Category 1
The nurse should visit which of the following clients first?
Correct Answer: C. The client with chest pain and a history of angina
The client with chest pain should be seen first because this could indicate a myocardial infarction. Despite many advances in treatment, acute MI still carries a mortality rate of 5-30%; the majority of deaths occur prior to arrival to the hospital. In addition, within the first year after an MI, there is an additional mortality rate of 5% to 12%. The overall prognosis depends on the extent of heart muscle damage and ejection fraction.
The client with color blindness will most likely have problems distinguishing which of the following colors?
Correct Answer: B. Violet
Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The most common forms are protanopia and deuteranopia, conditions arising from loss of function of one of the cones, leading to dichromic vision. Protanopia is the loss of L cones (red) resulting in green-blue vision only. Deuteranopia is the loss of M cones (green) resulting in red-blue vision only.
The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?
Correct Answer: B. Chest tubes serve as a method of draining blood and serous fluid and assist in re inflating the lungs.
Chest tubes work to reinflate the lung and drain serous fluid. Physicians use a chest tube to create negative pressure in the chest cavity and allow re-expansion of the lung. It helps remove air (pneumothorax), blood (hemothorax), fluid (pleural effusion or hydrothorax), chyle (chylothorax), or purulence (empyema) from the intrathoracic space.
A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
Correct Answer: D. Fetal development depends on adequate insulin regulation.
Fetal development depends on adequate nutrition and insulin regulation. Significant alterations in maternal metabolism during pregnancy ensure a continuous supply of nutrients to the fetus. Glucose is the primary energy source for the fetus. In early pregnancy, increases in maternal insulin sensitivity enable the storage of energy and nutrients.
Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?
Correct Answer: C. Affected parents have a one in four chance of passing on the defective gene.
Autosomal recessive disorders can be passed from the parents to the infant. If both parents pass the trait, the child will get two abnormal genes and the disease results. Parents can also pass the trait to the infant. Patients affected with autosomal recessive (AR) diseases have a disease allele on each chromosome. The pattern of individuals affected with an AR disease can be traced through a family to determine which individuals are carriers and which individuals are likely to become impacted.
A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
Correct Answer: B. Three times per day with meals
Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body in digesting needed nutrients. Chronic, supportive therapy for patients with CF includes regular pancreatic enzymes, fat-soluble vitamins (A, D, E, K), mucolytics, bronchodilators, antibiotics, and anti-inflammatory agents.
The client with a pacemaker should be taught to:
Correct Answer: D. Monitor his pulse rate
The client with a pacemaker should be taught to count and record his pulse rate. Pacemakers are adjustable artificial electrical pulse generators, frequently emitting a pulse with a duration between 0.5 and 25 milliseconds with an output of 0.1 to 15 volts, at a frequency up to 300 times per minute. The cardiologist or pacemaker technologist will be able to interrogate and control the pacing rate, the pulse width, and the voltage, whether the device is temporary or permanent.
A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:
Correct Answer: D. Mother’s desire to breastfeed
Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue breastfeeding until the infant and mother have time to adapt. Breastfeeding is an important part of a newborn’s life. Breastfeeding or lactation provides total nutritional and emotional dependency of the baby on the mother. The strong emotional bonding between the mother-child dyad is needed for successfully prolong breastfeeding.
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
Correct Answer: A. Providing a calm environment
A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Establish measures to lessen likelihood of seizures; i.e., keep the room quiet and dimly lit, limit visitors, plan and coordinate care, and promote rest. Lessens environmental factors that may stimulate irritable cerebrum and cause a convulsive state.
A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
Correct Answer: D. To detect neurological defects
Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. Alpha-fetoprotein (AFP) is a plasma protein produced by the embryonic yolk sac and the fetal liver. AFP levels in serum, amniotic fluid, and urine functions as a screening test for congenital disabilities, chromosomal abnormalities, as well as some other adult occurring tumors and pathologies.
Cataracts result in the opacity of the crystalline lens. Which of the following best explains the functions of the lens?
Correct Answer: C. The lens focuses light rays on the retina.
The lens allows light to pass through the pupil and focus light on the retina. The lens is a curved structure in the eye that bends light and focuses it for the retina to help you see images clearly. The crystalline lens, a clear disk behind the iris, is flexible and changes shape to help you see objects at varying distances.
The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:
Correct Answer: A. 1900
Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1900. If you go to the toilet too frequently “just in case,” you might end up making the overactive bladder symptoms worse, because the bladder is then “trained” to send a signal that you need to urinate as soon as there is only a small amount of urine in it.
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
Correct Answer: C. The presence of green-tinged amniotic fluid
Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. Amniotic fluid should be clear, or straw tinged with small vernix particles in the fluid. Brown or green staining of the fluid indicates the passage of meconium. Because the fetus swallows amniotic fluid in utero, meconium can be present in the infant’s oropharynx at delivery. During delivery, if meconium-stained amniotic fluid is noted, a neonatal resuscitation team should be promptly involved
A primigravida, age 42, is 6 weeks pregnant. Based on the client’s age, her infant is at risk for:
Correct Answer: A. Down syndrome
The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations. The risk of chromosome abnormalities is higher. Babies born to older mothers have a higher risk of certain chromosome problems, such as Down syndrome.
A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:
Correct Answer: B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. During pregnancy, there are increased metabolic needs of the maternal body resulting in changes in thyroid physiology. These changes in thyroid physiology reflect in altered thyroid function tests.
A client who has glaucoma is to have miotic eye drops instilled in both eyes. The nurse knows that the purpose of the medication is to:
Correct Answer: C. Constrict the pupils
Miotic eye drops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. Pilocarpine is a muscarinic acetylcholine agonist that is effective in the treatment and management of acute angle-closure glaucoma and radiation-induced xerostomia. Although not a first-line treatment for glaucoma, it is useful as an adjunct medication in the form of ophthalmic drops.
Which of the following diet instructions should be given to the client with recurring urinary tract infections?
Correct Answer: D. Drink a glass of cranberry juice every day.
Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria do not grow freely in acidic urine. A 2003 study that included 324 women found that frequently drinking freshly squeezed, 100% juice — especially berry juice, as well as consuming fermented dairy products like yogurt, was associated with a decreased risk of UTI occurrence
The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?
Correct Answer: C. Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
Duration is measured from the beginning of one contraction to the end of the same contraction. Duration is timed from when you first feel a contraction until it is over. This time is usually measured in seconds.
A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
Correct Answer: C. Dinoprostone (Prostin E.)
The client with a missed abortion will have induction of labor. Prostin E. is a form of prostaglandin used to soften the cervix. Prostaglandin E2 (PGE2), also known by the name dinoprostone, is a naturally occurring compound that is involved in promoting labor, though it is also present in the inflammatory pathway. Prostaglandin E2 is FDA approved for cervical ripening for the induction of labor in patients for which there is a medical indication for induction.
The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse would expect to find:
Correct Answer: C. Cyanosis of the feet and hands
Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. Acrocyanosis is bluish discoloration around the mouth and extremities, with the remaining area pink. It is a benign finding often seen in healthy newborns and is common in the initial days of life due to initial peripheral vasoconstriction. This is managed by routine newborn care. The routine newborn care management which involves pulse oximetry and screening of congenital heart disease (CHD).
A client with a severe corneal ulcer has an order for Gentamicin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?
Correct Answer: A. Allow 5 minutes between the two medications.
When using eye drops, allow 5 minutes between the two medications. Antibiotic eye drops are prescribed by a doctor to treat bacterial eye infections. They work by killing the bacteria (microscopic organism) that entered the eye and caused the infection.
The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
Correct Answer: C. “I will eat a snack around three o’clock each afternoon.”
NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. It is on the list of essential medicines of the world health organization (WHO).NPH insulin is FDA-approved in the adult and pediatric population for the control of type 1 and type 2 diabetes mellitus. It is currently the most widely used basal insulin that simulates the physiological basal insulin action. Basal insulin provides a constant supply of insulin in the body that is necessary for glucose regulation despite fasting, such as between meals and overnight.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
Correct Answer: B. Fetal bradycardia
The client receiving Pitocin should be monitored for decelerations. It is essential to monitor patient fluids (both intake and outtake) while administering oxytocin, as well as the frequency of uterine contractions, patient blood pressure, and heart rate of the unborn fetus.
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:
Correct Answer: A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure
The client’s blood pressure and urinary output are within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8–9.6mg/dL. Magnesium levels must be monitored frequently by checking serum levels every 6 to 8 hours or clinically by following patellar reflexes or urinary output.
A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for:
Correct Answer: A. Supplemental oxygen
Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. The supply of extra oxygen with oxygen therapy may be beneficial for some patients with sickle cell disease. But the use of oxygen therapy in sickle cell disease is controversial because high levels of oxygen are known to suppress the formation of new red blood cells. Oxygen therapy is, therefore, only recommended when oxygen levels drop below a critical threshold.