CATEGORY 1
A pediatric nurse is performing a routine assessment of a one-month-old infant during a well-baby visit at the primary care clinic. The infant’s mother reports no concerns and states that the baby has been feeding well and has had regular bowel movements. Upon assessment, which of the following findings warrants further investigation by the nurse?
Select all that apply.
Correct Answers: C, E, F, & G
In a wound care clinic, Nurse Palmer is assigned to Ms. Harris, a 27-year-old female client with a history of deep vein thrombosis. Ms. Harris presents with a venous stasis ulcer on her left lower leg, which has persisted for the last three months despite home care efforts. Ms. Harris has been managing the ulcer with over-the-counter dressings and is concerned about the lack of progress. She has also mentioned that she’s been feeling fatigued lately and has unintentionally lost 5 kg over the past month. Based on the assessment and the client’s history, which nursing intervention would be most effective in promoting the healing of the ulcer?
Correct Answer: B. Improve the client’s nutrition status
Venous stasis occurs when venous blood collects and stagnates in the lower leg due to incompetent venous valves. Eventually, little oxygen and nutrients are supplied to the cells of the lower extremities causing the cells to die or necrose. This ultimately leads to the formation of venous stasis ulcers characterized by shallow but large brown wounds with irregular margins that typically develop on the lower leg or ankle. The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. Nutritional deficiencies are common causes of venous ulcers. Alterations in the diet to include foods high in protein, iron, zinc, and vitamins C and A are encouraged to promote wound healing.
A nurse is reviewing a patient’s medication during shift change. Which of the following medications would be contraindicated if the patient were pregnant? Select all that apply.
Correct Answer: A. Warfarin (Coumadin); B. Finasteride (Propecia, Proscar)
A second-year nursing student, who is on a clinical rotation in the infectious diseases unit of a major urban hospital, has just suffered a needlestick injury. The incident occurred while the student was assisting in drawing blood from a patient known to have a high viral load and is positive for AIDS. The student is visibly shaken, as they are aware of the patient’s medical history.
Given the circumstances and potential risk, which of the following is the most significant action that the nursing student should take immediately after the incident?
Correct Answer: B. Start prophylactic AZT treatment
Azidothymidine (AZT) treatment is the most critical intervention. It is an antiretroviral medication used to prevent and treat HIV/AIDS by reducing the replication of the virus. Post-exposure prophylaxis (PEP) for HIV is a treatment to suppress the virus and prevent infection after exposure. PEP should be taken within 72 hours of possible exposure to HIV, so it is important to seek treatment quickly. While reporting the incident, seeking counseling, and other actions are also important, the immediate priority is to reduce the risk of HIV transmission.
A first-time mother, who is a pediatrician herself, has recently given birth to twins. While one of the twins has been diagnosed with phenylketonuria (PKU), the other has not. She approaches the nurse with a series of technical questions regarding PKU, its diagnosis, and implications.
Given her medical background and the unique situation of having twins with different PKU statuses, which of the following statements made by a nurse would NOT be correct regarding PKU?
Correct Answer: D. “The effects of PKU, once manifested, are completely reversible with dietary modifications.”
Phenylketonuria (PKU) is an inherited disorder that increases the levels of phenylalanine (a building block of proteins) in the blood. If PKU is not treated, phenylalanine can build up to harmful levels in the body, causing intellectual disability and other serious health problems. The signs and symptoms of PKU vary from mild to severe. The most severe form of this disorder is known as classic PKU. Infants with classic PKU appear normal until they are a few months old.
During her shift in the maternity ward, Nurse Jackson cares for Ms. Greene, who is at 42 weeks of gestation and shows no signs of labor. Given that the fetus is now considered postmature, Nurse Jackson recalls the risks associated with postmaturity. Among the following potential complications, which one is primarily linked to the postmature status of the fetus?
Correct Answer: D. Progressive placental insufficiency
Postmature or post-term pregnancy is prolonged and exceeds the limits of 38 to 42 weeks (normal-term pregnancy). Infants of such gestation are considered postmature or dysmature if there is evidence that placental insufficiency has occurred and interfered with fetal growth. It occurs in 12% of all pregnancies. The placenta loses its adequacy to function after 42 weeks, after which it acquires calcium deposits which decrease the blood perfusion, supply of oxygen and nutrients to the fetus.
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the order in which the nurse must carry out the following actions prior to the administration of preoperative medications.
Raise the side rails on the bed.
Place the call bell within reach.
Instruct the client to remain in bed.
Have the client empty bladder
A nurse is reviewing a patient’s past medical history (PMH). The history indicates the patient has photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select all that apply.
Correct Answer: A, B, C, D, and E.
Photosensitivity is an extreme sensitivity to ultraviolet (UV) rays from the sun and other light sources. A type of photosensitivity called Phototoxic reactions are caused when medications in the body interact with UV rays from the sun. Anti-infectives are the most common cause of this type of reaction.
A thirty-five-year-old male, who is a professional marathon runner, has been an insulin-dependent diabetic for five years. He visits the clinic, expressing concerns about recent changes in his training performance. He mentions fatigue, occasional dizziness, and now, an inability to urinate for the past 24 hours.
Given his profession, medical history, and the presented symptoms, which of the following complications of diabetes would you most likely suspect?
Correct Answer: C. Autonomic neuropathy
Autonomic neuropathy (also known as Diabetic Autonomic Neuropathy) affects the autonomic nerves, which control the bladder, intestinal tract, and genitals, among other organs. Paralysis of the bladder is a common symptom of this type of neuropathy, as manifested by bladder urgency and inability to start urination.
A 50-year-old male patient, who is a known case of congestive heart failure and was recently diagnosed with osteoarthritis, is admitted to the ER. The patient’s wife reports that he might have taken an overdose of aspirin in an attempt to manage his joint pain.
Given his medical history and the potential implications of aspirin overdose, which of the following complications should a nurse most closely monitor for during the acute management of this patient.
Correct Answer: A. Onset of pulmonary edema
Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development. Early symptoms of aspirin poisoning also include tinnitus, hyperventilation, vomiting, dehydration, and fever. Late signs include drowsiness, bizarre behavior, unsteady walking, and coma. Abnormal breathing caused by aspirin poisoning is usually rapid and deep. Pulmonary edema may be related to an increase in permeability within the capillaries of the lung leading to “protein leakage” and transudation of fluid in both renal and pulmonary tissues. The alteration in renal tubule permeability may lead to a change in colloid osmotic pressure and thus facilitate pulmonary edema (via Medscape).
In the post-surgical unit, the nurse is attending to a client who had a total hip replacement seven (7) days ago. This client has a history of hypertension, mild asthma, and is on anticoagulant therapy. The client provides feedback about their current condition. Which of the following statements by the client is most concerning and necessitates the nurse’s immediate intervention?
Correct Answer: B. “I just can’t ‘catch my breath’ over the past few minutes, and I think I am in grave danger.”
The nurse would be concerned about all of these comments, however, the most life-threatening is Option B. Clients who had hip or knee surgery are at higher risk for the development of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Without prophylaxis (e.g., anticoagulation medications), deep vein thrombosis can develop within 7 to 14 days following the surgery and can lead to pulmonary embolism. The nurse should be aware of the other signs of DVT which include pain and tenderness at or below the area of the clot, skin discoloration, swelling, or tightness of the affected leg. Signs of pulmonary embolism include acute onset of dyspnea, tachycardia, confusion, and pleuritic chest pain.
Nurse Jackson has recently taken on the role of Nurse Manager for a busy medical-surgical unit. She wants to implement an effective reward-feedback system to improve team performance and foster professional growth. During a team meeting, she discusses potential strategies for feedback. Which of these statements a team member makes best describes the characteristics of an effective reward-feedback system?
Correct Answer: A. “We should provide specific feedback immediately after a task is completed or observed.”
Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.
A 68-year-old female patient, recently diagnosed with Parkinson’s disease and rheumatoid arthritis, tells you during a follow-up visit that her urine is starting to look discolored. She also mentions that she has been taking over-the-counter medications for constipation and occasional headaches. Given her medical history and the potential side effects of medications, which of the following of the patient’s medications is least likely to cause urine discoloration?
Correct Answer: D. Aspirin
Aspirin is not known to cause discoloration of the urine. Side effects and complications of taking aspirin include stroke caused by a burst blood vessel. The Food and Drug Administration doesn’t recommend aspirin therapy for the prevention of heart attacks in people who haven’t already had a heart attack, stroke or another cardiovascular condition.
You are conducting a health assessment in a high school clinic. A 14-year-old girl, who is a lead ballet dancer in her school’s performing arts program, comes in for a routine check-up. She has a BMI of 18 and appears fatigued. During the assessment, she hesitantly discloses her inability to eat, occasionally induced vomiting after meals, and severe constipation. She also mentions increased pressure to maintain a certain physique for her upcoming performances.
Given her age, extracurricular activities, and the presented symptoms, which of the following conditions would you most likely suspect?
Correct Answer: B. Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by weight loss, difficulties maintaining an appropriate body weight for height, age, and stature, and, in many individuals, a distorted body image. The girl’s BMI of 18, inability to eat, induced vomiting, and the context of pressure from her ballet performances strongly suggest anorexia nervosa. While bulimia nervosa also involves episodes of overeating followed by purging, the girl’s low BMI and inability to eat align more closely with anorexia nervosa. The other options are less consistent with the presented symptoms and context.
A 50-year-old patient, who is blind and deaf and has recently undergone a major abdominal surgery, has been admitted to your post-operative floor. The patient has a history of anxiety and has been on medication for the same.
As the charge nurse, considering the patient’s sensory deficits, recent surgery, and psychological background, what should be your primary responsibility for this patient?
Correct Answer: D. Provide a secure environment for the patient.
This patient’s safety is your primary concern. Patient safety protocols can help reduce medical mistakes and prevent adverse patient outcomes. When the goal is to help people, it seems obvious that it’s important to work to protect them from unintended or unexpected harm. Given the patient’s sensory deficits, recent surgery, and history of anxiety, creating a safe environment becomes paramount. This encompasses both physical safety (preventing falls, ensuring surgical recovery) and emotional safety (addressing anxiety, ensuring the patient feels secure).
In the cardiology unit, a nurse closely monitors a 33-year-old male client diagnosed with heart failure. The client, a previously active triathlete, was recently started on furosemide due to increased fluid retention. The client mentions a few changes he’s noticed over the past week. Which of the following statements from the client would suggest he may be experiencing a negative side effect from the furosemide?
Correct Answer: D. “I haven’t been as hungry this past week, even for my favorite foods.”
Furosemide is a loop diuretic that is used for pulmonary edema, edema in heart failure, nephrotic syndrome, and hypertension. Furosemide causes potassium loss unless a supplement or a potassium-rich diet is taken. A decrease in appetite is caused by hypokalemia. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias, reduced urine osmolality, and altered level of consciousness.
Nurse Martinez is caring for Mr. Reyes, a 45-year-old client newly diagnosed with multiple sclerosis. Mr. Reyes is an active individual and has voiced concerns about how this diagnosis will affect his fitness regimen. During a teaching session about safe exercises and physical activities for MS patients, Nurse Martinez provides various recommendations. She later evaluates Mr. Reyes’ understanding of the information provided. The nurse determines the client needs additional teaching if Mr. Reyes makes which of the following statements? Select all that apply.
Correct answers: B & E.
You are a charge nurse responsible for reviewing the nursing unit’s refrigerator at a busy urban hospital that has recently experienced a power outage. The outage lasted for a short period, but you’re ensuring that all medications are stored correctly post-outage. During your review, you find several medications, some of which are critical for patients with chronic conditions. Which of the following drugs, if found inside the fridge, should be removed and replaced due to incorrect storage?
Correct Answer: A. Corgard
Nadolol (Corgard) is a beta-blocker used to treat high blood pressure and angina (chest pain). It does not require refrigeration and should be stored at room temperature (59 to 86 ºF or 15 to 30ºC), away from heat, moisture, and light. The other medications listed, such as Humulin N, Urokinase, Epoetin alfa, Glargine, and Cyanocobalamin, have specific storage requirements that may include refrigeration, especially once opened or in-use.
A 24-year-old female, who recently returned from a mountaineering expedition, is admitted to the ER presenting with confusion. The patient’s medical records indicate a history of a myeloma diagnosis. She also reports having experienced constipation, intense abdominal pain, and polyuria during her expedition. She mentions that she had limited access to water and relied heavily on packaged foods during her trip.
Given her recent activities, medical history, and the presenting signs and symptoms, which of the following conditions would you most likely suspect?
Correct Answer: B. Hypercalcemia
Hypercalcemia is characterized by elevated calcium levels in the blood. Myeloma can lead to bone destruction, which releases calcium into the bloodstream. The symptoms of hypercalcemia include confusion, polyuria (increased urination), constipation, and abdominal pain, all of which the patient is experiencing. While the other options might be considered given certain aspects of her presentation, the combination of her myeloma diagnosis and the specific symptoms she’s exhibiting make hypercalcemia the most likely suspect.
A 72-year-old patient, who is a retired miner, is getting discharged from a skilled nursing facility (SNF) after a 3-week stay for a lower limb fracture. The patient has a history of severe COPD, likely due to his occupational exposure, and PVD. He lives alone in a two-story house and is primarily concerned about his ability to breathe easily, especially when he needs to climb stairs to his bedroom.
Given his living situation, medical history, and concerns, which of the following would be the best instruction for this patient to manage his respiratory challenges?
Correct Answer: C. Cough following bronchodilator utilization
For a patient with severe COPD, deep breathing techniques can help increase oxygen levels in the blood and improve overall lung function. This can be particularly beneficial for activities that may exacerbate shortness of breath, such as climbing stairs. While the other options have their merits, deep breathing techniques offer a proactive approach to managing the patient’s primary concern about breathing easily.
A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage ten years ago at 12 weeks gestation. How would the nurse accurately document this information? Fill in the blanks.
Answer: Gravida: para:
Correct Answer: Gravida 3 para 1
Gravida is the number of confirmed pregnancies and each pregnancy is only counted one time, even if the pregnancy was a multiple gestation (i.e., twins, triplets). Para (parity) indicates the total number of pregnancies that have reached viability (20 weeks) regardless of whether the infants were born alive. Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
Nurse Anderson is visiting the home of Mrs. Thompson, an 80-year-old woman with advanced Alzheimer’s disease. Mrs. Thompson’s family, including her daughter and son-in-law, have been primary caregivers and made several modifications to accommodate her needs. Nurse Anderson, assessing the quality of home care provided to Mrs. Thompson, seeks to prioritize the safety and well-being of the patient. During her evaluation, which statement made by the daughter will the nurse reinforce as being of utmost importance?
Correct Answer: C. We have safety bars installed in the bathroom and have 24-hour alarms on the doors.
Note all options are correct statements. However, safety is most important to reinforce.
A 34-year-old female, who is a renowned biologist specializing in immunology, has recently been diagnosed with an autoimmune disease. During a consultation, she discusses her concerns with the nurse, mentioning her recent discovery of being pregnant. She expresses her worries about the potential impact of her condition on the fetus and is curious about the body’s natural protective mechanisms.
Given her background and concerns, which of the following immunoglobulins should the nurse explain as the only one that will provide protection to the fetus in the womb?
Correct Answer: D. IgG
IgG is the only immunoglobulin that can cross the placental barrier. About 70-80% of the immunoglobulins in the blood are IgG. Specific IgG antibodies are produced during an initial infection or other antigen exposure, rising a few weeks after it begins, then decreasing and stabilizing. The body retains a catalog of IgG antibodies that can be rapidly reproduced whenever exposed to the same antigen. IgG antibodies form the basis of long-term protection against microorganisms.
A 28-year-old woman, in her second pregnancy, visits the prenatal clinic. During her first pregnancy, she did not receive any postnatal Rhogam shots. Her medical records indicate that she is RH negative. The father of the child, however, is RH positive.
Given the potential risks associated with Rh incompatibility and the importance of preventive care, under which circumstances would Rhogam most likely be administered to the mother to prevent hemolytic disease in the infant?
Correct Answer: C. When the mother is RH negative and the infant is RH positive.
Rhogam (Rho(D) immune globulin) is given to RH negative mothers to prevent the development of antibodies against RH positive blood. This is crucial when an RH negative mother has an RH positive infant, as the mother’s body may see the baby’s RH positive red blood cells as foreign and develop antibodies against them, leading to hemolytic disease in the infant. Rhogam is administered to prevent this immune response.
A nurse is assigned to the pediatric cardiology unit where she is caring for a 6-month-old infant. The infant was brought in by concerned parents who noticed their baby was less active and had difficulty feeding. After a series of tests, the infant has been diagnosed with a congenital heart defect.
Given the infant’s age, recent behavioral changes, and the diagnosis, which of the following clinical signs would most likely be present and should be closely monitored by the nurse?
Correct Answer: B. Weight gain
Weight gain due to fluid accumulation is associated with heart failure and congenital heart defects. When the heart does not circulate blood normally, the kidneys receive less blood and filter less fluid out of the circulation into the urine. The extra fluid in the circulation builds up in the lungs, the liver, around the eyes, and sometimes in the legs.