oil for newborn skin care would come from studies that directly compare the use of olive oil to other commonly used baby oils.
Studies that Explored the Experience of Using Olive Oil: These may provide qualitative insights but are not the strongest form of evidence for making recommendations.
Studies that Considered Pediatrician Opinion on Using Olive Oil: Expert opinion can be valuable but is less robust compared to direct comparative studies.
Studies that Assessed Parent’s Perception on the Use of Olive Oil: These provide subjective insights and are not as strong as objective comparisons of effectiveness and safety.
Studies that Compared the Use of Olive Oil Versus Manufactured Baby Oils: Comparative studies provide direct evidence on the effectiveness and safety of olive oil compared to other products, making them the most reliable source of evidence for making an informed recommendation.
Reference: Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice Cochrane Database of Systematic Reviews: Skincare Interventions for Infants
D
Explanation:
The best evidence for educating parents on the use of olive oil for newborn skin care would come from studies that directly compare the use of olive oil to other commonly used baby oils.
Studies that Explored the Experience of Using Olive Oil: These may provide qualitative insights but are not the strongest form of evidence for making recommendations.
Studies that Considered Pediatrician Opinion on Using Olive Oil: Expert opinion can be valuable but is less robust compared to direct comparative studies.
Studies that Assessed Parent’s Perception on the Use of Olive Oil: These provide subjective insights and are not as strong as objective comparisons of effectiveness and safety.
Studies that Compared the Use of Olive Oil Versus Manufactured Baby Oils: Comparative studies provide direct evidence on the effectiveness and safety of olive oil compared to other products, making them the most reliable source of evidence for making an informed recommendation.
Reference: Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice Cochrane Database of Systematic Reviews: Skincare Interventions for Infants
Question #24
The doctor heard a staff nurse saying "That doctor is incompetent".
The doctor can file a complaint against the staff nurse for:
- A . Libel
- B . Assault
- C . Slander
- D . Malpractice
Correct Answer: C
C
Explanation:
The situation described is one where a verbal statement is made that can harm a doctor’s reputation.
This is best described as slander.
Libel: Libel refers to written defamation, not spoken.
Assault: Assault involves a threat or attempt to physically harm someone, which is not relevant here.
Slander: Slander refers to spoken defamation. The nurse’s verbal statement about the doctor’s competence falls under this category.
Malpractice: Malpractice involves professional negligence that causes harm to a patient, not defamation.
Reference: American Nurses Association (ANA): Code of Ethics for Nurses Legal Aspects of Nursing: Documentation, Confidentiality, and Defamation
C
Explanation:
The situation described is one where a verbal statement is made that can harm a doctor’s reputation.
This is best described as slander.
Libel: Libel refers to written defamation, not spoken.
Assault: Assault involves a threat or attempt to physically harm someone, which is not relevant here.
Slander: Slander refers to spoken defamation. The nurse’s verbal statement about the doctor’s competence falls under this category.
Malpractice: Malpractice involves professional negligence that causes harm to a patient, not defamation.
Reference: American Nurses Association (ANA): Code of Ethics for Nurses Legal Aspects of Nursing: Documentation, Confidentiality, and Defamation
Question #25
A nurse is providing education to a new parent about the psychosocial development of the newborn.
Applying Erikson’s psychosocial development theory, the nurse would BEST instruct the parents to:
- A . Ignore and distract the newborn when crying
- B . Anticipate and plan for the newborn demands
- C . Observe and respond to the newborn signals of needs
- D . Provide and maintain comfortable environment for newborn
Correct Answer: C
C
Explanation:
Applying Erikson’s psychosocial development theory, the nurse should instruct the parents to observe and respond to the newborn’s signals of needs. According to Erikson, the first stage of psychosocial development is "Trust vs. Mistrust," which occurs from birth to approximately 18 months.
Trust vs. Mistrust: In this stage, infants learn to trust their caregivers when their needs for food, comfort, and affection are consistently met. If caregivers are responsive to the infant’s needs, the infant develops a sense of trust and security.
Ignoring and Distracting the Newborn: This approach may lead to feelings of mistrust as the infant’s needs are not being adequately addressed.
Anticipating and Planning for the Newborn’s Demands: While planning is important, it is more crucial to be responsive to the infant’s immediate signals.
Providing a Comfortable Environment: This is beneficial but must be combined with responsive caregiving to establish trust.
Reference: Erikson, E. H. (1963). Childhood and Society.
American Psychological Association (APA): Erikson’s Stages of Psychosocial Development
C
Explanation:
Applying Erikson’s psychosocial development theory, the nurse should instruct the parents to observe and respond to the newborn’s signals of needs. According to Erikson, the first stage of psychosocial development is "Trust vs. Mistrust," which occurs from birth to approximately 18 months.
Trust vs. Mistrust: In this stage, infants learn to trust their caregivers when their needs for food, comfort, and affection are consistently met. If caregivers are responsive to the infant’s needs, the infant develops a sense of trust and security.
Ignoring and Distracting the Newborn: This approach may lead to feelings of mistrust as the infant’s needs are not being adequately addressed.
Anticipating and Planning for the Newborn’s Demands: While planning is important, it is more crucial to be responsive to the infant’s immediate signals.
Providing a Comfortable Environment: This is beneficial but must be combined with responsive caregiving to establish trust.
Reference: Erikson, E. H. (1963). Childhood and Society.
American Psychological Association (APA): Erikson’s Stages of Psychosocial Development
Question #26
A nurse is educating a client who was involved in a gunshot incident for the purpose of preventing post-trauma syndrome.
Which of the following behaviors indicates client’s understanding of the education?
- A . Client expresses beliefs and values freely
- B . Client demonstrates an increase in activity level
- C . Client maintains anxiety level at manageable level
- D . Client demonstrates ability to deal with emotional reactions
Correct Answer: D
D
Explanation:
In educating a client involved in a gunshot incident to prevent post-trauma syndrome, the most indicative behavior of understanding is the client’s ability to deal with emotional reactions. This is a critical aspect of managing post-traumatic stress.
Expressing Beliefs and Values Freely: This is important for overall well-being but does not directly address coping with trauma.
Increasing Activity Level: Physical activity can help, but it is not the primary indicator of understanding trauma management.
Maintaining Manageable Anxiety Levels: While managing anxiety is important, it is part of the broader goal of dealing with emotional reactions.
Dealing with Emotional Reactions: This directly addresses the psychological impact of trauma and demonstrates effective coping mechanisms and emotional resilience.
Reference: American Psychiatric Association (APA): Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
National Institute of Mental Health (NIMH): Post-Traumatic Stress Disorder
D
Explanation:
In educating a client involved in a gunshot incident to prevent post-trauma syndrome, the most indicative behavior of understanding is the client’s ability to deal with emotional reactions. This is a critical aspect of managing post-traumatic stress.
Expressing Beliefs and Values Freely: This is important for overall well-being but does not directly address coping with trauma.
Increasing Activity Level: Physical activity can help, but it is not the primary indicator of understanding trauma management.
Maintaining Manageable Anxiety Levels: While managing anxiety is important, it is part of the broader goal of dealing with emotional reactions.
Dealing with Emotional Reactions: This directly addresses the psychological impact of trauma and demonstrates effective coping mechanisms and emotional resilience.
Reference: American Psychiatric Association (APA): Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
National Institute of Mental Health (NIMH): Post-Traumatic Stress Disorder
Question #27
A nurse is checking laboratory findings of a patient with Sickle Cell Disease (SCD).
Which of the following laboratory values would be MOSTLY seen in this disease?
- A . High platelet level
- B . Low hematocrit level
- C . Low leucocyte level
- D . High reticulocyte level
Correct Answer: D
D
Explanation:
In patients with Sickle Cell Disease (SCD), a high reticulocyte level is commonly observed.
High Platelet Level: This is not typically associated with SCD.
Low Hematocrit Level: While common in SCD due to anemia, it is not as specific as reticulocyte count.
Low Leucocyte Level: This is not characteristic of SCD.
High Reticulocyte Level: Elevated reticulocyte count indicates increased red blood cell production in response to chronic hemolysis (breakdown of red blood cells) seen in SCD.
Reference: National Heart, Lung, and Blood Institute (NHLBI): Sickle Cell Disease
American Society of Hematology (ASH): Sickle Cell Disease and Reticulocyte Count
D
Explanation:
In patients with Sickle Cell Disease (SCD), a high reticulocyte level is commonly observed.
High Platelet Level: This is not typically associated with SCD.
Low Hematocrit Level: While common in SCD due to anemia, it is not as specific as reticulocyte count.
Low Leucocyte Level: This is not characteristic of SCD.
High Reticulocyte Level: Elevated reticulocyte count indicates increased red blood cell production in response to chronic hemolysis (breakdown of red blood cells) seen in SCD.
Reference: National Heart, Lung, and Blood Institute (NHLBI): Sickle Cell Disease
American Society of Hematology (ASH): Sickle Cell Disease and Reticulocyte Count
Question #28
A nurse is assigned to care for a client diagnosed with brain cancer who is undergone radiation therapy. On assessment, the nurse notes cachexia.
Which of the following nursing measures would take FIRST for this client?
- A . Encourage high protein and high calorie diet
- B . Encourage frequent oral hygiene
- C . Encourage daily physical activity
- D . Encourage small cold meals
Correct Answer: A
A
Explanation:
For a client with brain cancer undergoing radiation therapy and exhibiting cachexia, the first nursing measure should be to encourage a high protein and high-calorie diet.
High Protein and High Calorie Diet: Cachexia is a severe form of malnutrition often seen in cancer patients, characterized by weight loss, muscle wasting, and decreased quality of life. Ensuring adequate nutrition is crucial to improve strength, immune function, and overall well-being. Frequent Oral Hygiene: This is important, especially if the patient has oral side effects from radiation, but it does not address the primary issue of malnutrition.
Daily Physical Activity: Beneficial for maintaining muscle mass and overall health but should be secondary to addressing severe nutritional deficits.
Small Cold Meals: These may be more palatable if the patient has nausea but should also be high in
calories and protein to combat cachexia.
Reference: American Cancer Society: Managing Cancer Cachexia
Oncology Nursing Society (ONS): Nutrition and Cancer Care
A
Explanation:
For a client with brain cancer undergoing radiation therapy and exhibiting cachexia, the first nursing measure should be to encourage a high protein and high-calorie diet.
High Protein and High Calorie Diet: Cachexia is a severe form of malnutrition often seen in cancer patients, characterized by weight loss, muscle wasting, and decreased quality of life. Ensuring adequate nutrition is crucial to improve strength, immune function, and overall well-being. Frequent Oral Hygiene: This is important, especially if the patient has oral side effects from radiation, but it does not address the primary issue of malnutrition.
Daily Physical Activity: Beneficial for maintaining muscle mass and overall health but should be secondary to addressing severe nutritional deficits.
Small Cold Meals: These may be more palatable if the patient has nausea but should also be high in
calories and protein to combat cachexia.
Reference: American Cancer Society: Managing Cancer Cachexia
Oncology Nursing Society (ONS): Nutrition and Cancer Care
Question #29
Which of the following characteristics of older adults would be expected in today’s society?
- A . Chronic conditions result in some limitations in ADL
- B . Most older adults live independently or in home care centers
- C . There is steady increase in percentage of workers in the labor force
- D . Married people have higher mortality rate than unmarried people at all ages
Correct Answer: A
A
Explanation:
Chronic Conditions and ADLs:
Older adults are more likely to suffer from chronic conditions such as arthritis, hypertension, heart disease, and diabetes. These conditions can lead to some limitations in Activities of Daily Living (ADLs), which include tasks like bathing, dressing, eating, and walking.
According to the Centers for Disease Control and Prevention (CDC), chronic diseases are the leading cause of death and disability in the United States, and they significantly impact the quality of life of older adults.
Living Arrangements:
While many older adults do live independently or in home care settings, a significant number also live with chronic conditions that impact their ADLs, hence answer B is less accurate compared to A. As per the Administration for Community Living (ACL), the majority of older adults do live independently; however, chronic conditions still play a significant role in their daily lives.
Labor Force Participation:
There is an increase in the percentage of older adults in the labor force, but this is not a primary characteristic affecting most older adults today.
Marital Status and Mortality:
Studies have shown that married individuals often have a lower mortality rate compared to unmarried individuals, making option D incorrect.
Reference: Centers for Disease Control and Prevention (CDC)
Administration for Community Living (ACL)
A
Explanation:
Chronic Conditions and ADLs:
Older adults are more likely to suffer from chronic conditions such as arthritis, hypertension, heart disease, and diabetes. These conditions can lead to some limitations in Activities of Daily Living (ADLs), which include tasks like bathing, dressing, eating, and walking.
According to the Centers for Disease Control and Prevention (CDC), chronic diseases are the leading cause of death and disability in the United States, and they significantly impact the quality of life of older adults.
Living Arrangements:
While many older adults do live independently or in home care settings, a significant number also live with chronic conditions that impact their ADLs, hence answer B is less accurate compared to A. As per the Administration for Community Living (ACL), the majority of older adults do live independently; however, chronic conditions still play a significant role in their daily lives.
Labor Force Participation:
There is an increase in the percentage of older adults in the labor force, but this is not a primary characteristic affecting most older adults today.
Marital Status and Mortality:
Studies have shown that married individuals often have a lower mortality rate compared to unmarried individuals, making option D incorrect.
Reference: Centers for Disease Control and Prevention (CDC)
Administration for Community Living (ACL)
Question #30
A couple attends infertility clinic to review the investigation results. The laboratory results show that the man has aspermia. He asked the nurse about the meaning of aspermia.
The nurse replied that: "the aspermia means
- A . absence of sperms"
- B . prematurity of sperms"
- C . abnormalities of the sperms’"
- D . sperms count is lower than 20 million/milliliter"
Correct Answer: A
A
Explanation:
Aspermia Definition:
Aspermia is a medical term used to describe the complete absence of semen, which includes the absence of sperms.
This condition can result from various factors such as hormonal imbalances, obstruction of the reproductive tract, or surgeries like vasectomy.
Differentiation from Other Terms:
Prematurity of Sperms: Refers to sperm cells that are not fully mature.
Abnormalities of Sperms: Indicates that the sperm present have structural or functional defects.
Low Sperm Count (Oligospermia): Describes a condition where the sperm count is lower than the normal threshold (20 million/milliliter).
Reference: Mayo Clinic
American Society for Reproductive Medicine (ASRM)
A
Explanation:
Aspermia Definition:
Aspermia is a medical term used to describe the complete absence of semen, which includes the absence of sperms.
This condition can result from various factors such as hormonal imbalances, obstruction of the reproductive tract, or surgeries like vasectomy.
Differentiation from Other Terms:
Prematurity of Sperms: Refers to sperm cells that are not fully mature.
Abnormalities of Sperms: Indicates that the sperm present have structural or functional defects.
Low Sperm Count (Oligospermia): Describes a condition where the sperm count is lower than the normal threshold (20 million/milliliter).
Reference: Mayo Clinic
American Society for Reproductive Medicine (ASRM)
Question #31
Babies born to mothers with diabetes mellitus should be thoroughly assessed for which of the following conditions?
- A . Cystic fibrosis
- B . Congenital heart defects
- C . Polycystic kidney disease
- D . Developmental dysplasia of the hip
Correct Answer: B
B
Explanation:
Diabetes Mellitus and Pregnancy:
Mothers with diabetes mellitus, especially if poorly controlled, have a higher risk of having babies with congenital anomalies.
Common Conditions in Infants:
Congenital Heart Defects (CHDs): These are the most common congenital anomalies seen in babies born to mothers with diabetes. This includes conditions like ventricular septal defect, atrial septal defect, and transposition of the great arteries.
Other Possible Conditions: Although cystic fibrosis, polycystic kidney disease, and developmental dysplasia of the hip can occur in newborns, they are not directly associated with maternal diabetes.
Reference: American Diabetes Association (ADA) Centers for Disease Control and Prevention (CDC)
B
Explanation:
Diabetes Mellitus and Pregnancy:
Mothers with diabetes mellitus, especially if poorly controlled, have a higher risk of having babies with congenital anomalies.
Common Conditions in Infants:
Congenital Heart Defects (CHDs): These are the most common congenital anomalies seen in babies born to mothers with diabetes. This includes conditions like ventricular septal defect, atrial septal defect, and transposition of the great arteries.
Other Possible Conditions: Although cystic fibrosis, polycystic kidney disease, and developmental dysplasia of the hip can occur in newborns, they are not directly associated with maternal diabetes.
Reference: American Diabetes Association (ADA) Centers for Disease Control and Prevention (CDC)
Question #32
The destruction of the alveoli walls is defined as:
- A . Asthma
- B . Bronchitis
- C . Bronchiolitis
- D . Emphysema
Correct Answer: D
D
Explanation:
Definition of Emphysema:
Emphysema is a chronic lung condition characterized by the destruction of the alveoli (air sacs) walls.
This leads to reduced surface area for gas exchange and difficulty in breathing.
It is a major component of Chronic Obstructive Pulmonary Disease (COPD).
Differentiation from Other Conditions:
Asthma: A condition where the airways become inflamed and narrowed.
Bronchitis: Inflammation of the bronchial tubes, often resulting in cough and mucus production.
Bronchiolitis: Inflammation of the small airways (bronchioles), commonly seen in children.
Reference: American Lung Association (ALA)
National Heart, Lung, and Blood Institute (NHLBI)
D
Explanation:
Definition of Emphysema:
Emphysema is a chronic lung condition characterized by the destruction of the alveoli (air sacs) walls.
This leads to reduced surface area for gas exchange and difficulty in breathing.
It is a major component of Chronic Obstructive Pulmonary Disease (COPD).
Differentiation from Other Conditions:
Asthma: A condition where the airways become inflamed and narrowed.
Bronchitis: Inflammation of the bronchial tubes, often resulting in cough and mucus production.
Bronchiolitis: Inflammation of the small airways (bronchioles), commonly seen in children.
Reference: American Lung Association (ALA)
National Heart, Lung, and Blood Institute (NHLBI)
Question #33
A nurse is conducting a physical assessment of a 12-month-old child whose birth weight was 3.2 kg.
What would be the child’s expected current weight?
- A . 6.4 kg
- B . 7.3 kg
- C . 9.6 kg
- D . 12.8 kg
Correct Answer: C
C
Explanation:
Weight Doubling by 5-6 Months:
Typically, a newborn’s birth weight doubles by the time they are 5-6 months old.
For this child, that would be: 3.2 kg×2=6.4 kg3.2 , text{kg} times 2 = 6.4 , text{kg}3.2kg×2=6.4kg.
Weight Tripling by 1 Year:
By the age of 12 months, a child’s birth weight is expected to triple.
So, for a child with a birth weight of 3.2 kg, the expected weight at 12 months is: 3.2 kg×3=9.6 kg3.2 , text{kg} times 3 = 9.6 , text{kg}3.2kg×3=9.6kg.
Reference: American Academy of Pediatrics (AAP)
World Health Organization (WHO) Growth Standards
C
Explanation:
Weight Doubling by 5-6 Months:
Typically, a newborn’s birth weight doubles by the time they are 5-6 months old.
For this child, that would be: 3.2 kg×2=6.4 kg3.2 , text{kg} times 2 = 6.4 , text{kg}3.2kg×2=6.4kg.
Weight Tripling by 1 Year:
By the age of 12 months, a child’s birth weight is expected to triple.
So, for a child with a birth weight of 3.2 kg, the expected weight at 12 months is: 3.2 kg×3=9.6 kg3.2 , text{kg} times 3 = 9.6 , text{kg}3.2kg×3=9.6kg.
Reference: American Academy of Pediatrics (AAP)
World Health Organization (WHO) Growth Standards
Question #34
A 37 weeks pregnant woman presents with labor-like pain. She has mild uterine contractions (2-3 contractions in 10 minutes). On abdominal palpation, the nurse notes the fetus lie is transverse. The nurse reported to the doctor who confirm the malpresentation via an ultrasound.
The immediate nursing action is to:
- A . Provide oral fluids
- B . Offer the woman pain relief
- C . Prepare for cesarean section
- D . Monitor the progress of labor
Correct Answer: C
C
Explanation:
Transverse Lie and Delivery:
A transverse lie means the fetus is positioned horizontally in the uterus, making vaginal delivery impossible and risky.
In such cases, a cesarean section is usually required to safely deliver the baby.
Immediate Nursing Action:
Oral Fluids and Pain Relief: While important, these are not the immediate priorities in this scenario.
Monitoring Labor: This is less relevant due to the malpresentation.
Preparing for Cesarean Section: Given the transverse lie, this is the immediate and appropriate action to ensure the safety of both mother and baby.
Reference: American College of Obstetricians and Gynecologists (ACOG)
Mayo Clinic Guidelines on Labor and Delivery
C
Explanation:
Transverse Lie and Delivery:
A transverse lie means the fetus is positioned horizontally in the uterus, making vaginal delivery impossible and risky.
In such cases, a cesarean section is usually required to safely deliver the baby.
Immediate Nursing Action:
Oral Fluids and Pain Relief: While important, these are not the immediate priorities in this scenario.
Monitoring Labor: This is less relevant due to the malpresentation.
Preparing for Cesarean Section: Given the transverse lie, this is the immediate and appropriate action to ensure the safety of both mother and baby.
Reference: American College of Obstetricians and Gynecologists (ACOG)
Mayo Clinic Guidelines on Labor and Delivery
Question #35
A nurse is teaching a group of workers about risk factors for developing diabetes mellitus and obesity.
Which of the following statements made by the workers would indicate their understanding?
- A . "Insufficient sleep can lead to obesity"
- B . "Depression does not have affect on weight"
- C . "Work stress leads to type 1 diabetes mellitus"
- D . "Obese workers are less active than those of normal weight"
Correct Answer: A
A
Explanation:
Insufficient Sleep and Obesity:
Lack of sleep disrupts hormones that regulate hunger, such as leptin and ghrelin, leading to increased appetite and potential weight gain.
Studies have shown a clear link between insufficient sleep and higher body mass index (BMI).
Other Statements:
Depression and Weight: Depression can affect weight, often leading to weight gain or loss.
Work Stress and Diabetes: Stress is linked to type 2 diabetes, not type 1.
Activity Levels: While obesity can reduce activity levels, it is not universally true that all obese individuals are less active than those of normal weight.
Reference: Centers for Disease Control and Prevention (CDC)
National Institutes of Health (NIH)
A
Explanation:
Insufficient Sleep and Obesity:
Lack of sleep disrupts hormones that regulate hunger, such as leptin and ghrelin, leading to increased appetite and potential weight gain.
Studies have shown a clear link between insufficient sleep and higher body mass index (BMI).
Other Statements:
Depression and Weight: Depression can affect weight, often leading to weight gain or loss.
Work Stress and Diabetes: Stress is linked to type 2 diabetes, not type 1.
Activity Levels: While obesity can reduce activity levels, it is not universally true that all obese individuals are less active than those of normal weight.
Reference: Centers for Disease Control and Prevention (CDC)
National Institutes of Health (NIH)