1. Answer: B
a) Gastric lavage
Gastric lavage cannot be used as a general treatment for poisoning. It has limited therapeutic effects and produces problems related to the procedure.
b) Activated charcoal
The administration of activated charcoal is the most effective in the management of poisoning because it absorbs chemicals in the gastrointestinal tract, thus reducing its toxicity.
c) Cathartic administration
The elimination of the poisonous substance could be aided by cathartic administration. However, it is not the most effective intervention.
d) Milk dilution
Diluting the ingested poison with milk is not the most effective management for ingested poison.
2. Answer: A
a) Botulism
Botulism is treated with antitoxins and induced vomiting or enema in the emergency department. There is no vaccine available for the agent.
b) Smallpox
There is no exact treatment for smallpox, but antiviral medications and vaccines can help improve the client’s condition.
c) Anthrax
Antibiotics are the preferred treatment for anthrax.
d) Tularemia
The treatment for tularemia does not involve the introduction of antitoxins.
3. Answer: C
Rationale:
a) Let the client rest.
The client is already experiencing respiratory depression so the nurse must administer naloxone (Narcan).
b) Administer oxygen.
It may be given but is not the priority at this time.
c) Administer naloxone (Narcan) per physician’s order.
This is given to reverse respiratory depression.
d) Place epinephrine at the bedside.
This is unnecessary at the moment.
4. Answer: B
a) Temperature: 38.9°C, BP 90/60, pulse 98 and thready.
This indicates dehydration.
b) Cool skin, respiratory crackles, pulse 84 and bounding.
Symptoms present in fluid volume overload are elevated blood pressure, bounding pulse, edema, distended neck veins, headache, diarrhea, polyuria and hepatomegaly.
c) Abdominal pain, headache and lethargy.
This is not related to fluid volume overload.
d) CVP of 5, Urinary output: 700 cc/24 hours and nystagmus.
The CVP must be elevated (greater than 10 mm/H2O) and nystagmus is not present.
5. Answer: C
a) Stopping bleeding from open wounds
Circulatory needs or interventions can be done immediately after client’s airway is established and respirations have been stabilized.
b) Checking for neck fracture
Although this is also an important intervention this can be done after the priority interventions were given to the client
c) Establishing an airway
This is the priority when caring for unconscious clients with multiple injuries. The nurse should take note of ABC (airway, breathing and circulation) as a priority.
d) Replacing blood loss
Circulatory needs or interventions can be done immediately after the client’s airway is established and respirations have been stabilized.
6. Answers: B, C, E and F
Rationale: Clients with a stoma should be advised to regularly wash the stoma using a washcloth, apply a thin layer of petroleum jelly into the skin surrounding the stoma to avoid skin cracking, and to keep water away from the stoma. Items such as soaps, cotton swabs, and tissues must not be used when caring for the stoma as these can potentially enter the stoma and block the airway. The use of alcohol should not be practiced as well as it can promote irritation and drying.
7. Answer: D
Rationale:
Fluid volume deficit is related to various conditions such as diarrhea, vomiting, increased urinary output, heightened rates of respiration, inadequate fluid replacement, ileostomy, draining fistulas and colostomy. Fluid volume excess, on the other hand, can be observed in clients with liver cirrhosis, diminished kidney function and congestive heart failure.
8. Answers: B, E and F
Rationale:
Fingertips should not be used to handle casts while it is still drying since it causes indentations in the cast and can produce continuous pressure into the underlying skin. Instead of using the fingertips, the palms of the hand should be used to lift the cast. Sharp objects and small toys must be kept away from the cast, and padded objects should not be placed inside the cast as it can increase the risk of altered skin integrity. Heating pads should not be applied into the cast or fingers because the presence of cold fingers may signify the development of neurovascular impairment and must be reported to the doctor immediately. The affected side must also be elevated to prevent swelling. And any signs of neurovascular impairment such as numbness and tingling in the extremity should be reported right away to the health care provider.
9. Answer: B
Rationale:
a) “Give a bottle if Ipecac to your child to induce vomiting.”
Parents are advised to have Ipecac at home for each child. Doses range from 10 to 30 cc.
b) “Induce vomiting if your child swallows lighter fluid.”
Vomiting is contraindicated if hydrocarbons such as lighter fluid is ingested. This increases the client’s risk for aspiration.
c) “Give your child water or milk to dilute the poison.”
These fluids may dilute toxins.
d) “Store harmful chemicals in hard to reach areas.”
Store harmful chemicals so that children cannot gain access to it.
10. Answer: D
a) The graft is warm to touch
A skin graft that is warm to touch indicates good circulation.
b) Brisk capillary refill is noted
Brisk capillary refill also indicates good circulation and skin perfusion.
c) Sanguinous fluid at the surgical drain
Sanguinous fluid noted at the surgical drain is normal after the surgical procedure and would gradually turn into serosanguinous fluid then into a serous fluid.
d) Graft has a different color from the patient’s skin
The skin graft should have the same color as with the patient’s skin. Discoloration indicates poor perfusion to the skin graft.
11. Answer: C
Rationale:
Regression is characterized by a return to earlier behavior (such as in childhood) to reduce anxiety is the basic defense mechanism in undifferentiated schizophrenia. Projection involves blaming others and is related to paranoid schizophrenia. Rationalization involves the justification of one’s actions. Repression is the basic defense mechanism in neuroses.
12. Answer: A
Rationale:
Echopraxia is the copying and imitating of another’s behaviors and is related to the loss of ego boundaries. Ego-syntonicity is behaviors that correspond with the person’s sense of self. Modeling is the conscious copying or imitating of someone’s behaviors. Ritualism refers to repetitive and compulsive behaviors.
13. Answer: D
a) A schizophrenic client hearing voices
ECT is not used in schizophrenia, tranquilizers are commonly prescribed.
b) Client with an Antisocial personality disorder with a history of brawling
ECT is not commonly used in treatment of personality disorders.
c) Client who exhibits 7 different personalities or persona
ECT is not the treatment of choice for clients with a split personalities.
d) Client with major depression who is in antidepressants for 2 months
ECT is commonly used for treatment of major depression in clients who have not responded to antidepressants.
14. Answer: B
a) Serotonin
Benzodiazepines do not affect the regulation of serotonin in the body.
b) GABA
Benzodiazepines are able to attach the receptors of GABA. The drug potentiates the ability of GABA in the body.
c) Dopamine
Benzodiazepine does not affect the regulation of dopamine in the body.
d) Acetylcholine
When Benzodiazepine is absorbed in the body it does not alter the levels of acetylcholine.
15. Answer: B
a) Serotonin
Benzodiazepines do not affect the regulation of serotonin in the body.
b) GABA
Benzodiazepines are able to attach the receptors of GABA. The drug potentiates the ability of GABA in the body.
c) Dopamine
Benzodiazepine does not affect the regulation of dopamine in the body.
d) Acetylcholine
When Benzodiazepine is absorbed in the body it does not alter the levels of acetylcholine.
16. Answer: C
a) Patient is drowsy
Drowsiness and patient lethargy are therapeutic effects of drugs. Excessive levels of magnesium would cause muscle weakness and unresponsiveness.
b) Exaggerated deep tendon reflexes
Below normal or absent deep tendon reflex is a sign of magnesium toxicity.
c) Urinary output of 180 ml for 8 hours
Magnesium is exclusively excreted by the kidneys. Urine output of <30ml/hour suggests accumulation of toxic magnesium levels in the body.
d) Respiratory rate of 16/min
Magnesium sulfate toxicity would cause respiratory depression (RR is <12/min).
17. Answer: D
a) Early-onset breast milk jaundice is common in breastfed infants.
This occurs in the first week of life due to insufficient breastfeeding.
b) Don’t worry, jaundice is normal after birth.
Yellowish discoloration of the eyes and the skin is not normal if it occurs within the first 24 hours after birth.
c) Your baby was delivered preterm that is why he has jaundice.
Preterm and low birth weight infants will have physiologic jaundice that appears on the second or third day after birth.
d) Breastfeed your baby frequently while we further assess your baby’s condition.
Jaundice occurred twelve hours after birth, which needs further investigation and management. Frequent breastfeeding will provide nutrient needs and enhances bilirubin excretion.
18. Answer: A
a) Effacement precedes dilatation
In a primipara, effacement usually occurs before dilatation begins.
b) Effacement and dilatation occur simultaneously
In a multipara, effacement and dilatation progress together.
c) Dilatation precedes effacement
Effacement precedes dilatation or it can happen simultaneously with dilatation.
d) Effacement is not necessary
Effacement is always necessary in the labor process of the client.
19. Answer: B
a) A large amount of bloody fluid
This can be a sign when the client is experiencing vaginal bleeding and is a danger sign during pregnancy.
b) A moderate amount of clear to straw-colored fluid
With the fetus in a vertex LOA presentation and no other indicators of distress, the amniotic fluid should have a clear to straw-colored appearance.
c) A small amount of greenish fluid
This is noted when there is meconium passed before or during labor.
d) A small segment of the umbilical cord
This happens in a prolapsed umbilical cord.
20. Answer: A
a) Assess for presence of a full bladder.
Encourage the client in labor to void as necessary. Inform the client that a full bladder can hinder efficient uterine contractions. An empty bladder allows more space for the presenting part to pass through for delivery.
b) Suggest placement of an internal uterine pressure catheter to determine the adequacy of contractions.
This is a device placed into the amniotic space to measure the strength of uterine contractions during labor. This is not a priority to use this time.
c) Encourage the woman to do deep breathing techniques.
Breathing techniques can help to handle discomfort during contractions but is not a priority this time.
d) Suggest to a physician that oxytocin augmentation be started to stimulate labor.
Induction of labor may be done when the labor process is not progressing normally. For this time, assessment for a full bladder is the priority.
21. Answer: B
a) Higher altitude changes the body’s absorption of essential nutrients.
Nutrition has nothing to do with the high number of RBC in higher altitudes.
b) Decrease in atmospheric oxygen stimulates erythropoiesis.
Clients residing at a higher altitude have less atmospheric oxygen available that is why RBC production is stimulated and enhanced to cope up with the environment.
c) RBC sequestration of the spleen is impaired in higher altitudes.
The function of the spleen is not altered in high altitudes.
d) Limited production of leukocytes and platelets in higher altitudes makes the ratio of RBC higher.
Platelet and leukocyte production are not altered in high altitudes.
22. Answer: B
a) Tremor
Tremor is clinically defined as rhythmic and repetitive muscle movement.
b) Chorea
Chorea is clinically defined as brief and involuntary muscle twitching of the face or limbs which hinders the client’s mobility.
c) Athetosis
Athetosis is clinically defined as the presence of irregular and slow twisting motions.
d) Dystonia
Dystonia is similar to the definition of Athetosis but involves larger muscle areas.
23. Answer: C
a) Stand at arm’s length from the working area.
Standing close to the working area is a proper body mechanics to prevent muscle fatigue.
b) Elevate adjustable beds to the hip level.
The nurse should adjust the bed to waist level in order to prevent stretching and muscle strain.
c) Swivel the body when moving the client.
Proper body mechanic includes turning the body as a whole unit when moving the client to avoid twisting the back.
d) Move the client with a wide base and straight knees.
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.
24. Answer: D
a) Move the left crutch and the right foot forward.
The two-point gait is applied when moving the left crutch and right foot at the same time.
b) Move both crutches forward.
The swing-to or swing-through gait starts by placing both crutches forward.
c) Advance the affected leg and crutches together.
The three-point gait is applied when both crutches and the affected leg are moved together.
d) Move the right crutch forward followed by the left foot
The four-point gait is applied by moving the right clutch forward followed by the left foot. Then the left crutch will be moved forward followed by the right foot.
25. Answer: C
a) Osteoporosis
When too much calcium is dissolved from the bones, they lose density and are easily fractured.
b) Arthritis
As we age, our joint tissues become less resilient to wear and tear and start to degenerate manifesting swelling, pain, and oftentimes, loss of mobility of joints. This is called arthritis.
c) Coccydynia
This is an Inflammation of the tailbone. Coccydynia is associated with pain and tenderness at the tip of the tailbone between the buttocks. The condition is worsened by sitting.
d) Muscular dystrophy
A muscular dystrophy is a group of inherited diseases in which the muscles that control movement progressively weaken.
26. Answer: B
a) Monitor duration of stiffness and not the intensity to determine when to perform ROM
This intervention is for arthritis.
b) When swallowing is difficult, give semi-solid foods instead of liquids to lessen the risk of choking
This is a nursing intervention for Myasthenia Gravis due to difficulty swallowing.
c) Have the client sleep with a pillow between the trunk and arm to decrease tension on the supraspinatus tendon and to prevent blood flow compromise in its watershed region
This is for a Rotator cuff tear condition. This is to provide comfort for the client.
d) Position the client in a semi-fowler’s position to relieve dyspnea
This is for respiratory disorders such as Pneumonia. We place the client in this position to relieve the difficulty of breathing.
27. Answer: B
a) Surgery
As much as possible, surgery should be the last resort for musculoskeletal pain.
b) Opioids
When the pain was not relieved by NSAIDs, opioids will be the next choice of treatment most especially for moderate to severe pain rated 9/10.
c) Alternative NSAID
Since previous NSAID seems to be ineffective, there is no reason to prescribe another brand. They have the same content.
d) Chiropractic treatment
This treatment involves spinal adjustment, but since physical therapy did not produce a beneficial outcomes, this is no longer advisable.
28. Answer: D
a) Albumin
Albumin is a protein made by the liver. A serum albumin test measures the amount of this protein in the clear liquid portion of the blood.
b) CPK-MB
The CPK-MB test is a cardiac marker used to assist diagnoses of acute myocardial infarction.
c) RBS
A random glucose test or random blood glucose (RBG) is taken from a non-fasting subject.
d) RH-factor
This is the correct answer. The rheumatoid factor (RF) test is primarily used to help diagnose rheumatoid arthritis (RA) and to help distinguish RA from other forms of arthritis or other conditions that cause similar symptoms.
29. Answer: C
a) Notify the physician immediately.
The nurse must check the peripheral pulses before notifying the physician.
b) Schedule the client for emergency surgery.
This is not a priority intervention for a client with arterial insufficiency.
c) Recheck pedal pulses with a Doppler.
For 15% of the normal population, the dorsalis pedis is not palpable. Also, the pulses may disappear after exercise, so reassessing the peripheral pulse would be an appropriate intervention.
d) Assess the apical and radial pulses for any irregularity.
The pulses to be assessed are the distal and peripheral pulse.
30. Answer: A
a) It is the constriction of the cutaneous vessels due to the vasospasm of the arterioles and the arteries of the upper and lower extremities. Raynaud’s disease affects primarily the fingers, toes, ears and cheeks due to the vasospasm of the arterioles and the arteries of the upper and lower extremities. It, therefore, causes numbness, tingling, sweating and coldness of the affected body part.
b) It is an occlusive disease of the median and small arteries and veins. This is a description of Buerger’s disease.
c) It is the abnormal dilation of the arterial wall caused by localized weakness and stretching in the wall of the artery. This is what happens in an aortic aneurysm.
d) It is a chronic disorder in which partial or total arterial occlusion deprives the lower extremity of oxygen and nutrients. This is a description suitable for explaining peripheral arterial disease.
31. Answer: C
a) First degree AV block
In this type of AV block, the interval between the PR node increases.
b) Second degree AV block
In this type of AV block, electrical conduction between the atria and ventricle is blocked.
c) Third-degree AV block
In this type of AV block, there is no conduction of impulses through the AV node. It is also known as complete heart block.
d) Fourth degree AV block
This type of AV block does not exist.
32. Answer: D
a) A complete health history with an emphasis on preceding events.
It may provide vital information but is not the priority this time.
b) Chest exam with auscultation
It may also provide vital information but is not the priority this time.
c) An electrocardiogram
It may provide information about the electrical activity of the heart but is not the priority this time.
d) Take the client’s vital signs.
This action provides a baseline wherein further interventions can be based.
33. Answer: C
a) Ventricular septal defect (VSD)
It is a defect in the ventricular septum, which is the wall dividing the left and right ventricles of the heart. Infants having this kind of condition show signs of pansystolic murmur along the lower left of sternal border
b) Atrioventricular septal defect (AVSD)
It is characterized by an abnormal or inadequate fusion of the superior and inferior endocardial cushion with the mid-portion of the atrial septum and the muscular portion of the ventricular septum. Upon cardiac auscultation, atypical murmur and loud heart tones can be heard.
c) Tetralogy of Fallot (ToF)
Tetralogy of Fallot is one of the most common congenital heart disorders. Infants with ToF disorder often display difficulty with feeding, failure to thrive, episodes of bluish pale skin during crying or feeding and exertional dyspnea, usually worsening with age.
d) Ebstein’s Anomaly
It is a rare heart defect that’s present at birth (congenital). In Einstein’s anomaly, the tricuspid valve doesn’t work properly and blood leaks back through the valve. This condition may also lead to enlargement of the heart or heart failure.
34. Answer: A
a) Creatinine kinase
Creatinine kinase levels are used primarily to aid in the diagnosis of acute MI or skeletal muscle damage. However, vigorous exercise, a fall, or deep intramuscular injections can cause a significant increase in CK levels.
b) Amylase
Amylase is the enzyme produced by the pancreas that helps digest carbohydrates. When the pancreas is inflamed, amylase is released into the blood. An increase in the blood amylase levels may occur due to acute pancreatitis, cancer of the pancreas, ovaries or lungs, cholecystitis, or gastroenteritis.
c) Acid phosphatase
Acid phosphatase is an enzyme found in the kidneys, serum, semen, and prostate gland. An increase in this enzyme can cause prostate cancer or infarction, Paget’s disease, Gaucher’s disease, and multiple myeloma.
d) Alkaline phosphatase
Alkaline phosphatase is found primarily in the liver and bone. The importance of measuring alkaline phosphatase is to check the possibility of bone disease or liver disease. An increase in serum alkaline phosphatase may be due to liver congestion or cholestasis and osteoblastic bone conditions.
35. Answer: B
a) Diaxozide
This drug is used in the treatment of hypoglycemia.
b) Nitroprusside
Sodium Nitroprusside is the drug of choice for hypertensive emergencies because it has the most reliable antihypertensive activity. It takes effect immediately upon administration.
c) Hydralazine
It was considered as the drug of choice for hypertensive emergencies but it is replaced by Sodium Nitroprusside because of its unpredictable therapeutic profile.
d) Trimethaphen
It is a short-acting ganglionic blocking agent, used to produce controlled hypotension during surgery.
While reading the answers I just found out that number14 and 15 has the same answers and rationale.. 😅