LACNO MARY JANE R.

BSN IV
NCM 119
ANSWER QUESTION WITH RATIONALE
TAKING TEST STRATEGIES

QUESTION NO.1
WHILE ASSESSING A ONE-MONTH-OLD, WHICH OF THE FINDINGS WARRANT FURTHER
INVESTIGATION BY THE NURSE.
THE CORRECT ANSWER IS OPTION D
INSPIRATORY GRUNT, CYNOSIS, ASYMMETRIC CHEST MOVEMENT

 Grunting occurs when an infant attempts to maintain an adequate functional residual

capacity in the face of poorly compliant lungs by partial glottic closure. As the infant
prolongs the expiratory phase against this partially closed glottis, there is a prolonged and
increased residual volume that maintains the airway opening and also an audible
expiratory sound.
 Nasal flaring occurs when the nostrils widen while breathing and is a sign of troubled
breathing or respiratory distress.
 Cyanosis refers to the bluish discoloration of the skin and indicates a decrease in oxygen
attached to the red blood cells in the bloodstream.
 Asymmetric chest movement occurs when the abnormal side of the lungs expands less and
lags behind the normal side. This indicates respiratory distress.
 Abdominal respiration is normal among infants and young children. Since their intercostal
muscles are not yet fully developed, they use their abdominal muscles much more to pull
the diaphragm down for breathing.
 Newborns can have irregular breathing patterns ranging from 30 to 60 breaths per minute
with short periods of apnea (15 seconds).
 An increase in heart rate is normal for an infant during activity (including crying).
Fluctuations in heart rate follow the changes in the newborn’s behavioral state – crying,
movement, or wakefulness corresponds to an increase in heart rate.
QUESTION NO.2
ALING MARA A 32 YEAR OLD PREGNANT WOMEN COMES TO THE CLINIC FOR HER PRENATAL
VISIT. THE NURSE GATHER DATA ABOUT HER OBSTETRIC HISTORY, WHICH INCLUDES 3 YEAR
OLD TWINS AT HOME AND A MISCARRIAGE 10 YEARS AGO AT 12 WEEEKS GESTATION. HOW
WOULD THE NURSE ACCURATELY DOCUMENT THIS INFORMATION.
THE CORRECT ANSWER IS OPTION B
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)

QUESTION NO. 3
KC A 15 YEARL OLD FEMALEW INGESTED 15 TABLETS OF MAXIMUM STRENGTH
ACETAMINOPHERI 45 MINUTES AGO IS RUSHED TO THE EMERGENCY DEPARTENT. WHICH OF
THESE ORDERS SHOULD THE NURSE DO FIRST.
THE CORRECT ANSWER IS OPTION A
GASTRIC LAVAGE

 Option A: Acetaminophen overdose is extremely toxic to the liver causing hepatotoxicity.

Early symptoms of hepatic damage include nausea, vomiting, abdominal pain, and diarrhea.
If not treated immediately, hepatic necrosis occurs and may lead to death. Removing as
much of the drug as possible is the first step in treatment for acetaminophen overdose, this
is best done through gastric lavage. Gastric lavage (irrigation) and aspiration consist of
flushing the stomach with fluids and then aspirating the fluid back out. This procedure is
done in life-threatening cases such as acetaminophen toxicity and only if less than one (1)
hour has occurred after ingestion.
 Option B: The oral formulation of acetylcysteine is the drug of choice for the treatment of
acetaminophen overdose but should be done after GI decontamination with activated
charcoal. Liver damage is minimized by giving acetylcysteine (Mucomyst), the antidote for
acetaminophen. Acetylcysteine reduces injury by substituting for depleted glutathione in
the reaction that converts the toxic metabolite of acetaminophen to its nontoxic form. When
given within 8 hours of acetaminophen toxicity, acetylcysteine is effective in preventing
severe liver injury. It is administered orally or intravenously.
 Option C: Intermittent IV infusion with Dextrose 5% may be considered for late-presenting
or chronic ingestion.
 Option D: Oral activated charcoal (AC) avidly adsorbs acetaminophen and may be
administered if the patient presents within 1 hour after ingesting a potentially toxic dose.
 Charcoal should not be administered immediately before or with antidotes since it can
effectively adsorb it and neutralize the benefits

QUESTIONS NO. 4
WHICH COMPLCATIONS OF CARDIAC CATHETERIZATION SHOULD THE NURSE MONITOR FOR
THE INITIAL 24 HOURS AFTER THE PROCEDURE
THE CORRECT ANSWER IS OPTION B
THROMBUS FORMATION

 A thrombus formation may prevent blood from flowing normally through the circulatory
system, which may become an embolism, and block the flow of blood towards major organs
in the body.

 Option A: The reported incidence of myocardial infarction with angina at rest is less than
0.1%, and is mostly influenced by patient-related factors like the extent and severity of
underlying cardiovascular-related diseases and technique-related factors.
 Options C & D: A falling BP and dizziness occur along with hemorrhage of the insertion site
which is associated with the first 12 hours after the procedure.

QUESTION NO. 5
A CLIENT IS ADMITTED TO THE EMERGENCY ROOM WITH RENAL CALCULI AND IS
COMPLAINING OF MODERATE TO SEVERE FLANK PAIN AND NAUSEA. THE CLIENT’S
TEMPERATURE IS 100.8 DEGREES FAHRENHEIT. THE PRIORITY NURSING GOAL FOR THIS CLIENT
IS;
THE CORRECT ANSWER IS OPTION C
MANAGING PAIN
Managing pain is always a priority because it ultimately improves the quality of life. The
cornerstone of ureteral colic management is analgesia, which can be achieved most
expediently with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs).

 Option A: IV hydration in the setting of acute renal colic is controversial. Whereas some
authorities believe that IV fluids hasten the passage of the stone through the urogenital
system, others express concern that additional hydrostatic pressure exacerbates the pain of
renal colic.
 Option B: Because nausea and vomiting frequently accompany acute renal colic,
antiemetics often play a role in renal colic therapy. Several antiemetics have a sedating
effect that is often helpful.
 Option D: Overuse of the more effective antibiotic agents leaves only highly resistant
bacteria, but failure to adequately treat a UTI complicated by an obstructing calculus can
result in potentially life-threatening urosepsis and pyonephrosis.
QUESTION NO.6
A 25 YEAR OLD MALE CLIENT HAS BEEN NEWLY DIAGNOSED WITH HYPOTHYROIDISM AND WILL
TAKE HEVOTHYROXINE(SYNTHROID) 50 MCG/DAY BY MOUTH. AS PART OF THE TEACHING PLAN
THE NURSE EMPHASIZES THAT THIS MEDCATION;
THE CORRECT ANSWER IS OPTION A
SHOULD BE TAKING IN THE MORNING

 Option A: Levothyroxine (Synthroid) has a side effect of insomnia. Taking it in the morning
could prevent interfering with the client’s sleeping pattern.
 Option B: Some of the side effects of Levothyroxine include hyperactivity and an increase in
heart rate.
 Option C: Keep this drug in a cool, dark, and dry place.
 Option D: A decrease in the heart rate is the desired effect of Levothyroxine.

QUESTION NO.7
IN CHILDREN SUSPECTED TO HAVE A DIAGNOSIS OF DIABETES, WHICH ONE OF THE FOLLOWING
COMPLAINTS WOULD BE MUST LIKELY TO PROMPT PARENTS TO TAKE THEIR SCHOOL AGE
CHILD FOR EVALUTION
THE CORRECT ANSWER IS OPTION C
BEDWETTING

 One of the first symptoms of type 1 diabetes in children is bedwetting. Bedwetting in a

school-age child is readily detected by the parents.

 Option A: Polyphagia or extreme hunger is one of the most common symptoms of diabetes
both among adults and children.
 Option B: Dehydration is not a symptom of type 1 diabetes, but it can be one of the many
complications.
 Option D: Unintentional weight loss would develop gradually in a child with type 1
diabetes.
QUESTION NO.8
A CLIENT COMES TO CLINIC FOR TREATMENT OF RECURRENT PELVIC INFLAMMATORY
DISEASES. THE NURSE RECOGNIZES THAT THIS CONDITION MOST FREQUENTLY FOLLOWS
WHICH TYPE OF INFECTION
THE CORRECT ANSWER IS OPTION B
CHLAMYDIA

 Option B: Chlamydial infections are one of the most frequent causes of salpingitis or pelvic
inflammatory disease. Chlamydial bacteria could travel up toward the vagina or cervix into
the reproductive organs.
 Option A: Trichomoniasis is a very common sexually transmitted disease, but it rarely
predisposes to pelvic inflammatory disease.
 Options C & D: Staphylococcus and streptococcus may cause PID but it rarely occurs

QUESTION NO.9
A CHILD WHO HAS RECENTLY BEEN DIAGNOSED WITH CYSTIC FIBROSIS IS IN PEDIATRIC CLINIC
WHERE A NURSE IS PERFORMING AN ASSESSMENT. WHICH LATER FINDING OF THIS DISEASE
WOULD THE NURSE NOT TO EXPECT TO SEE AT THIS TIME
THE CORRECT ANSWER IS OPTION C
MOIST PRODUCTIVE COUGH

 Noisy respirations and a dry non-productive cough are commonly the first of the
respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other
options are the earliest findings. CF is an inherited (genetic) condition affecting the cells
that produce mucus, sweat, saliva, and digestive juices. Normally, these secretions are thin
and slippery, but in CF, a defective gene causes the secretions to become thick and sticky.
Instead of acting as a lubricant, the secretions plug up tubes, ducts, and passageways,
especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence
of CF.
 Option A: A positive sweat test is one of the indications of cystic fibrosis.
 Option B: A patient with CF experiences frequent greasy, bulky stools or difficulty with
bowel movements as the thick mucus blocks the intestines.
 Option D: Meconium ileus is one of the early signs of CF
QUESTION NO.10
A TRIAGE NURSE HAS THESE FOUR(4) CLIENTS ARRIVE IN THE EMERGENCY DEPARTMENT
WITHIN 15 MINUTES. WHICH CLIENT SHOULD THE TRIAGE NURSE SEND BACK TO BE SEEN
FIRST.
THE CORRECT ANSWER IS OPTION B
A TEENAGER WHO GOT A SINGED BEARD WHILE CAMPING

 This client is in the greatest danger with a potential of respiratory distress. Any client with
singed facial hair has been exposed to heat or fire in close range that could have caused
serious damage to the interior of the lungs. Note that the interior lining of the lungs has no
nerve fibers so the client will not be aware of swelling.
 Option A: When an infant is crying, the fontanels may look like they are bulging.
 Option C: The client in Option C can wait to be seen within the first hour.
 Option D: The client in Option D does not have a life-threatening condition but will still
require immediate pain relief