1.

) Answer: D
Dark green leafy vegetables are good sources of iron.
Oranges are good sources of vitamin C that enhances iron
absorption in the small intestines.
 
2.) Answer: B
Individuals with G6PD may exhibit hemolytic anemia when
exposed to infection, certain medications or chemicals.
Salicylates such as Aspirin damages plasma membranes
of erythrocytes, leading to hemolytic anemia.
 
3.) Answer: B
Lower GI fluids are alkaline in nature and can be lost via
ileostomy. Thus, loss of HCO3, results in metabolic
acidosis.
 
4.) Answer: C
Initially, the respiratory system will try to compensate
metabolic acidosis. Patients with metabolic acidosis have
a high respiratory rate.
 
5.) Answer: A
Normal phosphorus level is 2.5 – 4.5 mg/dL .The level
reflects hyperphosphatemia which is inversely proportional
to calcium. Client should be assessed for tetany which is a
prominent symptom of hypocalcemia.
 
6.) Answer: C
Clinical manifestations of pyloric stenosis include projectile
vomiting, irritability, constipation, and signs of dehydration,
including a decrease in urine output.
 
 7.) Answer: A, E, F, C, B, D
In accordance with the new guidelines, remember AB-
CABS. A-airway B-breathing normally? − C-chest
compression A-airway open B-breathing for patient S-
serious bleeding, shock, spinal injury. The nurse should
first assess the consciousness of the patient. Next, open
the patient’s airway to check for breathing. When there is
no breathing, immediately perform chest compression
then give 2 breaths, do the cycle of care over. Finally,
check for serious bleeding, shock, and spinal injury.
 
8.) Answer: D
Continuous bubbling seen in the water-seal bottle/
chamber indicates an air leak or loose connection, and the
air is sucked continuously into the closed chest drainage
system.
 
9.) Answer: C
Testicular cancer is most likely to affect males in late
adolescence. Undescended testis is also one major risk
for testicular cancer.
 
10.) Answer: D
Hypocalcemia occurs when there is accidental removal or
destruction of parathyroid tissue during surgical removal of
the thyroid gland.  Laryngospasm is one of the clinical
manifestations of tetany, an indicator of hypocalcemia.
 
11.) Answer: A
It’s normal for a toddler to have bowlegs and a protruding
belly. The head still appears somewhat large in proportion
from the rest of the body.
 
12.) Answer: D
 
13.) Answer: B
There is 6-8 months activity restriction following a spinal
fusion.  Sitting, lying, standing, normal stair climbing,
walking, and gentle swimming is allowed. Bending and
twisting at the waist should be avoided, along with lifting
more than 10 lbs.
 
14.) Answer: D
Z-track technique is used to administer drugs especially
irritating to the subcutaneous tissue. This method
promotes absorption of the drug by preventing drug
leakage into the subcutaneous layer.
 
15.) Answer: B
Establishing rapport is a way to gain trust that will lead for
a patient to relax. You can get more insights and
information from a patient when rapport is established.
 
16.) Answer: A
Low magnesium (hypomagnesemia) produces clinical
manifestations like increased reflexes, tremors, and
seizures. Magnesium Sulfate is the drug of choice to
prevent seizures in pre-eclampsia and eclampsia.
 
17.) Answer: C
The ear canal of children ages 3years and above can be
straightened by pulling the pinna up then backwards. For
children below 3 years of age, the ear canal can be
straightened by pulling the pinna down then backwards.
 
18.) Answer: A
Infants are nose breathers. A gastric tube may be inserted
to facilitate lung expansion and stomach decompression,
but not a nasogastric tube as it can occlude the nare, thus,
making breathing difficult for the infant.
 
19.) Answer: B
 
20.) Answer: B
Blind finger sweeps are not recommended in all CPR
cases especially for infants and children because the
foreign object may be pushed back into the airway.
 
21.) Answer: B
The first step in cardiopulmonary resuscitation (CPR) is
assessing the responsiveness of the patient.
 
22.) Answer: C
Priority nursing action is to administer oxygen to patients
with chest pain.  Chest pain is caused by insufficient
myocardial oxygenation.
 
23.) Answer: D
Pneumococcal Vaccine is a priority immunization for the
elderly. Seniors, ages 65 years old and above, have a
higher risk for serious pneumococcal infection and likely
have low immunity. This is administered every 5 years.
 
24.) Answer: A
Burns on the face and neck can cause swelling of the
respiratory mucosa that can lead to airway obstruction
manifested by hoarseness of voice and difficulty in
breathing. Maintaining airway patency is the main
concern.
 
25.) Answer: C
An in-line filter is required for blood transfusions.
 
26.) Answer: D
Negative outcome: Hemodialysis decreases red blood cell
count which worsens anemia, because RBCs are lost in
dialysis from anticoagulation during the procedure, and
from residual blood that is left in the dialyzer.
 
27.) Answer: D
A decrease in level of consciousness and headache are
early signs of increase in intracranial pressure (ICP).
Altered level of consciousness is the most common
symptom that indicates a deficit in brain function.
 
28.) Answer: B
Recall the anatomy of the colon. The appropriate position
is left lateral to facilitate the flow of enema by gravity into
the colon.
 
29.) Answer: D
Recall the 12 Rights of administration. Checking the
patient’s name is critical for client-safety.
 
30.) Answer: A , D
Crohn’s disease is a chronic inflammation of the colon with
symptoms of diarrhea, abdominal pain, and weight loss.
Corticosteroid is a treatment for Crohn’s disease.
Antidiarrheal can give relief to diarrheal episodes. Aspirin
should be avoided as it can worsen inflammation. Those
with Crohn’s disease are mostly lactose intolerant, so
choice no. (2) is incorrect.
 
 1. Answer: C
Rationale: Initially, the respiratory system will try to
compensate for metabolic acidosis. Patients with
metabolic acidosis have high respiratory rates.

2. Answer: A, E, F, C, B, D
Rationale: In accordance with the new guidelines,
remember AB-CABS. A-airway B-breathing normally? − C-
chest compression A-airway open B-breathing for patient
S-serious bleeding, shock, spinal injury. The nurse should
first assess the consciousness of the patient. Next, open
the patient’s airway to check for breathing. When there is
no breathing, immediately perform chest compression
then give 2 breaths, do the cycle of care over. Finally,
check for serious bleeding, shock, and spinal injury.

3. Answer: B
Rationale: There is 6-8 months activity restriction following
a spinal fusion. Sitting, lying, standing, normal stair
climbing, walking, and gentle swimming are allowed.
Bending and twisting at the waist should be avoided,
along with lifting more than 10 lbs.

4. Answer: D
Rationale: Z-track technique is used to administer drugs
especially irritating to the subcutaneous tissue. This
method promotes the absorption of the drug by preventing
drug leakage into the subcutaneous layer.

5. Answer: B
Rationale: Blind finger sweeps are not recommended in all
CPR cases especially for infants and children because the
foreign object may be pushed back into the airway.

6. Answer: C
Rationale: Priority nursing action is to administer oxygen
to patients with chest pain. Chest pain is caused by
insufficient myocardial oxygenation.

7. Answer: A
Rationale: Burns on the face and neck can cause swelling
of the respiratory mucosa, leading to airway obstruction
manifested by hoarseness of voice and difficulty in
breathing. Maintaining an airway patency is the main
concern.

8. Answer: B
Rationale: Recall the anatomy of the colon. The
appropriate position is left lateral to facilitate the flow of
enema by gravity into the colon.

9. Answer:  D
Rationale: In hypokalemia, the electrocardiogram may
show flattening and inversion of the T wave, the
appearance of a U wave, and ST depression.
Hypercalcemia can cause a shortened ST and widened T
wave. The electrocardiogram of a hyperkalemic client
shows tall peak T waves, widened QRS complexes,
prolonged PR intervals, or flat P waves.

10.  Answer: D
Rationale: The lowest possible score for any response is
1. If a client is unresponsive to painful stimuli, the score is
1. A score lower than 8 indicates that the client is in a
comatose state. The highest score for the GCS is 15. A
score of 15 indicates an alert and oriented person. A score
of 3-8 indicates severe head injury.

11. Answer: C
Rationale: Ketoacidosis is associated with high levels of
ketone bodies in the body brought by the breakdown of
fatty acids and is not related to vomiting. Metabolic
acidosis happens when the body produces an excessive
quantity of acid. Severe vomiting will result in loss of HCL
and acids coming from extracellular fluids which in turn
lead to metabolic alkalosis. Respiratory alkalosis occurs
when there is an increased respiration which elevates the
blood pH beyond the normal range of 7.35-7.45.

12. Answer: B
            Rationale: Pets are discouraged when parents are
trying to allergy-proof a home for a child with bronchial
asthma unless the pets are kept outside. Pets with hair or
feathers are especially likely to trigger asthma attacks. A
fish is a satisfactory pet for this child, but the parents
should be taught to keep the fish tank clean to prevent it
from harboring mold.

13. Answer: C
            Rationale: The three-point gait, in which the client
advances the crutches and the affected leg at the same
time while weight is supported on the unaffected
extremity, is the appropriate gait of choice. This allows for
non-weight-bearing on the affected extremity. The two-
point, four-point, and swing-to gaits require some weight
bearing on bot

14. Answer: A
            Rationale: Health-promoting strategies for clients
with a history of cardiovascular disease require knowledge
in three areas: diet, exercise, and medication. Pain
management and management of social activities do not
usually feature health promotion activities for these clients.

15. Answer: C
            Rationale: Physical activity is gradually increased
after a myocardial infarction while the client is still
hospitalized and through a period of rehabilitation. The
client is progressing too rapidly if activity significantly
changes respirations, causing dyspnea, chest pain, a
rapid heartbeat, or fatigue. When any of these symptoms
appear, the client should reduce activity and progress
more slowly. Edema suggests a circulatory problem that
must be addressed but doesn’t necessarily indicate
overexertion. Cyanosis indicates the reduced oxygen-
carrying capacity of red blood cells and indicates a severe
pathology. It is not appropriate to use cyanosis as an
indicator for overexertion. Weight loss indicates several
factors but not overexertion.

16. Answer: B
            Rationale: The client should report tinnitus
because vancomycin can affect the acoustic branch of the
eighth cranial nerve. Vancomycin does not affect the
vestibular branch of the acoustic nerve; vertigo and ataxia
would occur if the vestibular branch were involved. Muscle
stiffness is not associated with vancomycin.

17. Answer: A
            Rationale: When examining the tympanic
membrane of a child younger than age 3 years, the nurse
should pull the pinna down and back. For an older child,
the nurse should pull the pinna up and back to view the
tympanic membrane.

18. Answer: D
            Rationale: Tingling and numbness of the toes
would be the earliest indication of circulatory impairment.
Inability to move the toes and cyanosis are later
indicators. Complaints of cast tightness should be
investigated because cast tightness can lead to circulatory
impairment; it is not, however, an indicator of impairment.

19. Answer: C
            Rationale: The baseline laboratory data that are
established before a client is started on tissue
plasminogen activator or alteplase recombinant include
hematocrit, hemoglobin level, and platelet count.
 20. Answer: D
            Rationale: The antidote for heparin is 1%
protamine sulfate. Vitamin K is the antidote for warfarin,
an oral anticoagulant. Thrombin is a topical anticoagulant.

21. Answer: C
            Rationale: A distended bladder produces dullness
when percussed because of the presence of urine.
Hyperresonance is a percussion sound that is present in
hyperinflated lungs. Tympany, a loud drum-like sound,
occurs over gas-filled areas such as the intestines. Flat
sounds occur over very dense tissue that has no air
present.

22. Answer: C
            Rationale: The bluish pigment on the buttocks and
back of an African American infant is a common finding
and should be documented as Mongolian spots in the
child’s record. These spots typically fade by the time the
child is 5 or 6 years. Additional assessment by the
physician is not indicated. Laser therapy is not used.
Rather, laser therapy is useful for port-wine stains, which
are dark purple and disfiguring.

23. Answer: D
            Rationale: A supine position in extension is the
position most likely to prevent contractures. Clients who
have experienced burns will find a flexed position most
comfortable. However, flexion promotes the development
of contractures. The high Fowler’s and semi-Fowler’s
positions create hip flexion. The prone position is
contraindicated because of head and neck burns. In
clients with head and neck burns, pillows should not be
used under the head or neck because it promotes neck
flexion contractures.

24. Answer: C
            Rationale: When the nurse cannot elicit the Moro
reflex of a 4-day-old preterm infant and the Moro reflex
was present at birth, intracranial hemorrhage or cerebral
edema should be suspected. Other symptoms include
lethargy, bulging fontanels, and seizure activity.
Confirmation can be made by ultrasound. Postnatal
asphyxia is suggested by respiratory distress, grunting,
nasal flaring, and cyanosis. A skull fracture can be
confirmed by radiography. However, it is unlikely to occur
in a preterm neonate. Rather, it is more common in the
large-for-gestational-age neonate. Facial nerve paralysis
is indicated when there is no movement on one side of the
face. This condition is more common in the large-for-
gestational-age neonate.

25. Answer: B
            Rationale: Exposure to moisture can lead to
maceration and the development of pressure ulcers. It is
important for the client’s skin to be kept clean and dry with
prompt attention to cleanliness after incidents of
incontinence. The client’s age and the presence of
hypertension are not factors leading to pressure ulcers.
Smoking affects the oxygen status of the client but does
not directly lead to the development of pressure ulcers.

26. Answer: B
            Rationale: Recommended restraints for a child
who has had palate surgery is elbow restraints. They
minimize the limitation placed on the child but still prevent
the child from injuring the repair with fingers and hands. A
safety jacket or wrist or body restraints restrict the child
unnecessarily.

27. Answer: D
            Rationale: During an episode of acute respiratory
distress, it is important that the nurse focus the
assessment on the client’s respiratory system and distress
to quickly address the client’s problem. Conducting a
complete health history and a comprehensive physical
examination can be deferred until the client’s condition is
stabilized. It is not appropriate to delay all assessments
until the respiratory distress is resolved because the nurse
must have data to guide treatment.

28. Answer: D
            Rationale: The most likely indication of a
dislocated hip is a shortening of the affected leg. Other
indications of dislocation include increasing pain, loss of
function to the extremity, and deformity. Abduction of the
leg after total hip replacement is a desirable position to
prevent dislocation. Loosening of the prosthesis does not
necessarily indicate that the hip has dislocated. External
rotation of the hip can occur without the hip’s being
dislocated. However, a neutral position of rotation is the
desired position.

29. Answer: B
            Rationale: Cardiomyopathy is a broad term that
includes three major forms: dilated, hypertrophic, and
restrictive cardiomyopathies. The underlying etiology of
hypertrophic cardiomyopathy is unknown; it is typically
observed in young men but is not limited to them.
Common symptoms are fatigue, low tolerance to activity
related to the low ejection fraction, and shortness of
breath. Angina may be observed if coronary artery
disease is present. Abdominal pain and hypertension are
not common.

30. Answer: C
            Rationale: Establishing a patent airway is the
priority intervention. Prophylactic intubation is initiated if
heat has been inhaled or if the neck, head, or face is
involved. Swelling of the upper airways can progress to
obstruction. Fluid replacement can best be achieved using
a large-caliber peripheral I.V. catheter, and morphine
sulfate are appropriate for analgesia in a burn client.
Although these are priorities, they are secondary to
establishing a patent airway. Administering tetanus toxoid
is a secondary priority.
1. Answer:  A

Rationale:

Angina pectoris is a substernal pain that radiates to the

neck, jaw, back and arms and is relieved by rest. Lower
abdominal pain may indicate other gastrointestinal
problems.

2. Answer: A

Rationale:

50 mL/hr is the normal urine output. A normal urine output

indicates that there is a good renal perfusion, and also
connotes that the client is hemodynamically stable,
therefore, the repair is successful.

3. Answer: A

Rationale:

In cardiac catheterization or coronary angiogram, a

catheter is inserted into the heart via a vein to measure
the ventricular function. A dye is used to provide further
assessment of the structure and motion of the heart.
Thallium is a radioactive isotope injected parenterally so
that the scintillation camera can count the radioactive
uptake. This is observed when a physician requests for a
Nuclear Cardiology test. When performing a
Transesophageal Echocardiogram (TEE), a probe with a
transducer tip is swallowed by the client to visualize for
valvular abnormalities, possible thrombus, bacterial
endocarditis and any congenital heart defects. When
performing an Intracoronary Ultrasound, a tiny ultrasound
probe is inserted into the coronary artery to evaluate for
plaque size and consistency, arterial walls and
effectiveness of the treatment.

4. Answer: D

Rationale:
The central venous pressure is within the superior vena
cava. The Normal CVP is 2-6 mmHg. A decrease in the
CVP indicates a decrease in the circulating blood volume,
which may be a result of hemorrhage or fluid imbalances.
The right atrium is located at the midaxillary line at the
fourth intercostal space, and the zero points on the
transducer needs to be at the level of the right atrium. The
client needs to be supine, with the head of the bed
elevated at 45 degrees to correctly assess the CVP.

5. Answer: D

Rationale:

In hypokalemia, the electrocardiogram may show

flattening and inversion of the T wave, the appearance of
a U wave, and ST depression. Hypercalcemia can cause
a shortened ST and widened T wave. The
electrocardiogram of a hyperkalemic client shows tall peak
T waves, widened QRS complexes, prolonged PR
intervals or flat P waves.

6. Answer:  A, B, E

Rationale:

Loading of drugs depends on the type of dry powder

inhaler. Take note that some dry powder inhalers do not
require loading. Dry powder inhalers are kept dry always
and are place at room temperature. Never shake a dry
powder inhaler. It is not a pressurized container. There is
no propellant, only the client’s breath can pull the drug in.
Because the drug is a dry powder and there is no
propellant, the client will not feel, smell, or taste the drug
during inhalation. The client’s breath will moisten the
powder causing it to clump and not be delivered
accurately. Immediately after inhalation of the drug, the
inhaler must be removed from the client’s mouth to
prevent moisture.

7. Answer: C, D, E

Rationale:

Stripping is not allowed. Also when changing the drainage

system or when checking air leaks, clamp the chest tube
for short periods only. Emptying of the collection chamber
or changing the drainage system should be done before
the drainage comes in contact with the bottom of the tube.
Avoid kinks and dependent loops to allow effective
drainage and prevent disrupting the system. Report
excessive drainage that is cloudy or red. Drainage will
often increase with position changes or coughing.
Bubbling is expected and indicates air drainage from the
client. Absence of bubbling may mean that the chest tube
is obstructed, the lungs have fully re-expanded and no
more air is leaking into the pleural space. Keep the
drainage system lower than the level of the chest to allow
effective drainage.

8. Answer: D

Rationale:

Sodium Bicarbonate should be slowly administered

because fast infusion may result in an abrupt reduction of
serum potassium level which can eventually lead to
arrhythmias. Diluting or mixing the drug with hypotonic
solution (i.e. D5W) or isotonic solution (0.9% NaCl) can be
ordered but not with the hypertonic solution (I.e D10W).

9. Answer: D

Rationale:

Loosening tight clothing, applying a warm blanket to

prevent heat loss, and administering oxygen supply might
help but is not the priority this time. Direct pressure over
the bleeding site is a priority to prevent shock but placing
a tourniquet on the artery is done by a surgeon. Because
the client is showing signs of altered mental status, there
is likely less perfusion in the brain, which calls for fluid
resuscitation. At least two IV access allows administration
of fluids – crystalloid, blood or clotting factors as
necessary which is vital in correcting acidosis,
hypothermia, and coagulopathy, and to restore perfusion
rapidly.

10. Answer: A

Rationale:

Cushing’s syndrome is clinically defined as the presence

of excessive corticosteroids. Addison’s disease is clinically
defined as adrenocortical insufficiency. Hypothyroidism is
a condition wherein there is insufficient thyroid hormone
produced by the thyroid glands while SIADH is
characterized by excessive release of anti-diuretic
hormone.

11. Answer: C
Rationale:

Facial tremors will occur even without performing a

specific maneuver. Exaggerated reflexes such as
hyperreflexia can be assessed by performing a different
maneuver. Gentle tapping of the area below the zygomatic
bone just in front of the ear is used to elicit Chvostek’s
sign to assess the presence of hypocalcemia. Trousseau
sign is characterized by spasm of the muscles of the hand
and forearm upon inflation of a BP cuff on it.

12. Answer: A, B, C, D, E and F

Rationale:

The leaking of vesicant drugs into surrounding tissue

causes local tissue damage like delayed healing, tissue
necrosis, disfigurement, loss of function and even
amputation.

13. Answer: B, C, E

Rationale:

Manual stimulation is recommended to evacuate impacted

stool. Having the client sit up straight and raise his head
so that he is looking ahead helps reduce the blood
pressure as it allows the gravitational pooling of blood in
the lower extremities. Constrictive clothing may trigger an
autonomic reaction that would cause the blood pressure to
go up so this must be removed. Manual compression or
tapping the bladder to allow urine to flow down the
catheter should be avoided because this would trigger an
increase in blood pressure. Administration of prescribed
vasodilators is done to reduce high blood pressure.

14. Answer: D

Rationale:

Option A is ataxic breathing. Option B is apneustic

breathing. Option C is central neurogenic hyperventilation.
Cheyne-stokes breathing respirations are a pattern of
breathing in which phases of hyperpnea regularly
alternate with apnea in a crescendo-decrescendo pattern.

15. Answer: D

Rationale:
The lowest possible score for any response is 1. If a client
is unresponsive to painful stimuli, the score is 1. A score
lower than 8 indicates that the client is in a comatose
state. The highest score for the GCS is 15. A score of 15
indicates an alert and oriented person. A score of 3-8
indicates severe head injury.

16. Answer: D

Rationale:

Helping the client maintain an exercise program is a

therapeutic intervention to maintain joint mobility and good
body alignment. This will also prevent venous stasis due
to impaired mobility. Client encouragement will not only
address the physical aspect of the disease but the client’s
emotions and self-esteem as well. The safety of the client
with impaired physical mobility should always be
considered. Continuous physical activity is not
recommended. There should be an alternate period of
activity and rest to prevent excessive fatigue.

17. Answer: B

Rationale:

Receptive Aphasia refers to the inability to understand

spoken words but can freely express and verbalize.
Expressive Aphasia refers to the inability to speak and
communicate formulated thoughts and sentiments. Global
aphasia affects both expressive ability and auditory
comprehension. Apraxia is characterized by loss of the
ability to perform activities that a person is physically able
and willing to do.

18. Answer: B

Rationale:

Graphesthesia is the ability to identify the writing on the

skin even with the eyes closed. The client provides a
verbal response, identifying the figure that was drawn.
Option A is a test for stereognosis. Option C is a test used
to assess Romberg’s sign while option D is a test for
Kernig’s sign.
19. Answer: D

Rationale:

Any deterioration of oxygen saturation may necessitate

intubation. However, the priority this time is to maintain a
patent airway. Infusion of IV fluids and administration of
antibiotics are expected nursing actions but not the top
priority this time. Completing vaccination at this time will
not suffice or treat the underlying respiratory problem. The
situation calls for a curative management and not
preventive measures. Airway closure is the top priority.
Throat examination is avoided as this increases the risk of
laryngeal obstruction. Aggression or agitation can also
compromise airway and breathing.

20. Answer: B

Rationale:

Absorption is the process when the drug is transferred

from the site of origin into the bloodstream. Distribution
occurs when the drug in the blood is distributed to different
parts of the body and accumulates in specific tissues.
Metabolism or biotransformation is the process wherein
the drug is broken down into its inactive form. Excretion is
the body’s response to eliminate all the inactive form of
the drug.

21. Answer: D

Rationale:

The Ventrogluteal site is safe for most intramuscular

injections because it only involves the gluteus medius and
gluteus minimus muscles. The Vastus lateralis muscle is
also a safe injection site for intramuscular medications
because there are no adjacent large blood vessels and
nerves. The deltoid muscle is a smaller muscle and is safe
for administration of intramuscular medications less than 1
mL. The Dorsogluteal muscle is not recommended for
intramuscular medications because of the potential
damage to the sciatic nerve. Large blood vessels are also
located near the dorsogluteal muscle and should be
avoided.

22. Answer: B

Rationale:

Prescribing or stopping medications is the responsibility of

the physician, thus the nurse must refer this first. Thiazide
diuretics cause loss of blood potassium while conserving
blood calcium, thus, the electrolyte level must be
evaluated first.

23. Answer: D

The Brandt-Andrew maneuver is the proper extraction of

the umbilical cord and placenta. McRobert’s maneuver is
performed in case of shoulder dystocia during childbirth.
The Schultz mechanism is used to describe placental
delivery. Ritgen’s maneuver is performed by applying
pressure over the perineum and counter-pressure on the
fetal head. The Ritgen’s maneuver controls the exit of the
fetal head and prevents severe damage to maternal
tissues.

24. Answer: B

Rationale:

The uterine fundus should start to descend after 24 hours

of delivery. The normal rate of uterine descent is 1
cm/day.

25. Answer: B

Rationale:

In Somatoform Disorder, there is no real organ damage,

but the client verbalizes symptoms of a disease in an
unconscious manner. In Malingering, verbalization of
symptoms of a disease is conscious and is used by the
client to achieve a secondary gain or benefit. Anxiety
comes in many forms of panic attacks, phobia, and social
anxiety and the distinction between a disorder and
“normal” anxiety isn’t always clear. Amnesia refers to the
loss of memories, such as facts, information and
experiences.

26. Answer: D

Rationale:

Not all chemotherapeutic agents alter the molecular

structure of DNA. Chemotherapy should slow down cell
division not hasten it. All cells are sensitive to drug toxins.
Chemotherapeutic agents act on all rapidly dividing cells –
most action of chemotherapeutic agents is that it affects
all rapidly dividing cells including the normal and cancer
cells.
27. Answer: C

Rationale:

Ketoacidosis is associated with high levels of ketone

bodies in the body brought by the breakdown of fatty acids
and is not related to vomiting. Metabolic acidosis happens
when the body produces an excessive quantity of acid.
Severe vomiting will result in loss of HCL and acids
coming from extracellular fluids which in turn leads to
metabolic alkalosis. Respiratory alkalosis occurs when
there is an increased respiration which elevates the blood
pH beyond the normal range of 7.35-7.45.

28. Answer: D

Rationale:

2nd-degree skin reactions are evident by scaly skin, an

itchy feeling, and dry desquamation. Reddening of the
skin is not seen in 2nd-degree skin reactions.

29. Answer: B

Rationale:

Tremor is clinically defined as rhythmic and repetitive

muscle movement. Chorea is clinically defined as brief
and involuntary muscle twitching of the face or limbs
which hinders the client’s mobility. Athetosis is clinically
defined as the presence of irregular and slow twisting
motions. Dystonia is similar to the definition of Athetosis
but involves larger muscle areas.

30. Answer: C

Rationale:

Standing close to the working area is a proper body

mechanics to prevent muscle fatigue. The nurse should
adjust the bed to waist level in order to prevent stretching
and muscle strain. Proper body mechanic includes turning
the body as a whole unit when moving the client to avoid
twisting the back. The knees are bent to support the
body’s center of gravity and maintain body balance.
Bending the knees will provide a wider base of support for
effective leverage and use of energy.
1. D. In the patient’s room.

It is best to keep the equipment inside the room for easy

access to it when needed and also for infection control
measures. The patient in isolation may be
immunocompromised or have an infectious disease.
Making sure that the thermometer is only on him limits the
risk of infection.

2. B. They shuffle their feet while taking small steps

Typical walk of patients with Parkinson’s disease is

usually described as shuffling gait, which is due to the
degeneration of the basal ganglia. This change in
movement is considered part of the extrapyramidal
symptoms observed among patients with Parkinson’s
disease.

3. D. Left side-lying with the head of the bed elevated 45

degrees

This position helps ensure that the patient is protected

from accidental puncture of the surrounding structures in
the thoracic cavity. It also exposes the puncture site while
helping ensure that the patient has optimal breathing for
his condition

4. A, B, D.

Pain during the first stage of labor is primarily caused by

hypoxia of the uterine and cervical muscle cells during
contraction, stretching of the lower uterine segment,
dilatation of the cervix and perineum, and pressure on
adjacent structures. Ambulating will assist in increasing
circulation of blood to the area and relaxing the muscles.
Slow chest breathing is appropriate during the first stage
of labor to promote increased oxygenation as well as
relaxation. The woman or her coach can lightly massage
the abdomen (effleurage) while using slow chest
breathing. Chest breathing and massaging increase
oxygenation and relaxation of uterine muscles. Pain
medication is not used during the first stage of labor
because most medications will slow labor; anesthesia may
be considered during the second stage of labor. Sipping
ice water, while helpful for maintaining hydration, will not
be useful as a pain management strategy.

5. C.
Parameters such as vital signs (especially heart rate),
urinary output volume, adequacy of capillary filling, and
state of sensorium determine adequacy of fluid
resuscitation. Although options 1, 2, and 4 may provide
some information related to fluid
volume, in a burn injury, and from the options provided,
adequacy of capillary filling is most accurate.

6. 3.

The posterior fontanel should be closed by age 2 months.

The anterior fontanel and sagittal and frontal sutures
should be closed by age 18 months.

7. C.

The intravenous infusion is secured appropriately; the

sandbag is used to limit movement of the leg. It is not
necessary to also secure the uninvolved extremity. The
intravenous site should be visible; the nurse should not
cover it with tape. The nurse should use an infusion pump
with monitoring alarms, and check the infusion rate every
hour.

8. C.

PVCs are characterized by a QRS of longer than 0.10

second and by a wide, notched, or slurred QRS complex.
There is no P wave related to the QRS complex, and the T
wave is usually inverted.

9. D.

Sinus tachycardia is characterized by normal conduction

and a regular rhythm, but with a rate exceeding 100 bpm.
A P wave precedes each QRS, and the QRS is usually
normal.

10. A.
Decreased blood flow is a common characteristic of all
PVD. When the demand for oxygen to the working
muscles becomes greater than the supply, pain is the
outcome. Slow blood flow throughout the circulatory
system may suggest pump failure. Thrombus formation
can result from stasis or damage to the intima of the
vessels.

11. D.

If surgery is scheduled, the nurse should avoid

venipunctures in the affected extremity. The goal should
be to prevent unnecessary trauma and possible infection
in the affected arm. Disruptions in skin integrity and even
minor skin irritations can cause the surgery to be
canceled. The nurse can continue to monitor the
temperature and radial pulse in the affected arm; however,
doing so is not the priority. Keeping the patient warm is
important but is not the priority at this time.

12. A.

Beta-adrenergic medications block the beta-adrenergic

receptors. Therefore, the expected outcome of the
medication is to decrease the influence of the sympathetic
nervous system on the blood vessels in the hands. Beta-
adrenergic blockers have no analgesic effects. Increasing
blood supply to the affected area is an indirect effect of
beta adrenergic blockers. They do not increase
monoamine oxidase, which does not play a role in
Raynaud’s disease.

13. B.

The patient demonstrates classic symptoms of DVT, and

the nurse should continue to assess the patient. Signs and
symptoms of an aortic aneurysm include abdominal pain
and a pulsating abdominal mass. Patients with drug abuse
demonstrate confusion and decreased levels of
consciousness. Claudication is an intermittent pain in the
leg.

14. A.

Cardiac tamponade is a life-threatening complication of a

dissecting thoracic aneurysm. The sudden, painful
“tearing” sensation is typically associated with the sudden
release of blood, and the patient may experience cardiac
arrest. Stroke, pulmonary edema, and myocardial
infarction are not common complications of a dissecting
aneurysm.

15. A, D, E.
Antihistamines have an anticholinergic action and a drying
effect and reduce nasal, salivary, and lacrimal gland
hypersecretion (runny nose, tearing, and itching eyes). An
adverse effect is drowsiness, so operating machinery and
driving are not  recommended. There is also an additive
depressant effect when alcohol is combined with
antihistamines, so alcohol should be avoided during
antihistamine use. The patient should ensure adequate
fluid intake of at least 8 glasses per day due to the drying
effect of the drug. Antihistamines have no antibacterial
action. The effect of antihistamines is prompt, not delayed.

16. D.

The patient has undergone body changes and permanent

loss of verbal communication. He may feel isolated and
insecure. The nurse can encourage him to express his
feelings and use this information to develop an
appropriate plan of care. Discussing the patient’s behavior
with his wife may not reveal his feelings. Exploring future
plans is not appropriate at this time because more
information about the patient’s behavior is needed before
proceeding to this level. The nurse can respect the
patient’s need for privacy while also encouraging him to
express his feelings.

17. A.

The patient’s age is a predisposing factor for pneumonia;

pneumonia is more common in elderly or debilitated
patients. Other predisposing factors include smoking,
upper respiratory tract infections, malnutrition,
immunosuppression, and the presence of a chronic
illness. Osteoarthritis, a nutritionally sound vegetarian diet,
and frequent bathing are not predisposing factors for
pneumonia.

18. A.

Tuberculosis typically produces anorexia and weight loss.

Other signs and symptoms may include fatigue, low-grade
fever, and night sweats. Increased appetite is not a
symptom of tuberculosis; dyspnea on exertion and change
in mental status are not common symptoms of
tuberculosis.

19. A.

The arterial blood gas reveals a respiratory acidosis with

hypoxia. A quick-acting bronchodilator, albuterol, should
be administered via nebulizer to improve gas exchange.
Ipratropium is a maintenance treatment for bronchospasm
that can be used with albuterol. A chest x-ray and sputum
sample can be obtained once the patient is stable.

20. A.

Risk factors for postoperative pulmonary complications

include malnourishment, which is indicated by this
patient’s height and weight. It is thought that emotional
responses can affect overall health; however, not
verbalizing one’s feelings is not a contributing factor in
postoperative pulmonary complications. The patient’s
current activity level and age do not place her at increased
risk for complications.

21. D.

To promote chest tube drainage the drainage system must

be lower than the patient’s lungs. The amount of drainage
is not abnormal; it is not necessary to notify the physician.
The nurse should chart the amount and color of drainage
every 4 to 8 hours. The chest tube does not need to be
clamped; the tubing connection is intact. There is sufficient
water to maintain a water seal.

22. D.

It is important for individuals who are engaged in smoking

cessation efforts to feel comfortable with sharing their
fears of failure with others and seeking support. Although
fewer than 5% of smokers successfully quit on their first
attempt, it is not helpful to tell a patient that he should
anticipate failure. Telling the patient to exercise more self
control

does not provide him with support. Taking a vacation to

avoid job pressures does not address the issue of fearing
he will smoke a cigarette when in a stressful situation.

23. A.

The Cochrane Library provides systematic reviews of

health care interventions and will provide the best
resource for evidence for nursing care. CINHAL offers key
word searches to published articles in nursing and allied
health literature, but not reviews. A nursing textbook has
information about nursing care which may include
evidence based practices, but textbooks may not have the
most up-to-date information. While the policy and
procedure manual may be based on evidence-based
practices, the most current practices will be found in
evidence-based reviews of literature.
24. A.

The goal of TPN is to meet the patient’s nutritional needs.

TPN is not used to treat metabolic acidosis; ketoacidosis
can actually develop as a result of administering TPN.
TPN is a hypertonic solution containing carbohydrates,
amino acids, electrolytes, trace elements, and vitamins. It
is not used to meet the hydration needs of patients. TPN
is administered to provide a positive nitrogen balance.

25. C, D, B, A.

A potential complication of receiving TPN is leakage or

catheter puncture; notify the physician immediately and
prepare for changing of the catheter. If pneumothorax is
suspected, position a rolled towel under the patient’s back.
If there is drainage at the insertion site, culture the
drainage and change the dressing using sterile technique.

26. D.

Elevated serum concentrations of thyroid hormones and

suppressed serum TSH are the features of thyrotoxicosis.
Decreased or absent serum TSH is a very accurate
indicator of thyrotoxicosis. Increased levels of circulating
thyroid hormones cause the feedback mechanism to the
brain to suppress TSH secretion.

27. A.

The elevated blood glucose level indicates hyperglycemia.

The hemoglobin is normal. The patient’s cholesterol and
LDL levels are both normal. The nurse should determine if
there are standing orders for the hyperglycemia or notify
the physician.

28. D.

The patient with diabetes mellitus who is taking NPH

insulin (Humulin N) in the evening is most likely to become
hypoglycemic shortly after midnight because this insulin
peaks in 6 to 8 hours. The patient should eat a bedtime
snack to help prevent hypoglycemia while sleeping.

29. B, C, E.

The patient with a C3 to C4 fracture has neck control but

may tire easily using sore muscles around the incision
area to hold up his head. Therefore, the head and neck of
his wheelchair should be high. The seat of the wheelchair
should be lower than normal to facilitate transfer from the
bed to the wheelchair. When a patient can use his hands
and arms to move the wheelchair, the placement of the
back to the patient’s scapula is necessary. This patient
cannot use his arms and will need an electric chair with
breath, chin, or voice control to manipulate movement of
the chair. A firm or hard cushion adds pressure to bony
prominences; the cushion should instead be padded to
reduce the risk of pressure ulcers.

30. D.

Limiting fluid intake is likely to aggravate rather than

relieve symptoms when a bowel retraining program is
being implemented. Furthermore, water imbalance, as
well as electrolyte imbalance, tends to aggravate the signs
and symptoms of MS. A diet high in fiber helps keep
bowel movements regular. Setting a regular time each day
for elimination helps train the body to maintain a schedule.
Using an elevated toilet seat facilitates transfer of the
patient from the wheelchair to the toilet or from a standing
to a sitting position.