CARDIAC ANSWERS AND RATIONALES

ANSWERS AND RATIONALES
1. Answer: C
Rationale: The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels,
especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours,
peak in 12-18 hours and are elevated 48 hours after the occurrence of the
infarct. They are therefore most reliable in assisting with early diagnosis. The
cardiac markers elevate as a result of myocardial tissue damage.
2. Answer: C
Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12
minims. The nurse will administer 12 minims intravenously equivalent to 8mg
Morphine Sulfate
3. Answer: B
This is a typical early finding after a myocardial infarct because of the altered
contractility of the heart. The other choices are not typical of MI.
4. Answer: D
A cardiac glycoside such as digitalis increases force of cardiac contraction,
decreases the conduction speed of impulses within the myocardium and
slows the heart rate.
5. Answer: B
Restriction of sodium reduces the amount of water retention that reduces the
cardiac workload
6. Answer: B
Pulmonary congestion and edema occur because of fluid extravasation from the
pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure
creates a backward effect on the pulmonary system that leads to pulmonary
congestion.
7. Answer: B
Rationale: The primary goal of therapy for the client with pulmonary edema or
heart failure is increasing cardiac output. Pulmonary edema is an acute medical
emergency requiring immediate intervention.
8. Answer: A
Rationale: By the second day of hospitalization after suffering
a Myocardial Infarction, Clients are able to perform care without chest pain
9. Answer: D
Rationale: Anoxia of the myocardium occurs in myocardial infarction. Oxygen
administration will help relieve dyspnea and cyanosis associated with the
condition but the major purpose is to increase the oxygen concentration in
the damaged myocardial tissue.
10. Answer: B
Rationale: Clients that present with mitral stenosis often have a history of
rheumatic fever or bacterial endocarditis.
11. Answer: B
Rationale: The ECG reading of a client who had myocardial ischemia
Exam Code HAAD 1

www.onlinenursereviewalternative.com
would reveal an inverted T wave and SST segment elevation. The ECG tracing of
a client with myocardial injury is characterized by a symmetric and peaked T
wave and at least 1 mm ST segment elevation while myocardial infarction will
show an abnormal or pathologic Q wave that develops within 1-3 days after
MI.
12. Answer: A
Rationale: Managing hypertension is the priority for the client with hypertension.
Clients with hypertension frequently do not experience pain, deficient volume or
impaired skin integrity. It is the asymptomatic nature of hypertension that makes
it so difficult to treat.
13. Answer: D
Rationale: There is a potential alteration in renal perfusion manifested by
decreased urine output. The altered renal perfusion may be related to renal
artery embolism, prolonged hypotension, or prolonged aortic cross- clamping
during the surgery.
14. Answer: A
Rationale: An increased in LDL cholesterol concentration has been documented
at risk factor for the development of atherosclerosis. LDL cholesterol is not
broken down into the liver but is deposited into the wall of the blood
vessels.
15. Answer: B
Rationale: Morphine is a central nervous system depressant used to relieve the
pain associated with myocardial infarction, it also decreases apprehension and
prevents cardiogenic shock.
16. Answer: C Rationale: When diuretics are taken in the morning, client will void
frequently during daytime and will not need to void frequently at night.
17. Answer: D
Rationale: Administration of Intravenous Nitroglycerin infusion requires pump
for accurate control of medication.
18. Answer: D
Rationale: When mitral stenosis is present, the left atrium has difficulty
emptying its contents into the left ventricle because there is no valve to prevent
back ward flow into the pulmonary vein; the pulmonary circulation is under
pressure.
19. Answer: C
Rationale: Wheat cereal has low sodium content.
20. Answer: D
Rationale: Seeing yellow spots and colored vision are common symptoms of
digitalis toxicity
21. Answer: D
Rationale: When the heart rate is above 60 beats per minute and below
10 beats per minute, digoxin therapy is deemed effective. However, if too much
digoxin was administered to the client, Mobitz II heart block may be present.
Exam Code HAAD 1

22. Answer: C
Rationale: The client with left-sided heart failure usually has pulmonary
congestion, orthopnea, hemoptysis and experiences dyspnea and coughing. Right sided
heart failure is characterized by hepatomegaly, edema, ascites and distended neck
veins. Right sided heart failure is another complication of cardiomyopathy.
23. Answer: D
Rationale: Patients with Arterial Occlusive Disease have decreased perfusion of
tissues. By placing the patient in a dependent position, blood
flow to the lower extremities is enhanced, and, therefore, the nursing diagnosis
for this intervention would be Altered Tissue Perfusion.
24. Answer: A
Rationale: A "tet" spell is when the child is having difficulty meeting oxygen
demands. The knee chest position reduces venous blood return from the lower
extremities and increases vascular resistance to divert blood flow to the
pulmonary artery.
25. Answer: B
Rationale: The major complication of thromboembolytic therapy is hemorrhage,
and the antidote for this is Amicar, which aids in the stoppage of bleeding by
inhibiting plasminogen, which inhibits thrombolysis. This drug should be
available for any patient on this type of thromboembolytic therapy.
Protamine Sulfate and Vitamin K are the
antidotes for Heparin and Coumadin, respectively. Heparin is not correct, as it is
an anticoagulant.
26. Answer: A
Rationale: Straining or bearing down activities can cause vagal stimulation that
leads to bradycardia. Use of stool softeners promote easy bowel evacuation that
prevents straining or the valsalva maneuver.
27. Answer: B
Rationale: Clients that present with mitral stenosis often have a history of
rheumatic fever or bacterial endocarditis.
28. Answer: D
Rationale: Heartburn is a burning sensation caused by regurgitation of gastric
contents that is best relieved by sleeping position, eating small meals, and
not eating before bedtime.
29. Answer: A
Rationale: Polycythemia occurs as a physiological reaction to chronic hypoxemia
which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the
resultant increased viscosity of the blood increase the risk of thromboembolic
events. Cerebrovascular accidents may occur. Signs and symptoms include
sudden paralysis, altered speech, extreme irritability or fatigue, and seizures.
30. Answer: C
Rationale: PTCA (percutaneous transluminal coronary angioplasty) is performed to
improve coronary artery blood flow in a diseased artery. It is performed during a
cardiac catheterization. Aorta coronary bypass Graft is the surgical procedure
to repair a diseased coronary artery.
31. Answer: B
Exam Code HAAD 1

Rationale: Administering stool softeners every day will prevent straining on
defecation which causes the Valsalva maneuver. If constipation occurs then
laxatives would be necessary to prevent straining. If straining on defecation
produced the valsalva maneuver and rhythm disturbances resulted then
antidysrhythmics would be appropriate.
32. Answer: D
Rationale: “I smoke 1 1/2 packs of cigarettes per day.” Smoking has been
considered as one of the major modifiable risk factors for coronary artery
disease. Exercise and maintaining normal serum cholesterol levels help in its
prevention.
33. Answer: D
Rationale: The client should be advised by the nurse to avoid contact sports.
This will prevent trauma to the area of the pacemaker generator.
34. Answer: B
Rationale: Canned foods are generally rich in sodium content as salt is used
as the main preservative.
35. Answer: D
Rationale: Angina pectoris is caused by myocardial ischemia related to decrease
coronary blood supply. Giving nitroglycerine will produce coronary vasodilation that
improves the coronary blood flow in 3 – 5 mins. If the chest pain is unrelieved,
after three tablets, there is a possibility of acute coronary occlusion that
requires immediate medical attention.
36. Answer: D
Rationale: Administration of Intravenous Nitroglycerin infusion requires pump
for accurate control of medication.
37. Answer: D
Rationale: A cardiac glycoside such as digitalis increases force of cardiac
contraction decreases the conduction speed of impulses within the myocardium
and slows the heart rate.
38. Answer: D
Rationale: Ascending limb of the loop of Henle. This is the site of action of Lasix
being a potent loop diuretic.
39. Answer: B
Rationale: Dyspnea on exertion. Pulmonary congestion and edema occur because
of fluid extravasation from the pulmonary capillary bed, resulting in difficult
breathing. Left-sided heart failure creates a backward effect on the pulmonary
system that leads to pulmonary congestion.
40. Answer: B
Rationale: Restriction of sodium reduces the amount of water retention that
reduces the cardiac workload
41. Answer: B
Rationale: 2000 calories. There are 9 calories in each gram of fat and 4 calories
in each gram of carbohydrate and protein.
42. Answer: D
Rationale: Increased pulse rate
Exam Code HAAD 1
Fever causes an increase in the body’s metabolism, which results in an
Exam Code HAAD 1

increase in oxygen consumption and demand. This need for oxygen increases the
heart rate, which is reflected in the increased pulse rate. Increased BP, chest
pain and shortness of breath are not typically noted in fever.
43. Answer: B
Rationale: Refocus the conversation on his fears, frustrations and anger about
his condition. This provides the opportunity for the client to verbalize feelings
underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor
which can activate the sympathoadrenal response causing the release of
catecholamines that can increase cardiac contractility and workload that can
further increase myocardial oxygen demand.
44. Answer: B
Rationale: Elevated STsegments This is a typical early finding after a
myocardial infarct because of the altered contractility of the heart. The other
choices are not typical of MI.
45. Answer: C
Rationale: CK-MB. The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme
levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6
hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of
the infarct. They are therefore most reliable in assisting with early diagnosis.
The cardiac markers elevate as a result of myocardial tissue damage.
46. Answer: B
Rationale: Relieves pain and decreases level of anxiety. Morphine is a specific
central nervous system depressant used to relieve the pain associated with
myocardial infarction. It also decreases anxiety and apprehension and
prevents cardiogenic shock by decreasing myocardial oxygen demand.
47. Answer: A
Rationale: 60 microdrops/minute
2 gm=2000 mgm
2000 mgm/500 cc = 4 mgm/x cc
2000x = 2000
x= 2000/2000 = 1 cc of IV solution/minute CC x
60 microdrops = 60 microdrops/minute
48. Answer: D
Rationale: The primary goal in the management of CVA is to improve cerebral
tissue perfusion. Aspirin is a platelet deaggregator used in the prevention of
recurrent or embolic stroke but is not used in the acute management of a
completed stroke as it may lead to bleeding.
49. Answer: D
Rationale: Angiography involves the threading of a catheter through an artery
which can cause trauma to the endothelial lining of the blood vessel. The platelets
are attracted to the area causing thrombi formation. This is further enhanced by
the slowing of blood flow caused by flexion of the affected extremity. The
affected extremity must be kept straight and immobilized during the duration of
the bedrest after the procedure.
Ice bag can be applied intermittently to the puncture site.
Exam Code HAAD 1

50. Answer: C
Rationale: Using ratio and proportion 8 mg/10 mg = X minims/15 minims
10 X= 120 X = 12 minims The nurse will administer 12 minims
intravenously equivalent to 8mg Morphine Sulfate
51. Answer: D
Rationale: Angina pectoris is caused by myocardial ischemia related to
decreased coronary blood supply. Giving nitroglycerine will produce coronary
vasodilation that improves the coronary blood flow in 3 – 5 mins. If the
chest pain is unrelieved, after three tablets, there is a possibility of acute
coronary occlusion that requires immediate medical attention.
52. Answer: A
Rationale: Straining or bearing down activities can cause vagal stimulation that
leads to bradycardia. Use of stool softeners promotes easy bowel evacuation that
prevents straining or the valsalva maneuver.
53. Answer: D
Rationale: The client should be advised by the nurse to avoid contact sports.
This will prevent trauma to the area of the pacemaker generator.
54. Answer: B
Rationale: Inotropic effect of drugs on the heart causes increase force of its
contraction. This increases cardiac output that improves renal perfusion resulting
in an improved urine output.
55. Answer: C
Rationale: The clients who are misdiagnosed concerning MI’s usually present with
atypical symptoms. They tend to be female, be younger than
55 years old, be members of a minority group, and have normal
electrocardiograms.
56. Answer: D
Rationale: Hyperkalemia will cause a peaked T-wave; therefore, the nurse should
check this laboratory data.
57. Answer: A
Rationale: Medical client problems indicate the nurse and the physician must
collaborate to care for the client; the client must have medications for heart
failure.
58. Answer: D
Rationale: Cold, clammy skin is an indicator of cardiogenic shock, which is a
complication of MI and warrants immediate intervention.
59. Answer: A
Rationale: The second intercostal space, right sterna notch, is the area on the
chest where the aorta can best be heard opening and closing.
60. Answer: A
Rationale: The recommended diet for CAD is low fat, low cholesterol, and high
fiber. The diet described is a diet that is low in fat and cholesterol.
61. Answer: A
Rationale: This is a medical emergency; the nurse should stay with the
Exam Code HAAD 1

client, keep him calm, and call the nurses’ station to notify the health- care
provider. Cardiac output declines with each contraction as the pericardial sac
constricts the myocardium.
62. Answer: A
Rationale: This potassium level is below normal levels; hypokalemia can
potentiate digoxin toxicity and lead to cardiac dysrhythmias.
63. Answer: B
Rationale: Decreased cardiac output is responsible for all the signs/symptoms
associated with CHF and eventually causes death, which is why it is the priority
problem.
64. Answer: A
Rationale: The chest pain for an MI usually is described as an elephant sitting on
the chest or a belt squeezing the substernal mid-chest, often radiating to the
jaw or left arm.
65. Answer: D
Rationale: BNP is a hormone released by the heart muscle in response to
changes in blood volume and is used to diagnose and grade heart failure.
66. Answer: C
Rationale: Having the client lean forward and to the left uses gravity to force
the heart nearer to the chest wall, which allows the friction rub to be heard.
67. Answer: D
Rationale: Assessment is the first step in the nursing process and should be
implemented first; chest pain is priority.
68. Answer: C
Rationale: NPO decreases the chance of aspiration in case of emergency. In
addition, if the client has just had a meal, the blood supply will be shunted to the
stomach for digestion and away from the heart, perhaps leading to an inaccurate
test result.
69. Answer: B
Rationale: The client removes the old patch before placing the new one. This
behavior indicates the client understands the discharge teaching.
70. Answer: A
Rationale: This dosage is 10 times the normal dose for a client with CHF. This
dose is potentially lethal.
71. Answer: C
Rationale: An audible S3 indicates the client is developing left-sided heart failure
and needs to be assessed immediately.
72. Answer: C
Rationale: Cell phones may interfere with the functioning of the ICD if they
are placed too close to it.
73. Answer: B
Rationale: Without a heart transplant, this client will end up in end- stage
heart failure. A transplant is the only treatment for a client with dilated
cardiomyopathy.
Exam Code HAAD 1

74. Answer: B
Rationale: The nurse must first determine if the client has a pulse. Pulseless
ventricular tachycardia is treated as ventricular fibrillation. Stable ventricular
tachycardia is treated with medications.
75. Answer: A
Rationale: Cardioversion involves the delivery of a timed electrical current. The
electrical impulse discharges during ventricular depolarization and therefore there
might be a short delay. The nurse should wait until discharges.
76. Answer: A
Rationale: The DASH diet has proved beneficial in lowering blood pressure. It
recommends eating a diet high in vegetables and fruits.
77. Answer: D
Rationale: Orthostatic hypotension may occur when the blood pressure is
decreasing and may lead to dizziness and light-headedness so the client should
change position slowly.
78. Answer: B
Rationale: Rapid weight gain—for example, 2 kg in 1–2 days—indicates that the
loop diuretic is not working effectively; 2 kg equals 4.4 lbs; 1 L of fluid weighs l
kg.
79. Answer: A
Rationale: The decreased oxygen over time causes the loss of hair on top of feet
and ascends both legs.
80. Answer: C
Rationale: Numbness and tingling are paresthesia, which is a sign of a
severely decreased blood supply to the lower extremities.
81. Answer: B
Rationale: The nurse should question administering the beta blocker if the B/P is
low because this medication will cause the blood pressure to drop even lower,
leading to hypotension.
82. Answer: D
Rationale: After the surgery, the client’s legs will be elevated to help decrease
edema. The surgery has corrected the decreased blood supply to the lower legs.
83. Answer: C
Rationale: Walking promotes the development of collateral circulation to ischemic
tissue and slows the process of atherosclerosis.
84. Answer: A
Rationale: An absent pulse is not uncommon in a client diagnosed with arterial
occlusive disease, but the nurse must ensure that the feet can be moved and are
warm, which indicates adequate blood supply to the feet.
85. Answer: C
Rationale: This is the scientific rationale why diabetes mellitus is a
modifiable risk factor for atherosclerosis.
Exam Code HAAD 1

86. Answer: D
Rationale: Fluids will help flush the contrast dye out of the body and help
prevent kidney damage.
87. Answer: C
Rationale: Intermittent claudication is a sign of generalized atherosclerosis and is a
marker of atherosclerosis.
88. Answer: D
Rationale: This response explains in plain terms why the client’s legs hurt from
atherosclerosis.
89. Answer: B
Rationale: A systolic bruit over the abdomen is a diagnostic indication of an
Abdominal Aortic Aneurysm.
90. Answer: A
Rationale: The client has a foot ulcer, therefore the protective lining of the
body—the skin— has been impaired.
91, Answer: B
Rationale: This is the classic symptom of arterial occlusive disease.
92. Answer: C
Rationale: Angiotensin-converting enzyme (ACE) inhibitors prevent the
conversion of angiotensin I to angiotensin II, and this, in turn, prevents
vasoconstriction and sodium and water retention.
93. Answer: D
Rationale: The leg dressing needs to be assessed for hemorrhaging or signs
of infection.
94. Answer: B
Rationale: The client needs to be taught ways to lower the cholesterol level.
95. Answer: C
Rationale: Baked, broiled, or grilled meats are recommended: a plain baked
potato is appropriate; and skim milk is low in fat—so this meal is appropriate
for a low-fat, low cholesterol diet.
96. Answer: B
Rationale: Only about two-fifths of clients with AAA have symptoms; the
remainder is asymptomatic.
97. Answer: A
Rationale: Low back pain is present because of the pressure of the aneurysm on
the lumbar nerves; this is a serious symptom, usually indicating that the
aneurysm is expanding rapidly and about to rupture.
98. Answer: B
Rationale: The client must have 30 mL urinary output every hour. Clients who are
post-operative AAA are at high risk for renal failure because of the anatomical
location of the AAA near the renal arteries.
Exam Code HAAD 1

99. Answer: A
Rationale: Assessment is the first part of the nursing process and is the first
intervention the nurse should implement.
100. Answer: B
Rationale: Increased pressure in the abdomen secondary to a tap water enema
could cause the abdominal aortic aneurysm to rupture.
Exam Code HAAD 1

EXAM CODE HAAD2
1. Answer: D
Rationale: Weighing everyday is the most accurate means in monitoring
the hydration status.
2. Answer: B
Rationale: Administration of thyroid hormone will prevent problems. Early
identification and continued treatment with hormone replacement corrects
this condition.
3. Answer: B
Rationale: Peripheral neuropathy can lead to lack of sensation in the
lower extremities. Clients do not feel pressure and/or pain and are at
high risk for skin impairment.
4. Answer: D
Rationale: In diabetic patients, the nurse should watch out for signs of
hypoglycemia manifested by dizziness, tremors, weakness, pallor
diaphoresis and tachycardia. When this occurs in a conscious client, he
should be given immediately carbohydrates in the form of fruit juice,
hard candy, honey or, if unconscious, glucagons or dextrose per IV.
5. Answer: D
Rationale: posterior neck fat pad and thin extremities. Buffalo hump is
the accumulation of fat pads over the upper back and neck. Fat may also
accumulate on the face. There is truncal obesity but the extremities are
thin. All these are noted in a client with Cushing’s syndrome.
6. Answer: A
Rationale: Deflate the esophageal balloon. When a client with a Sengstaken-
Blakemore tube develops difficulty of breathing, it means the tube is
displaced and the inflated balloon is in the oropharynx causing airway
obstruction
7. Answer: A
Rationale: The largest source of ammonia is the enzymatic and bacterial
digestion of dietary and blood proteins in the GI tract. A protein-
restricted diet will therefore decrease ammonia production.
8. Answer: C
Rationale: Pain in acute pancreatitis is caused by irritation and edema of
the inflamed pancreas as well as spasm due to obstruction of the
pancreatic ducts. Demerol is the drug of choice because it is less likely
to cause spasm of the Sphincter of Oddi unlike Morphine which is
spasmogenic.
9. Answer: A
Rationale: Following surgery of the thyroid gland, bleeding is a potential
complication. This can best be assessed by checking the back and the
sides of the operative dressing as the blood may flow towards the side
and back leaving the front dry and clear of drainage.
10. Answer: C
EXAM CODE HAAD2

Rationale: Propranolol (Inderal) is a beta-adrenergic blocker that controls
the cardiovascular manifestations brought about by increased secretion of
the thyroid hormone in Grave’s disease.
11. Answer: C
Rationale: Lipodystrophy is the development of fibrofatty masses at the
injection site caused by repeated use of an injection site. Injecting
insulin into these scarred areas can cause the insulin to be poorly
absorbed and lead to erratic reactions.
12. Answer: C
Rationale: Progressive weight gain
Hypothyroidism, a decrease in thyroid hormone production, is characterized
by hypometabolism that manifests itself with weight gain.
13. Answer: C
Rationale: Keep legs elevated on 2 pillows while sleeping. The client with
DM has decreased peripheral circulation caused by microangiopathy.
Keeping the legs elevated during sleep will further cause circulatory
impairment.
14. Answer: A
Rationale: Metabolic acidosis is anaerobic metabolism caused by lack of
ability of the body to use circulating glucose. Administration of insulin
corrects this problem.
15. Answer: A
Rationale: Enlarged cirrhotic liver impinges the portal system causing
increased hydrostatic pressure resulting to ascites.
16. Answer: D
Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes
metabolic alkalosis because of the loss of hydrochloric acid which is a
potent acid in the body.
17. Answer: A
Rationale: Sodium, which is concerned with the regulation of extracellular
fluid volume, it is lost with vomiting. Chloride, which balances cations in
the extracellular compartments, is also lost with vomiting, because sodium
and chloride are parallel electrolytes, hyponatremia will accompany
18. Answer: A
Rationale: The thyroid gland is symmetrical, non-tender, and palpable only
if the patient has goiter. The palpable mass on the neck is the thyroid
cartilage. It is present in both males and females but is larger in males;
it develops during puberty
19. Answer: C
Rationale: Hypothyroidism causes a decrease in thyroid hormones, which in
turn causes decreased metabolism. Options A, B and D are all consistent
with decreased metabolism. Option C is a symptom of increased
metabolism found in hyperthyroidism.
20. Answer: A
EXAM CODE HAAD2

Rationale: Options B, C and D are all symptoms of hypoglycemia:
nightmares due to depression, weakness (extreme fatigue) and diaphoresis.
Option A is one of the 3 P’s of hyperglycemia: Polydipsia [excessive
thirst], Polyphagia [excessive hunger], and Polyuria [excess urine output].
21. Answer: C
Rationale: Avoid using a sleeping mask at night. The mask may irritate or
scratch the eye if the client turns and lies on it during the night.
22. Answer: B
Rationale: A tracheostomy set and oxygen. Acute respiratory obstruction in
the post-operative period can result from edema, subcutaneous bleeding
that presses on the trachea, nerve damage, or tetany.
23. Answer: B
Rationale: Eating habits are altered. For weight reduction to occur and
be maintained, a new dietary program, with a balance of foods from the
basic four food groups, must be established and continued
24. Answer: A
Rationale: Increase her lean body mass. Increased exercise builds
skeletal muscle mass and reduces excess fatty tissue.
25. Answer: B
Rationale: An occupational therapist can assist a client to improve the
fine motor skills needed to prepare an insulin injection.
26. Answer: D
Rationale: Aluminum hydroxide binds dietary phosphorus in the GI tract
and helps treat hyperphosphatemia. All the other medications mentioned
help treat hyperkalemia and its effects.
27. Answer: B
Rationale: A small part of the gland is left intact. Remaining thyroid
tissue may provide enough hormones for normal function. Total
thyroidectomy is generally done in clients with Thyroid Cancer.
28. Answer: C
Rationale: If the recurrent laryngeal nerve is damaged during surgery, the
client will be hoarse and have difficulty speaking.
29. Answer: B
Rationale: Dry skin is most likely caused by decreased glandular function
and fatigue caused by decreased metabolic rate. Body functions and
metabolism are decreased in hypothyroidism.
30. Answer: C
Rationale: Classic signs associated with hyperthyroidism are weight loss
and restlessness because of increased basal metabolic rate. Exopthalmos is
due to peribulbar edema.
31. Answer: D
Rationale: “Buffalo hump” is the accumulation of fat pads over the upper
back and neck. Fat may also accumulate on the face. There is truncal
obesity but the extremities are thin. All these are noted in a client with
EXAM CODE HAAD2
Cushing’s syndrome.
32. Answer: D
Rationale: In diabetic patients, the nurse should watch out for signs of
hypoglycemia manifested by dizziness, tremors, weakness, pallor
diaphoresis and tachycardia. When this occurs in a conscious client, he
should be given immediately carbohydrates in the form of fruit juice,
hard candy, honey or, if unconscious, glucagons or dextrose per IV.
33. Answer: C
Rationale: Lipodystrophy is the development of fibrofatty masses at the
injection site caused by repeated use of an injection site. Injecting
insulin into these scarred areas can cause the insulin to be poorly
absorbed and lead to erratic reactions.
34. Answer: A
Rationale: Following surgery of the thyroid gland, bleeding is a potential
complication. This can best be assessed by checking the back and the
sides of the operative dressing as the blood may flow towards the side
and back leaving the front dry and clear of drainage.
35. Answer: A
Rationale: Humulin N peaks in 6–8 hours, making the client at risk for
hypoglycemia around midnight, which is why the client should receive a
bedtime snack. This snack will prevent nighttime hypoglycemia.
36. Answer: B
Rationale: Biguanide medication must be held for a test with contrast
medium because it increases the risk of lactic acidosis, which leads to
renal problems
37. Answer: A
Rationale: The short-term goal must address the
part of the nursing diagnosis, which is “high risk for hyperglycemia,”
and this blood glucose level is within acceptable ranges for a client who
is noncompliant.
38. Answer: B
Rationale: The client’s level of consciousness can be altered because of
dehydration and acidosis.
If the client’s sensorium is intact, the client is getting better and
responding to the medical treatment.
39. Answer: A
Rationale: The initial fluid replacement is O.9%normal saline (an isotonic
solution) intravenously, followed by 0.45% saline. The rate depends on the
client’s fluid volume status and physical health, especially that of the
heart.
40. Answer: C
Rationale: Illness increases blood glucose levels; therefore the client must
take insulin and drink high-carbohydrate fluids such as regular Jell-O,
regular popsicles, and orange juice.
EXAM CODE HAAD2

41. Answer: B
Rationale: The client will not be compliant with the diet if he or she is
still hungry. Therefore, the nurse should request the dietician to talk to
the client to try and adjust the meals so that the client will adhere to
the diet.
42. Answer: D
Rationale: When the glucose level is decreased to around 300 mg/dL, the
regular insulin infusion therapy is decreased. Subcutaneous insulin will be
administered per sliding scale.
43. Answer: C
Rationale: Multifocal PVCs, which are secondary to
hypokalemia and which can occur in clients with DKA, are an emergency
and can be life threatening. This client needs an experienced nurse.
44. Answer: C
Rationale: Dry mucous membranes are a result of the hyperglycemia and
occur with both HHS and DKA.
45. Answer: C
Rationale: Narcotic addiction is related to the frequent, severe pain
episodes that often occur with chronic pancreatitis and its complications
and that require narcotics for relief.
46. Answer: B
Rationale: Autodigestion of the pancreas results in severe epigastric pain,
accompanied by nausea, vomiting, abdominal tenderness, and muscle
guarding.
47. Answer: A
Rationale: The nurse should assume the client is hypoglycemic and
administer IVP dextrose, which will rouse the client immediately. If the
collapse is the result of hyperglycemia, this additional dextrose will not
further injure the client.
48. Answer: C
Rationale: Regular insulin peaks in 2–4 hours. Therefore, the nurse should
think about the possibility that the client is having a hypoglycemic
reaction and should assess the client. The nurse should not delegate
nursing tasks to an assistant if the client is unstable.
49. Answer: C
Rationale: A necrotic big toe indicates “dead” tissue.
The client does not feel pain in the lower extremity and does not realize
there has been an injury and therefore does not seek treatment.
Increased blood glucose levels decrease oxygen supply that is needed to
heal the wound and increase the risk for developing an infection.
50. Answer: D
Rationale: All clients who exercise should perform warm-up and cool down
exercises to help prevent muscle strain and injury.
EXAM CODE HAAD2

51. Answer: C
Rationale: The most common precipitating factor is infection. The
manifestations may be slow to appear, with onset ranging from 24 hours
to 2 weeks.
52. Answer: B
Rationale: Client advocacy focuses support on the client’s autonomy. Even
if the nurse disagrees with his living on the street, it is the client’s
right. Arranging for someone to give him his insulin provides for his
needs and allows his choices.
53. Answer: A
Rationale: Age-related visual changes and diabetic retinopathy occur that
could lead to the client having difficulty in reading and drawing up
insulin dosage accurately.
54. Answer: C
Rationale: This result parallels a serum blood glucose level of
approximately 180 to 200 mg/dL.
An A1c is a blood test that reflects average blood glucose levels over a
period of 2–3 months; clients with elevated blood glucose levels are at
risk for developing long-term complications.
55. Answer: C
Rationale: Steatorrhea (fatty, frothy, foul-smelling stool) is caused by a
decrease in pancreatic enzyme secretion and indicates impaired digestion
and possibly an increase in the severity of the pancreatitis. The client
should see the HCP.
56. Answer: A
Rationale: Pancreatic enzymes must be administered with meals to
enhance the digestion of starches and fats in the gastrointestinal tract.
57. Answer: A
Rationale: Pancreatic enzymes enhance the digestion
of starches (carbohydrates) in the gastrointestinal
tract by supplying an exogenous
(outside) source of the pancreatic enzymes
protease, amylase, and lipase.
58. Answer: C
Rationale: The gag reflex will be suppressed as a result of the local
anesthesia applied to the throat to insert the endoscope into the
esophagus; therefore, the gag reflex must be assessed prior to allowing
the client to resume eating or drinking.
59. Answer: C
Rationale: The client should be NPO after midnight to make sure the
stomach is empty to reduce the risk of aspiration during the procedure.
60. Answer: B
Rationale: High-fat and spicy foods stimulate gastric and pancreatic
secretions and may precipitate an acute pancreatic attack.
EXAM CODE HAAD2

61. Answer: B
Rationale: The client in DKA loses potassium from increased urinary
output, acidosis, catabolic state, and vomiting. Replacement is essential
for preventing cardiac dysrhythmias secondary to hypokalemia.
62. Answer: D
Rationale: This ABG indicates metabolic acidosis, which is what is
expected in a client that is in diabetic ketoacidosis. Normal ABGs are pH
7.35–7.45; PaO2 80–100; PaCO2 35–45; HCO3 22–26.
63. Answer: C
Rationale: This fetal position decreases pain caused by stretching of the
peritoneum as a result of edema.
64. Answer: D
Rationale: The client will be NPO, which will decrease stimulation of the
pancreatic enzymes, which will result in decreased autodigestion of the
pancreas, therefore decreasing pain.
65. Answer: C
Rationale: Serum amylase increases within 2 to 12 hours of the onset of
acute pancreatitis to 2 to 3 times normal and returns to normal in 3 to
4 days; lipase elevates and remains elevated for 7 to 14 days.
66. Answer: A
Rationale: Cushing’s syndrome/disease predisposes the client to develop
infections as a result of the immunosuppressive nature of the disease.
67. Answer: C
Rationale: Smoking stimulates the pancreas to releasepancreatic enzymes
and should be stopped.
68. Answer: A
Rationale: The client will have an elevated sodium level as a result of
low circulating blood volume. The fluid is being lost through the urine.
Diabetes means “to pass through” in Greek, indicating polyuria, a symptom
shared with diabetes mellitus. Diabetes insipidus is a totally separate
disease process.
69. Answer: C
Rationale: Bronze pigmentation of the skin, particularly of the knuckles
and other areas of skin creases, occurs in Addison’s disease.
Hypotension and anorexia also occur with Addison’s.
70. Answer: B
Rationale: The adrenal gland secretes cortisol and thepituitary gland
secretes adrenocorticotropic hormone (ACTH), a hormone used by the body
to stimulate the production of
cortisol.
71. Answer: C
Rationale: The client is deprived of all fluids, and if the client has DI
the urine production will not diminish. Vital signs and weights are taken
every hour to determine circulatory status. If a marked decrease in
weight or vital signs occurs, the test is immediately terminated.
EXAM CODE HAAD2

72. Answer: C
Rationale: This is information given to all surgical clients on discharge.
73. Answer: C
Rationale: This is an intervention that will allow the client to discuss
feelings of body image.
74. Answer: B
Rationale: Cancer of the pancreas has a poor prognosis for most clients,
and the nurse should determine if the client has executed an advance
directive regarding their wishes.
75. Answer: A
Rationale: Clients diagnosed with Addison’s disease have adrenal gland
hypofunction. The hormones normally produced by the gland must be
replaced. Steroids and androgens are produced by the adrenal gland.
76. Answer: D
Rationale: Almost all of the iodine that enters the body is retained in the
thyroid gland. A deficiency in iodine will cause the thyroid gland to work
hard and enlarge, which is called a goiter. Goiters are commonly seen in
geographical regions that have an iodine deficiency. Most table salt in
the United
States has iodine added.
77. Answer: B
Rationale: A pulse oximeter reading of less than 93% is significant. A
90% pulse oximeter reading indicates a PaO2 of approximately 60 on an
arterial blood gas; this is severe hypoxemia and requires immediate
intervention.
78. Answer: A
Rationale: . A serum sodium level of 112 mEq/L is dangerously low, and
the client is at risk for seizures. A headache is a symptom of a low
sodium level.
79. Answer: D
Rationale: The client is excreting large amounts of dilute urine. If the
client is unable to take in enough fluids, the client will quickly become
dehydrated, so tissue turgor should be assessed frequently.
80. Answer: D
Rationale: The thyroid gland (in the neck) enlarges as a result of the
increased need for thyroid hormone production; an enlarged gland is
called a goiter.
81. Answer: C
Rationale: The first action should be to determine if the client is
experiencing polyuria and
polydipsia as a result of developing diabetes insipidus, a complication of
the head trauma.
82. Answer: B
Rationale: Medication taken for DI is usually every
8–12 hours, depending on the client. The client should keep the
medication close at hand.
EXAM CODE HAAD2
83. Answer: C
Rationale: Muscle twitching is a sign of early sodium imbalance. If an
immediate intervention is not made, the client could begin to seize.
84. Answer: D
Rationale: The client with hyperthyroidism has an increased appetite;
therefore, well-balanced meals served several times throughout the day
will help with the client’s constant hunger.
85. Answer: B
Rationale: Early signs and symptoms are nausea and vomiting. The client
has a syndrome of the inappropriate secretion of the antidiuresis (against
allowing the body to urinate) hormone. In other words, the client is
producing a hormone that will not allow the client to urinate.
86. Answer: C
Rationale: Untreated hypothyroidism is characterized by an increased
susceptibility to the effects of most hypnotic and sedative agents;
therefore, the nurse would question this medication.
87. Answer: C
Rationale: This is an example of autonomy (the client has the right to
decide for himself).
88. Answer: B
Rationale: The output is more than double the intake in a short time.
This client could be developing diabetes insipidus, a complication of
trauma to the head.
89. Answer: A
Rationale: An autocratic style is one in which the person in charge makes
the decision without consulting anyone else.
90. Answer: C
Rationale: This client has a low blood pressure and tachycardia. This
client could be about to go into an Addisonian crisis, a potentially life-
threatening condition. The most experienced nurse should care for this
client.
91. Answer: B
Rationale: Iatrogenic means that a problem has been caused by a medical
treatment or procedure— in this case, treatment with steroids for another
problem. Clients taking steroids over a period of time develop the clinical
manifestations of Cushing’s disease. Disease processes for which long-term
steroids are prescribed include chronic obstructive pulmonary disease,
cancer, and arthritis.
92. Answer: D
Rationale: Fluid volume deficit (dehydration) can lead to circulatory
impairment and hyperkalemia.
93. Answer: B
Rationale: Decreased metabolism causes the client to be cold frequently;
therefore, protecting the client from exposure to cold will help increase
comfort and decrease further heat loss.
EXAM CODE HAAD2
94. Answer: A
Rationale: A decrease in the thyroid hormone causes decreased
metabolism, which leads to fatigue and hair loss.
95. Answer: A
Rationale: Radioactive iodine therapy is used to destroy the overactive
thyroid cells. After treatment the client is followed closely for 3 to 4
weeks until the euthyroid state is reached.
96. Answer: B
Rationale: The abdominal pain is often made worse by eating and lying
supine in clients diagnosed with cancer of the pancreas.
97. Answer: B
Rationale: Type 2 diabetes is a disorder that usually occurs around the
age of 40, but it is now being detected in children and young adults as
a result of obesity and sedentary lifestyles. Wounds that do not heal are
a hallmark sign of Type 2 diabetes. This client weighs 248.6 pounds and
is short.
98. Answer: C
Rationale: This potassium level is below normal, which is 3.5–5.5 mEq/L.
Therefore, the nurse would question administering this medication because
loop diuretics cause potassium loss in the urine.
99. Answer: C
Rationale: The client with hypothyroidism frequently has a subnormal
temperature, so a temperature WNL indicates the medication is effective.
100. Answer: B
Rationale: Hyperpyrexia (high fever) and heart rate above 130
beats/minute are signs of thyroid storm, a severely exaggerated
hyperthyroidism.
EXAM CODE HAAD2

ANSWERS AND RATIONALES EXAM
CODE HAAD3
1. Answer: D
Rationale: AGN (acute glomerulonephritis) is generally accepted as an
immune-complex disease in relation to an antecedent streptococcal infection
of 4 to 6 weeks prior, and is considered as a noninfectious renal disease.
2. Answer: A
Rationale: Treatment will include Ranitidine and Antibiotics. One of the causes of
peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and
duodenal mucosa which decreases the gastric epithelium’s resistance to acid
digestion. Giving antibiotics will control the infection and Ranitidine, which is a
histamine-2 blocker, will reduce acid secretion that can lead to ulcer.
3. Answer: B
Rationale: Ulcerative colitis is a chronic inflammatory condition producing edema
and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes
stools as many as 10-20 times a day that is filled with blood, pus and mucus.
The other symptoms mentioned accompany the problem.
4. Answer: A
Rationale: Gnawing, dull, aching, hungerlike pain in the epigastric area that is
relieved by food intake. Duodenal ulcer is related to an increase in the
secretion of HCl. This can be buffered by food intake thus the relief of the
pain that is brought about by food intake.
5. Answer: B
Rationale: The client’s feeling of vomiting and the reduction in the volume of NGT
drainage that is thick are signs of possible abdominal distention caused by
obstruction of the NGT. This should be reported immediately to the MD to
prevent tension and rupture on the site of anastomosis caused by gastric
distention.
6. Answer: B
Rationale: Assess gag reflex prior to administration of fluids
The client, after gastroscopy, has temporary impairment of the gag reflex due to
the anesthetic that has been sprayed into his throat prior to the procedure.
Giving fluids and food at this time can lead to aspiration.
7. Answer: B
Rationale: Empty bladder before procedure. Paracentesis involves the removal of
ascitic fluid from the peritoneal cavity through a puncture made below the
umbilicus. The client needs to void before the procedure to prevent accidental
puncture of a distended bladder during the procedure.
8. Answer: A
Rationale: Sit upright for at least 30 minutes after meal. The dumping
syndrome occurs within 30 minutes after a meal due to rapid gastric emptying,
causing distention of the duodenum or jejunum produced by a bolus of food.
To delay the emptying, the client has to lie down after meals. Sitting up after
meals will promote the dumping syndrome.
Exam Code HAAD3
9. Answer: D
Rationale: 12 to 24 hours after subtotal gastrectomy gastric drainage is
normally brown, which indicates digested food.
10. Answer: A
Rationale: Sudden decrease in drainage or onset of severe abdominal pain should
be reported immediately to the physician because it could mean that obstruction
has been developed.
11. Answer: C
Rationale: Sudden, severe abdominal pain is the most indicative sign of
perforation. When perforation of an ulcer occurs, the nurse maybe unable to
hear bowel sounds at all.
12. Answer: C
Rationale: This is primarily caused by the trauma of intestinal manipulation
and the depressive effects anesthetics and analgesics.
13. Answer: B
Rationale: A client who has had abdominal surgery is best placed in a low
fowler’s position. This relaxes abdominal muscles and provides maximum
respiratory and cardiovascular function.
14. Answer: A
Rationale: Dark red to purple stoma indicates inadequate blood supply.
15. Answer: B
Rationale: With increased intraabdominal pressure, the abdominal wall will become
tender and rigid.
16. Answer: B
Rationale: Amylase concentration is high in the pancreas and is elevated in the
serum when the pancreas becomes acutely inflamed and also it distinguishes
pancreatitis from other acute abdominal problems.
17. Answer: A
Rationale: Clients with GERD should avoid eating prior to retiring or lying down
to decrease the incidence of reflux. The client with GERD will be prescribed a
low-fat, high-fiber diet. Antibiotics are not used to treat GERD, although
antibiotics are used for clients with Helicobacter pylori infection and peptic ulcer
disease. The client with GERD should elevate the head on pillows or use blocks
under the head of the bed to minimize reflux.
18. Answer: C
Rationale: Normally, stomas should appear pink-red and moist; a dark purple-
colored stoma indicates that blood supply to the stoma may be compromised.
Immediate intervention is crucial because the client may need surgery to
reestablish the blood supply.
19. Answer: C
Rationale: During an acute episode of diverticulitis, measures focus on resting
the colon, such as keeping the client on nothing-by-mouth status, administering
I.V. fluids, and maintaining nasogastric suctioning and bedrest. Administering
stimulant laxatives may be appropriate for
Exam Code HAAD3
restoring the client's normal bowel elimination, but their use during an acute
attack would only serve to irritate the bowel further.
20. Answer: D
Rationale: One day after abdominal surgery, the client's abdomen should be soft,
not rigid or hard. Also, the WBC count may be slightly elevated in response to
the surgery, but an elevation of 20,000 mmis highly suggestive of an infectious
process. A rigid, boardlike abdomen in conjunction with a seriously elevated WBC
count suggests peritonitis and requires immediate intervention.
21. Answer: B
Rationale: To promote adequate food and fluid intake while minimizing the effects
of stomatitis, the client should eat a bland diet and avoid spicy and acidic foods,
which would irritate the mucosa. Water, saline, or dilute solutions of hydrogen
peroxide are appropriate solutions for gargling instead of toothpaste or
mouthwash. The client should use a gauze or sponge toothbrush to cleanse oral
mucosa.
22. Answer: A
Rationale: With a duodenal ulcer, the client typically complains of aching or
gnawing pain in the right epigastrium, relieved by eating. Pain also occurs 2 to
3 hours after meals and may awaken the client at night.
Upper epigastric burning 30 to 60 minutes after meals suggests a gastric ulcer
23. Answer: A
Rationale: Increasing the client's fluid intake to more than 2,000 ml per day
distends the bowel and aids in propelling feces through the large intestines,
facilitating stool elimination. Isotonic exercises, such as walking, swimming, or
jogging (rather than isometric exercises), should be recommended.
24. Answer: B
Rationale: H2-receptor antagonists interfere with the histamine receptors in the
parietal cells of the stomach, thereby suppressing the stimulus for gastric acid
production, leading to a decrease in the amount of hydrochloric acid secreted by
these cells.
25. Answer: D
Rationale: Malabsorption syndrome results in impaired absorption of nutrients in
the small intestines; water-soluble and fat-soluble vitamins and minerals must
be replaced.
26. Answer: A
Rationale: For the client with a severe acute exacerbation of chronic
inflammatory bowel disease, fluid and electrolyte loss can be great because
of the profuse episodes of diarrhea; fluid and electrolyte replacement usually is
administered I.V. to reduce the client's risk for fluid volume deficit and
electrolyte imbalances.
27. Answer: D
Rationale: An inflammation of the stomach and small intestines that causes
abdominal cramping and diarrhea best describes gastroenteritis. An acute
inflammation of the esophageal mucosa resulting in heartburn and
Exam Code HAAD3
belching describes esophagitis. An inflammation of small saccular bowel wall
herniations resulting in low-grade fever and left lower-abdominal pain
describes diverticulitis. An inflammation of the peritoneum, which causes a
boardlike abdomen and severe abdominal pain, describes peritonitis.
28. Answer: A
Rationale: Omeprazole decreases gastric acid by slowing the hydrogen-
potassium-adenosine-triphosphatase pump on the surface of the parietal cells.
29. Answer: D
Rationale: Crohn's disease is also known as regional enteritis and can occur
anywhere along the GI tract, but most commonly at the distal ileum and in
the colon.
30. Answer: A
Rationale: With a sigmoid colostomy, the feces are solid. With a transverse
colostomy, the feces are mushy. With a descending colostomy, the feces are
semi-mushy. With an ascending colostomy, the feces are fluid.
31. Answer: D
Rationale: Saline agents use osmosis to stimulate peristalsis and act within 2
hours of consumption. Bulk-forming agents mix with intestinal fluids, swell, and
stimulate peristalsis. Stimulants irritate the colon epithelium. Fecal softeners
hydrate the stool by surfactant action on the colonic epithelium, resulting in
mixing of aqueous and fatty substances.
32. Answer: B
Rationale: Secretory diarrhea is usually high volume diarrhea and is caused by
increased production and secretion of water and electrolytes by the intestinal
mucosa into the intestinal lumen.
33. Answer: B
Rationale: Choledocholithotomy refers to incision of the common bile duct for the
removal of stones (liths). Choledochoduodenostomy refers to anastomosis of the
common duct to the duodenum. Choledochotomy refers to opening into the
common duct. Cholecystostomy refers to opening and drainage of the
gallbladder.
34. Answer: A
Rationale: Increasing fiber intake to 20-30 grams daily. The incorporation of high
fiber into the diet is an effective way to promote bowel elimination in the
elderly.
35. Answer: A
Rationale: When the client would have normally had a bowel movement
Irrigation should be performed at the time the client normally defecated before
the colostomy to maintain continuity in lifestyle and usual bowel function/habit.
36. Answer: D
Rationale: Projection is the attribution of unacceptable feelings and emotions to
others which may indicate the patient’s nonacceptance of his condition.
Exam Code HAAD3
37. Answer: C
Rationale: The irrigation bag should be hung 12-18 inches above the level of the
stoma; a clothes hook is too high which can create increase pressure and sudden
intestinal distention and cause abdominal discomfort to the patient.
38. Answer: B
Rationale: There is no special diet for clients with colostomy. These clients
can eat a regular diet. Only gas-forming foods that cause distention and
discomfort should be avoided.
39. Answer: B
Rationale: Difficulty of inserting the irrigating tube indicates stenosis of the stoma
and should be reported to the physician. Abdominal cramps and passage of flatus
can be expected during colostomy irrigations. The procedure may take longer than
half an hour.
40. Answer: B
Rationale: A difficult time accepting reality and is in a state of denial. As long as
no one else confirms the presence of the stoma and the client does not need to
adhere to a prescribed regimen, the client’s denial is supported
41. Answer: B
Rationale: Hyperventilation results in the increased elimination of carbon dioxide
from the blood that can lead to respiratory alkalosis.
42. Answer: A
Rationale: The medications he has been taking. Some medications, such as aspirin
and prednisone, irritate the stomach lining and may cause bleeding with prolonged
use.
43. Answer: B
Rationale: Regular meals and snacks to limit gastric discomfort. Presence of food
in the stomach at regular intervals interacts with HCl limiting acid mucosal
irritation. Mucosal irritation can lead to bleeding.
44. Answer: A
Rationale: The client should avoid lifting heavy objects and any strenuous activity
for 4-6 weeks after surgery to prevent stress on the inguinal area. There is no
special diet required. The fluid intake of eight glasses a day is good advice but
is not a priority in this case.
45. Answer: C
Rationale: To be exact, the appendix is anatomically located at the Mc
Burney’s point at the right iliac area of the right lower quadrant.
46. Answer: A
Rationale: Evisceration is a surgical emergency. A hernia is a weakness in the
abdominal wall. Dehiscence refers to partial or complete separation of wound
edges. Erythema refers to redness of tissue.
47. Answer: B
Rationale: The patient should not take aspirin while taking probenicid
because salicylates interfere with the action of the drug. This drugs
Exam Code HAAD3
inhibits uric acid reabsorption and increase uric acid excretion, thereby causing a
decrease in serum uric acid. It is important for the client to increase fluid
intake in order to prevent formation of uric acid calculi in the kidney. Probenecid
should be taken with milk or after meals to minimize gastric distress.
48. Answer: A
Rationale: Renal urate lithiasis (kidney stones) may result from precipitation of uric
acid in the presence of low urinary pH. This can be avoided by encouraging the
patient to have liberal fluid intake to promote urinary excretion of uric acid.
49. Answer: C
Rationale: Nausea is one of the common complaints of a patient after receiving
general anesthesia. But this complaint could be aggravated by gastric distention
especially in a patient who has undergone abdominal surgery. Insertion of the
NGT helps relieve the problem. Checking on the patency of the NGT for any
obstruction will help the nurse determine the cause of the problem and institute
the necessary intervention.
50. Answer: A
Rationale: The colon is ulcerated and unable to absorb water, resulting in bloody
diarrhea. 10 to twenty bloody diarrhea stools isthe most common symptom of
ulcerative colitis.
51. Answer: C
Rationale: This medication must be tapered off to prevent adrenal
insufficiency; therefore, the client must take this medication as
prescribed.
52. Answer: B
Rationale: Leg cramps are a sign of hypokalemia;
hypokalemia can lead to cardiac dysrhythmias and can be life threatening.
Assessment is priority for a potassium level that is just below normal level,
which is 3.5 to 5.5 mEq/L.
53. Answer: B
Rationale: The client requires fluids to help prevent dehydration from diarrhea
and to replace the fluid lost through normal body functioning.
54. Answer: A
Rationale: TPN is high in dextrose, which is glucose; therefore the client’s blood
glucose level must be monitored closely.
55. Answer: C
Rationale: The severity of the diarrhea helps determine the need for fluid
replacement. The liquid stool should be measured as part of the total output.
56. Answer: C
Rationale: The client is crying and is expressing feelings of powerlessness;
therefore the nurse should allow the client to talk.
57. Answer: B
Exam Code HAAD3
Rationale: An ileostomy will drain liquid all the time and should not routinely
be irrigated; only specially trained nurses are allowed to irrigate an ileostomy. A
sigmoid colostomy may need daily irrigation to evacuate feces.
58. Answer: D
Rationale: This antibiotic is poorly absorbed from the gastrointestinal tract and
acts topically on the colonic mucosa to inhibit the inflammatory process.
59. Answer: A
Rationale: The terminal ileum is the most common site for regional
enteritis and causes right lower quadrant pain that is relieved by
defecation.
60. Answer: C
Rationale: A low-residue diet is a low-fiber diet.
Products made of refined flour or finely milled grains, along with roasted, baked,
or broiled meats, are recommended.
61. Answer: A
Rationale: The cure for ulcerative colitis is a total colectomy, which is
removing the entire large colon and bringing the terminal end of the ileum up
to the abdomen in the right lower quadrant. This is an ileostomy.
62. Answer: B
Rationale: . Most clients with GERD have been selfmedicating with over- the-
counter medications prior to seeking advice from a health-care provider. It is
important to know what the client has been using to treat the problem.
63. Answer: A
Rationale: The client should elevate the head of the bed on blocks or use a foam
wedge to use gravity to help keep the gastric acid in the stomach and prevent
reflux into the esophagus.
Behavior modification is changing one’s behavior.
64. Answer: D
Rationale: Orange and tomato juices are acidic, and the client diagnosed with
GERD should avoid acidic foods until the esophagus has had a chance to heal.
65. Answer: C
Rationale: Clients should eat small, frequent meals and limit fluids with the meals
to prevent reflux into the esophagus from a distended stomach.
66. Answer: D
Rationale: The head of the bed should be elevated to allow gravity to help in
preventing reflux. Lifestyle modifications of losing weight, making dietary
modifications, attempting smoking cessation, discontinuing the use of alcohol, and
not stooping or bending at the waist all help to decrease reflux.
67. Answer: A
Exam Code HAAD3
Rationale: Of adult-onset asthma cases, 80%–90% are caused by
gastroesophageal reflux disease (GERD).
68. Answer: D
Rationale: A mucosal barrier agent must be administered on an empty
stomach for the medication to coat the stomach.
69. Answer: C
Rationale: The client’s WBC is elevated, indicating a possible infection, which
warrants notifying the HCP.
70. Answer: C
Rationale: This client is exhibiting symptoms of asthma, a complication of GERD;
therefore, the client should be assigned to the most experienced nurse.
71. Answer: B
Rationale: Frequent use of antacids indicates an acid reflux problem.
72. Answer: A
Rationale: Pyrosis is heartburn, water brash is the feeling of saliva
secretion as a result of reflux, and flatulence is gas—all symptoms of GERD.
73. Answer: C
Rationale: Barrett’s esophagitis results from longterm erosion of the esophagus as
a result of reflux of stomach contents secondary to GERD. This is a precursor
to esophageal cancer.
74. Answer: D
Rationale: In a client diagnosed with a gastric ulcer, pain usually occurs 30–60
minutes after eating, but not at night. In contrast, a client with a duodenal ulcer
has pain during the night that is often relieved by eating food. Pain occurs 1–3
hours after meals.
75. Answer: A
Rationale: The EGD is an invasive diagnostic test that visualizes the esophagus and
stomach to accurately diagnose an ulcer and evaluate the effectiveness of the
client’s treatment.
76. Answer: B
Rationale: Use of NSAIDs places the client at risk for peptic ulcer disease and
hemorrhage. Any client suspected of having peptic ulcer disease should be
questioned specifically about the use of NSAIDs.
77. Answer: A
Rationale: Auscultation should be used prior to palpation or percussion when
assessing the abdomen. If the nurse manipulates the abdomen, the bowel
sounds can be altered and give false information.
78. Answer: D
Rationale: Potential for alteration in gastric emptying is caused by edema or
scarring associated with peptic ulcer disease, which may cause a feeling of
“fullness,” vomiting of undigested food, or abdominal distention.
79. Answer: B
Exam Code HAAD3
Rationale: Maintaining lifestyle changes such as following an appropriate diet
and reducing stress indicates that the client is complying with the medical
teachings. Such compliance is the goal of treatment to prevent complications.
80. Answer: C
Rationale: A decrease of 20 mm Hg in blood pressure after changing position
from lying, to sitting, to standing is orthostatic hypotension. This could
indicate that the client is bleeding.
81. Answer: A
Rationale: E-mycin is irritating to stomach, and its use in a client with peptic
ulcer disease should be questioned.
82. Answer: D
Rationale: Antibiotics, proton pump inhibitors, and
Pepto-Bismol are administered to decrease the irritation of the ulcerative area
and cure the ulcer. A decrease in gastric distress indicates the medication is
effective.
83. Answer: B
Rationale: A rigid boardlike abdomen with rebound tenderness is the classic
sign and symptom of peritonitis, which is a complication of a perforated
gastric ulcer.
84. Answer: B
Rationale: Inserting a nasogastric tube and lavaging the stomach with saline is
the most important intervention because this directly stops the bleeding.
85. Answer: D
Rationale: The nurse should assess the client to determine if the abdomen is soft
and nontender.
A rigid tender abdomen may indicate peritonitis.
86. Answer: D
Rationale: The client should have regular bowel movements, preferably daily.
Constipation may cause diverticulitis, which is a potentially life- threatening
complication of diverticulosis.
87. Answer: C
Rationale: The nurse should question a clear liquid diet because the bowel must
be put on total rest, which means NPO.
88. Answer: C
Rationale: Chicken and whole-wheat bread are high in fiber, which is the
therapeutic diet prescribed for clients with diverticulosis. An adequate intake of
water helps prevent constipation.
89. Answer: D
Rationale: Bowel perforation is a potential complication of a colonoscopy.
Therefore signs of hypotension—decreased BP and increased pulse—would
warrant immediate intervention from the nurse.
Exam Code HAAD3

90. Answer: B
Rationale: The nurse should always ask about allergies to medication when
administering medications, but especially when administering antibiotics,
which are notorious for allergic reactions.
91. Answer: A
Rationale: These are signs of peritonitis, which is life threatening. The health-
care provider should be notified immediately.
92. Answer: A
Rationale: Green bile contains hydrochloric acid and should be draining from the
N/G tube; therefore the nurse should take no action and should document the
findings.
93. Answer: C
Rationale: Hemorrhoids would indicate the client has chronic constipation, which
is a strong risk factor for diverticulosis. Constipation increases the intraluminal
pressure in the sigmoid colon, leading to weakness in the intestinal lining, which,
in turn, causes outpouchings, or diverticula.
94. Answer: B
Rationale: The bowel must be put at rest. Therefore, the nurse should
anticipate orders for maintaining NPO and a nasogastric tube.
95. Answer: B
Rationale: Cruciferous vegetables, such as broccoli, cauliflower, and
cabbage, are high in fiber.
One of the risks for cancer of the colon is a high-fat, low-fiber, and high-
protein diet.
The longer the transit time (the time from ingestion of the food to the elimination
of the waste products) the greater the chance of developing cancer of the colon.
96. Answer: C
Rationale: The most common symptom of colon cancer is a change in bowel
habits, specifically diarrhea alternating with constipation.
97. Answer: A
Rationale: A long history of low-fiber, high-fat, high protein diets results in a
prolonged transit time. This allows the carcinogenic agents in the waste products
to have a greater exposure to the lumen of the colon.
98. Answer: D
Rationale: The pouch should be emptied when it is one-third to one-half full to
prevent the contents from becoming too heavy for the seal to hold and to
prevent leakage from occurring.
99. Answer: A
Rationale: The nurse should mark the drainage on the dressing to
determine if active bleeding is occurring because dark reddish-brown
drainage indicates old blood. This allows the nurse to assess what is
actually happening.
100. Answer: B
Exam Code HAAD3

Rationale: The nurse should determine what is concerning the client. It could be
a misunderstanding or a real situation where the client’s care is unsafe or
inadequate.
Exam Code HAAD3

CODE HAAD4
1. Answer: C
Rationale: The orthopneic position lowers the diaphragm and provides for
maximal thoracic expansion
2. Answer: A
Rationale: The chest tube normalizes intrathoracic pressure and restores
negative intra-pleural pressure, drains fluid and air from the pleural space,
and improves pulmonary function
3. Answer: B
Rationale: This nursing action prevents atelectasis and collection of
respiratory secretions and promotes adequate ventilation and gas
exchange.
4. Answer: B
Rationale: This assists in moving blood, fluid or air, which may be
obstructing drainage, toward the collection chamber
6. B. Excessive bubbling indicates an air leak which must be eliminated to

permit lung expansion.
7. B. Left sided heart failure causes fluid accumulation in the capillary network of
the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at
the end of inspiration.
8. Answer: C
Rationale: The client should be instructed to breath in the medication for 3-4
seconds in order to receive the correct dosage of medication.
9. Answer: C
Rationale: Positioning the client laterally with the neck extended does not obstruct
the airway so that drainage of secretions and oxygen and carbon dioxide
exchange can occur.
10. Answer: B
Rationale: The method of choice for opening the airway is the head-tilt- chin-lift
method. The jaw thrust method be used when neck injury is possible. Option C
is one method for treating airway obstruction by a foreign body.
11. Answer: D
Rationale: Bronchopulmonary dysplasia is an iatrogenic disease caused by
therapies such as use of positive-pressure ventilation used to treat lung disease.
12. Answer: C
Rationale: The non-rebreather mask has a one-way valve that prevents
exhales air from entering the reservoir bag and one or more valves covering
the air holes on the face mask itself to prevent inhalation of room air but to
allow exhalation of air. When a tight seal is achieved around the mask up to
100% of oxygen is available.
13. Answer: A
Exam Code HAAD4

Rationale: When removing a chest tube the physician will ask the patient to
exhale and hold their breath, or exhale and bear down. This will
serve to increase intrathoracic pressure, as well as prevent air from entering the
pleural space.
14. Answer: C
Rationale: Incentive Spirometry is used post-operatively especially after thoracic
and abdominal surgery to prevent collapse of the air passages or atelectasis. In
assisting the patient, the nurse should employ choices a, b and d although it is
more effective with the head of the bed elevated, it can be performed from any
position. It should be started immediately as atelectasis can start as soon
as one hour post-operatively.
15. Answer: D
Rationale: In suctioning a patient with a tracheostomy, the nurse should employ
all of the choices except D. However, when the catheter is inserted it should be
done gently, and to a depth of 10-12.5cms (4-5"s) or until the patient begins to
cough. Suction should never be applied when inserting the catheter, nor
should it be rotated during this period. Suction should be applied by occluding
the Y-port with the thumb of the unsterile gloved hand, while the catheter is
rotated gently during withdrawal. The patient should never be
suctioned for more than 10 seconds at one time to avoid the development of
hypoxia.
16. Answer: D
Rationale: Clients who have been on anti-TB drug regimes for at least 2-
3 weeks and have absence of AFB in at least two successive sputum cultures, no
longer need to be on Respiratory Isolation. Taking medication
alone, or the absence of adventitious breath sounds such as rhonchi, rales, etc,
or the absence of infiltrates on chest x-ray, usually seen with Pneumonia would
not be a reason to D/C Isolation making other choices incorrect.
17. Answer: C
Rationale: The client does not require intubation. The first ABG analysis reveals
respiratory acidosis frequently seen with a pneumothorax. After inserting a chest
tube, respiratory status of the client has improved, pH is increasing toward
normal and the PaCO2 is decreasing, ABG analysis in respiratory alkalosis shows
an elevated pH and a low PaCO2. Assessment findings are more significant if the
client requires intubation or if respiratory arrest is imminent.
18. Answer: C
Rationale: Assess his response to the equipment
It is a primary nursing responsibility to evaluate effect of interventions done to
the client. Nothing is achieved if the equipment is working and the client is not
responding
19. Answer: A
Rationale: Increased breath sounds
The chest tube normalizes intrathoracic pressure and restores negative intra-
pleural pressure, drains fluid and air from the pleural space, and improves
20. Answer: B
Exam Code HAAD4
Rationale: Encourage frequent coughing and deep breathing. This nursing action
prevents atelectasis and collection of respiratory secretions and promotes
adequate ventilation and gas exchange.
21. Answer: D
Rationale: For the safety of all personnel, if the defibrillator paddles are being
discharged, all personnel must stand back and be clear of all the contact with
the client or the client’s bed.
22. Answer: A
Rationale: Tetany may occur after thyroidectomy if the parathyroid glands are
accidentally injured or removed.
23. Answer: A
Rationale: Right side lying position or supine position permits ventilation of the
remaining lung and prevent fluid from draining into sutured bronchial stump.
24. Answer: B
Rationale: Compression of the lung by fluid that accumulates at the base of the
lungs reduces expansion and air exchange.
25. Answer: C
Rationale: In client’s diagnosed with COPD, the drive to breathe
is hypoxia. If oxygen is delivered at too high of a concentration, this drive will
be eliminated and the client’s depth and rate of respirations will decrease.
Therefore the first action should be to lower the oxygen rate.
26. Answer: B
Rationale: Clients with contraindications to heparin, recurrent PE or those with
complications related to the medical therapy may require vena caval interruption
by the placement of a filter device in the inferior vena cava. A filter can be
placed transvenously to trap clots before they travel to the pulmonary
circulation.
27. Answer: D
Rationale: Clients with chronic obstructive pulmonary disease have difficulty
exhaling fully as a result of the weak alveolar walls from the disease process.
Alveolar collapse can be avoided with the use of pursed- lip breathing. This is
the major reason to use it. The other options are secondary effects of purse-lip
breathing.
28. Answer: A
Rationale: The higher pitched a sound is, the more narrow the airway. Therefore,
the obstruction has increased or worsened. With no evidence of secretions no
support exists to indicate the need for suctioning.
29. Answer: B
Rationale: Facilitate ventilation of the left lung.
Since only a partial pneumonectomy is done, there is a need to promote
expansion of this remaining Left lung by positioning the client on the opposite
unoperated side.
30. Answer: C
Exam Code HAAD4
Rationale: Pneumonia, which is an infection, causes lobar consolidation thus
impairing gas exchange between the alveoli and the blood. Because the patient
would require adequate hydration, this makes him prone
to fluid volume excess.
31. Answer: C
Rationale: Applying pressure against the incision with a pillow will help lessen
the intra-abdominal pressure created by coughing which causes tension on the
incision that leads to pain.
32. Answer: C
Rationale: Lower the oxygen rate. The client with COPD is suffering from chronic
CO2 retention. The hypoxic drive is his chief stimulus for breathing. Giving O2
inhalation at a rate that is more than 2-3L/min can make the client lose his
hypoxic drive which can be assessed as decreasing RR.
33. Answer: D
Rationale: Slowly breath out through the mouth with pursed lips after
inhaling the drug. If the client breathes out through the mouth with pursed
lips, this can easily force the just inhaled drug out of the respiratory tract that
will lessen its effectiveness.
34. Answer: A
Rationale: Food and fluids will be withheld for at least 2 hours. Prior to
bronchoscopy, the doctors sprays the back of the throat with anesthetic to
minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving
the client food and drink after the procedure without checking on the return of
the gag reflex can cause the client to aspirate. The gag reflex usually returns
after two hours.
35. Answer: C
Rationale: Suction until the client indicates to stop or no longer than 20 second.
One hazard encountered when suctioning a client is the development of hypoxia.
Suctioning sucks not only the secretions but also the gases found in the airways.
This can be prevented by suctioning the client for an average time of 5-10
seconds and not more than 15 seconds and hyperoxygenating the client before
and after suctioning.
36. Answer: A
Rationale: Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for
breathing. COPD causes a chronic CO2 retention that renders the medulla
insensitive to the CO2 stimulation for breathing. The hypoxic state of the client
then becomes the stimulus for breathing. Giving the clientoxygen in low
concentrations will maintain the client’s hypoxic drive.
37. Answer: D
Rationale: Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12
mons. A prolonged treatment duration is necessary to ensure eradication of the
organisms and to prevent relapse. The increasing prevalence of drug resistance
points to the need to begin the treatment with drugs in combination. Using drugs
in combination can delay the drug resistance.
38. Answer: D
Exam Code HAAD4
Rationale: With emphysema, air trapping and chronic hyperexpansion of the
lungs lead to distant breath sounds. Copious amounts of sputum are produced
with chronic bronchitis; with emphysema, sputum production is usually scant.
39. Answer: C
Rationale: Uncontrolled coughing in the client following a thoracentesis may
indicate the development of pulmonary edema that requires immediate attention.
Bilateral crackles may indicate underlying inflammation or congestion, but
immediate attention is not necessary. Complaints of pain at the needle insertion
site and symmetrical respirations are normal findings.
40. Answer: D
Rationale: A tension pneumothorax occurs when the pressure increases in the
pleural space. Thus, removing an occlusive dressing will release the increased
pressure in the pleural space and help resolve the tension.
Typically, the health care provider will insert a large bore needle initially and
then a chest tube to aid in reinflating the lung. Applying an occlusive dressing
will increase the pressure in the chest and worsen the tension pneumothorax. An
occlusive dressing would be appropriate for an open pneumothorax.
41. Answer: D
Rationale: Pneumonia typically causes thick secretions that may be difficult for the
elderly client to expectorate; increasing fluid intake will help thin secretions,
ultimately aiding in their removal. A client with pneumonia typically does not
require oxygen at home.
42. Answer: C
Rationale: Splinting the affected side, such as by having the client lie on the right
side, restricts expansion and reduces friction between pleurae, which helps
decrease the pain. Oxygen will not help relieve pain, but it will help to relieve
dyspnea and hypoxemia. Coughing and deep-breathing is necessary, but these
typically will increase the client's pain, not relieve it. Opioid analgesics should be
administered with caution to prevent depression of the cough reflex and
respiratory drive.
43. Answer: B
Rationale: Following a thoracotomy, the goal is to promote adequate gas
exchange, evidenced by objective parameters including oxygen saturation, normal
blood gases, and breath sounds. Effective coughing and deep breathing help to
maintain a patent airway and promote lung expansion, but they do not ensure
adequate gas exchange.
44. Answer: D
Rationale: A client with massive trauma and multiple orthopedic injuries is at
increased risk for developing a PE. The injury may predispose the client to fat
emboli and bony fragments that can become emboli, and the prolonged period of
immobility that results from the injuries and their treatment further compounds
the client's risk.
45. Answer: D
Rationale: The primary stimulus to breathe for the client with COPD is hypoxia. If
oxygen were administered at too high a rate, the client's respiratory drive would be
depressed. Due to loss of supporting structures
Exam Code HAAD4
and narrowing of airways, the condition is irreversible; intermittent oxygen
is not effective.
46. Answer: A
Rationale: Barrel chest is a term that refers to an increase in the anteroposterior
diameter of the chest, resulting from overinflation of the lungs. A flail chest
results from fractured ribs when a portion of the chest pulls inward upon
inspiration. A funnel chest refers to a depression of the lower part of the
sternum. A pigeon chest refers to an anterior displacement of the sternum
protruding beyond the abdominal plane.
47. Answer: A
Rationale: Initially, for the client newly diagnosed with COPD, the health care
provider would order a bronchodilator to open the airways and ease dyspnea.
Corticosteroids may be ordered for the client with COPD, but they are usually
used for acute exacerbations, not as an initial drug.
Anticoagulants interfere with the clotting cascade and would be ordered for a
client with an embolic disorder such as pulmonary embolism. An antitussive
agent would be used for the client with coughing, such as that occurring with
pneumonia
48. Answer: D
Rationale; One aspect of exacerbation prevention focuses on eliminating the
causes and contributory factors associated with COPD, such as pulmonary irritants
(e.g., smoke, air pollution, occupational irritants, and allergies). Prevention would
focus on eliminating these irritants
49. Answer: A
Rationale: The client is at high risk for developing acute respiratory failure
because of his history of chronic lung disease requiring frequent intubations,
the anesthesia used during surgery, and the experience of surgery.
50. Answer: C
Rationale: PEEP helps keep the alveoli expanded, increasing the area available
for gas exchange, thus improving the client's oxygenation. PEEP has no effect on
the client's ability to rest, decreases pulmonary capillary pressure, and
decreases the client's carbon dioxide level by increasing the area for gas
exchange.
51. Answer: C
Rationale: Epiglottitis is an emergency situation requiring immediate
intervention: the inflamed epiglottis is blocking the entrance to the trachea;
therefore clearing the patient’s AIRWAY is the priority nursing action.
Endotracheal intubation will be difficult because the inflamed epiglottis will not
permit the insertion of a laryngoscope.
52. Answer: D
Rationale: Options A, B and C are early signs. The brain is the most sensitive organ
to hypoxia, causing restlessness and agitation. Tachycardia is a compensatory
mechanism to increase O2 in the brain.
53. Answer: C
Rationale: A patient with COPD has decreased respiration. Propranolol
[Inderal] is contraindicated for patients with COPD because of its PNS effects
(it will aggravate the patient’s respiratory depression).
Exam Code HAAD4
54. Answer: C
Rationale: Avoid giving him direct information and help him explore his feelings.
To help the patient verbalize and explore his feelings, the nurse must reflect and
analyze the feelings that are implied in the client’s question. The focus should be
on collecting data to minister to the client’s psychosocial needs.
55. Answer: C
Rationale: Supports combustion. The nurse should know that Oxygen is
necessary to produce fire, thus precautionary measures are important
regarding its use.
56. Answer: A
Rationale: INH can cause hepatocellular injury and hepatitis. This side effect is
age-related and can be detected with regular assessment of liver enzymes,
which are released into the blood from damaged liver cells.
57. Answer: B
Rationale: Milk the tube toward the collection container as ordered. This assists in
moving blood, fluid or air, which may be obstructing drainage, toward the
collection chamber
58. Answer: C
Rationale: The orthopneic position lowers the diaphragm and provides for maximal
thoracic expansion
59. Answer: D
Rationale: Dysphagia should be minimized during peak effect of Mestinon,
thereby decreasing the probability of aspiration. Mestinon can increase her
muscle strength including her ability to swallow.
60. Answer: A
Rationale: The absence of tubercle bacilli in the sputum indicates that the
patient can no longer transmit the infection to others via airborne route.
61. Answer: D
Rationale: Acetaminophen is suitable for a patient with asthma. Aspirin and
NSAIDs (nonsteroidal anti-inflammatory drugs) are not recommended because
these agents are implicated in the development of asthma.
62. Answer: B
Rationale: A positive Mantoux test indicates presence of TB antibodies which
means that the client has been exposed to TB but it does not indicate whether or
not the patient has active tuberculosis. As such, even BCG vaccination can cause
a false positive result. Sputum culture is the definitive diagnostic test for TB.
63. Answer: A
Rationale: Methyxanthines like theophylline is used with precaution and often as
a last resort in the treatment of asthma because the drug can cause
tachycardia and dysrhytmias
Exam Code HAAD4
64. Answer: C
Rationale: Petechiae indicate disseminated intravascular coagulation. Pulmonary
infarction is manifested by hemoptysis. Right ventricular failure is manifested by
distended neck veins.
65. Answer : D
Rationale: In a patient with emphysema, the stimulus for breathing is low oxygen
concentration and not increased carbon dioxide level in the blood. As much the
nurse should not supply oxygen in high concentration so as not to eliminate or
remove this stimulus for breathing.
66. Answer: C
Rationale: The drug can cause tachycardia and abnormal heart rhythm, as such, it
is important to monitor the patient's pulse rate.
67. Answer: B
Rationale: The nurse should hyperoxygenate the client before suctioning by
providing 100% oxygen. This is because suctioning also removes oxygen.
The other choices are not required before suctioning a client with
tracheostomy.
68. Answer: D
Rationale: Rotating the catheter while it is being inserted prevents trauma
on tissues.
69. Answer: A
Rationale: The cooperation of the patient is important during thoracentesis. When
the needle is inserted, it is important for the patient to sit and avoid unnecessary
movements which can dislodge the needle and puncture the lungs tissue or
visceral pleura. Tell the patient to avoid coughing, turning and breathing deeply.
70. Answer: C
Rationale: This position facilitates breathing. The ideal position for a patient with
asthma is the orthopneic position in which the patient is in high fowler's
position with head and arms resting on the over bed table. This position
promotes lung expansion and facilitates breathing.
71. Answer: A
Rationale: Orthopnea is the ability to breathe only when one is in an upright
or sitting position. Apnea is absence of breathing. Tachypnea is
fast breathing. Dyspnea is difficulty of breathing.
72. Answer: C
Rationale: After the procedure, pressure is applied on the puncture site to stop
bleeding and a sterile dressing is applied. The patient is maintained on bed rest
and place on the unaffected side for one hour to facilitate lung expansion.
73. Answer: A
Rationale: COPD is a disorder characterized by airway obstruction. In asthma,
obstruction is due to spasms, constriction and inflammation of mucus in the
airway. In emphysema, gas exchange is impaired by the destruction of over
distended alveoli. Asthma used to be included in COPD but now it is considered
a separate disorder.
Exam Code HAAD4
74. Answer: B
Rationale: Patient with chronic hypoxemia may react adversely with oxygen
therapy as increased oxygen blood levels removes their stimulus to breathe which
could result in respiratory depression characterized by decreasing respiration and
drowsiness.
75. Answer: C
Rationale: Increasing fluid intake will liquefy thick mucus secretions making it easy
to move them out of the respiratory tract by breathing, coughing postural
drainage and suctioning. Breathing and exercises, postural drainage and suctioning
can only remove the secretions, liquefy it or production of more thick secretions.
in addition, these interventions would not be effective if the secretions are too
thick and sticky.
76. Answer: B
Rationale: Methylxanthines, a group of drug in which aminophyllline (Truphylline)
and theophylline (Theo-Dur) belong is given to patient in acute asthmatic
attacks to help dilate the bronchioles and facilitate gas exchange.
77. Answer: C
Rationale: The patient is instructed to perform the Valsalva maneuver or to
breathe quietly when the chest tube is removed to facilitate its removal. the chest
is clamped and quickly removed. A small bandage is applied and made airtight
with petroleum gauze covered by a 4x4 gauze pad and thoroughly sealed by a
nonporous tape.
78. Answer: D
Rationale: Bronchospasm and mucus causes air to be trapped inside the alveoli.
Excessive distension can lead to eventual destruction of the walls of the alveoli.
79. Answer: D
Rationale: Supplemental oxygen is used during acute asthmatic attacks at high
flow rates.
Oxygen is given to treat dyspnea, hypoxemia and cyanosis. Heliox, a mixture of
50% oxygen and 50% helium can help improve oxygen delivery of the alveoli
because this gas mixture is lower in density than oxygen alone.
80. Answer: A
Rationale: Sedatives, tranquilizers and narcotics are given with caution to patients
with COPD as they cause respiratory depression which can further impair
ventilation.
81. Answer: C
Rationale: One hazard encountered when suctioning a client is the development of
hypoxia. Suctioning sucks not only the secretions but also the gases found in the
airways. This can be prevented by suctioning the client for an average time of 5-
10 seconds and not more than 15 seconds and hyperoxygenating the client
before and after suctioning.
82. Answer: D
Rationale: Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12
months. Prolonged treatment duration is necessary to ensure
Exam Code HAAD4
eradication of the organisms and to prevent relapse. The increasing prevalence of
drug resistance points to the need to begin the treatment with drugs in
combination. Using drugs in combination can delay the drug resistance.
83. Answer: A
Rationale: COPD causes a chronic CO2 retention that renders the medulla
insensitive to the CO2 stimulation for breathing. The hypoxic state of the client
then becomes the stimulus for breathing. Giving the clientoxygen in low
concentrations will maintain the client’s hypoxic drive.
84. Answer: A
Rationale: Prior to bronchoscopy, the doctors sprays the back of the throat with
anesthetic to minimize the gag reflex and thus facilitate the insertion of the
bronchoscope. Giving the client food and drink after the procedure without
checking on the return of the gag reflex can cause the client to aspirate. The gag
reflex usually returns after two hours.
85. Answer: B
Rationale: Since only a partial pneumonectomy is done, there is a need to promote
expansion of this remaining Left lung by positioning the client on the opposite
unoperated side.
86. Answer: D
Rationale: Slowly breath out through the mouth with pursed lips after inhaling
the drug.
If the client breathes out through the mouth with pursed lips, this can easily force
the just inhaled drug out of the respiratory tract that will lessen its effectiveness.
87. Answer: C
Rationale: The client with COPD is suffering from chronic CO2 retention. The
hypoxic drive is his chief stimulus for breathing. Giving O2 inhalation at a rate
that is more than 2-3L/min can make the client lose his hypoxic drive which
can be assessed as decreasing RR.
88. Answer: C
Rationale: Pneumonia, which is an infection, causes lobar consolidation thus
impairing gas exchange between the alveoli and the blood. Because the patient
would require adequate hydration, this makes him prone to fluid volume
excess.
89. Answer: C
Rationale: Options 1, 2, and 4. these allow for maximal chest expansion. The
client should not lie on the back because it reduces movement of a large area of
the client's chest wall. Sitting is better than standing, whenever possible. If no
chair is available, then leaning against a wall while standing allows accessory
muscles to be used for breathing and not posture control.
90. Answer: C
Rationale: When the client is experiencing respiratory acidosis, the respiratory rate
and depth increase in an attempt to compensate. The client also experiences
headache, restlessness, mental status changes, such as drowsiness and confusion,
visual disturbances, diaphoresis, cyanosis as
Exam Code HAAD4
the hypoxia becomes more acute, hyperkalemia, a rapid, irregular pulse, and
dysrhythmias.
91. Answer: C
Rationale: In the first few hours after surgery, the drainage from the chest tube is
bloody. After several hours, it becomes serosanguineous. The client should not
experience frequent clotting. Proper chest tube function should allow for drainage
of blood before it has the chance to clot in the chest or the tubing.
92. Answer: B
Rationale: Plugging a tracheostomy tube is usually done by inserting the
tracheostomy plug (decannulation stopper) into the opening of the outer cannula.
This closes off the tracheostomy, and airflow and respiration occur normally
through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff
must be deflated. If it remains inflated, ventilation cannot occur and respiratory
arrest could result. The ability to swallow or speak is unrelated to weaning and
plugging the tube.
93. Answer: A
Rationale: The client must have sputum cultures performed every 2 to 4 weeks
after initiation of antituberculosis drug therapy. The client may return to work
when the results of three sputum cultures are negative, because the client is
considered noninfectious at that point.
94. Answer: B
Rationale: Rationale: Bubbling in the water seal compartment is caused by air
passing out of the pleural space into the fluid in the chamber.
Intermittent bubbling is normal. It indicates that the system is accomplishing one of
its purposes, removing air from the pleural space. Continuous bubbling during
inspiration and expiration indicates that an air leak exists. If this occurs, it must
be corrected.
95. Answer: C
Rationale: In tracheostomy tubes with both an inner and outer cannula, it is
only the inner cannula which is removed for cleaning. Newer plastic
tubes have disposable inner cannulas that are changed as ordered.
96. Answer: D
Rationale: In suctioning a patient with a tracheostomy, the nurse should employ
all of the above choices except choice D. However, when the catheter is
inserted it should be done gently, and to a depth of 10- 12.5cms (4-5"s) or
until the patient begins to cough. Suction should never be applied when
inserting the catheter, not should it be rotated during this period. Suction
should be applied by occluding the Y-port with the thumb of the unsterile gloved
hand, while the catheter is rotated gently during withdrawal. The patient
should never be suctioned for more than 10 seconds at one time to avoid the
development of hypoxia.
97. Answer: A
Rationale: When removing a chest tube the physician will ask the patient to
exhale and hold their breath, or exhale and bear down. This will
serve to increase intrathoracic pressure, as well as prevent air from entering the
pleural space.
Exam Code HAAD4

98. Answer: B
Rationale: Water sealed chest drainage is designed to remove air and/or fluid
from the pleural cavity, and to restore negative pressure in the pleural cavity,
which promotes the re-expansion of the lung
99. Answer: A
Rationale: Beta Agonists, are usually the initial drugs used and serve to dilate
bronchial smooth muscle. Methylxanthines are among the most
commonly used bronchodilators and include Aminophylline and Theophylline.
Corticosteroids, which may be administered IV, or through inhalation help to
reduce inflammation and reduce bronchospasm. Calcium Channel Blockers
are not used in the treatment of Asthma.
100. Answer: C
Rationale: Incentive Spirometry is used post-operatively especially after thoracic
and abdominal surgery to prevent collapse of the air passages or atelectasis. In
assisting the patient, the nurse should employ the other choices although it is
more effective with the head of the bed elevated, it can be performed from any
position. It should be started immediately as
atelectasis can start as soon as one hour post-operatively.
Exam Code HAAD4

CODE HAAD5
1. Answer: A
Rationale: Weight loss and an increase in aerobic activity such as walking, with
special attention to quadriceps strengthening are important approaches to pain
management. Gastrointestinal complications, especially GI bleeding, are associated
with the use of nonsteroidal anti-inflammatory drugs (NSAIDs).
2. Answer: C
Rationale: Prickling sensation is an indication of compartment syndrome and
requires immediate action by the nurse. The other findings are normal for a
client in this situation.
3. Answer: A
Rationale: Unequal leg length. Shortening of a leg is a sign of
developmental dysplasia of the hip.
4. Answer: A
Rationale: Expose the cast to air and turn the child frequently. The child should
be turned every 2 hours, with surface exposed to the air.
5. Answer: B
Rationale: Risk factors for osteoporosis include being female, postmenopausal,
advanced age, inadequate intake of calcium, excessive alcohol intake, being
sedentary and history smoking cigarettes. Long term use of corticosteroids,
anticonvulsants and furosemide also increase the risk.
6. Answer: D
Rationale: A 305 to 50% of body weight on the affected limb is allowed for a
client who has partial weight bearing status. Full weight bearing status is
placing full weight on the limb. Non-weight bearing status does not allow the
client to let the limb touch the floor. Touchdown weight bearing allows the
client to let the limb touch the floor but not bear weight.
7. Answer: A
Rationale: To assess the cutaneous nerve status, the client should raise his
forearm and inspect for the flexion of the biceps, Choice B is used to assess the
radial nerve status, choice C is done to asses the median nerve status while
choice D is performed to assess for the ulnar nerve status.
8. Answer: A
Rationale: Fractured pain is generally described as sharp, continuous, and
increasing in frequency.
9. Answer: D
Rationale: Signs and symptoms of infection under a casted area include odor or
purulent drainage and the presence of “hot spot” which are areas on the cast
that are warmer than the others.
10. Answer: B
Exam Code HAAD5
Rationale: The nurse should focus more on developing less stressful ways of
accomplishing routine task.
11. Answer: C
Rationale: Positioning the client with the head of the bed elevated and his
knees slightly flexed increases the disc space and may help to decrease the
client's pain.
12. Answer: C
Rationale: Anticholinesterase agents inhibit the breakdown of acetylcholine at the
neuromuscular junction; taking the medication 30 minutes before activities allows
the drug to reach its peak effect, thereby increasing the client's muscle strength.
13. Answer: A
Rationale: Infection at the tong sites is a complication that can be prevented with
scrupulous wound site care and thorough assessment. If the client is not a
quadriplegic, active range-of-motion exercises would be done more often than
daily to prevent contractures or pressure ulcers.
The client would wear high-top tennis shoes to prevent foot drop. The
weights should never be removed.
14. Answer: D
Rationale: Accept and acknowledge that his withdrawal is an initially normal
and necessary part of grieving. The withdrawal provides time for the client to
assimilate what has occurred and integrate the change in the body image.
Acceptance of the client’s behavior is an important factor in the nurse’s
intervention.
15. Answer: D
Rationale: Dorsiflexion, plantar flexion, eversion and inversion. These movements
include all possible range of motion for the ankle joint
16. Answer: A
Rationale: 25 gtt/min. To get the correct flow rate: multiply the amount to be
infused (50 ml) by the drop factor (10) and divide the result by the amount of
time in minutes (20)
17. Answer: A
Rationale: Exercising the triceps, finger flexors, and elbow extensors. These sets of
muscles are used when walking with crutches and therefore need strengthening
prior to ambulation.
18. Answer: C
Rationale:The palms should bear the client’s weight to avoid damage to the
nerves in the axilla (brachial plexus)
19. Answer: C
Rationale: The “shrinker” bandage is applied to prevent swelling of the stump. It
should be applied with the distal end with the tighter arms. Applying the tighter
arms at the proximal end will impair circulation and cause swelling by reducing
venous flow.
20. Answer: D
Rationale: Patients with osteoarthritis have decreased mobility caused by joint
pain. Over-reaching and stretching to get an object are to be
Exam Code HAAD5
avoided as this can cause more pain and can even lead to falls. The nurse
should see to it therefore that objects are within easy reach of the patient.
21. Answer: C
Rationale: Encourage range of motion and ambulation. Mobility reduces the risk of
deep vein thrombosis in the post-surgical client and the adult at risk.
22. Answer: C
Rationale: Maintain in a flat position, logrolling as needed. The bed should
remain flat for at least the first 24 hours to prevent injury. Logrolling is
the best way to turn for the client while on bed rest.
23. Answer: A
Rationale: The nurse should instruct the client on isometric exercises for the
muscles of the casted extremity, i.e., instruct the client to alternately contract
and relax muscles without moving the affected part. The client should also be
instructed to do active range of motion exercises for every joint that is not
immobilized at regular and frequent intervals.
24. Answer: B
Rationale: Before log rolling, remove the pillow from under the client’s head
and use no pillows between the client’s legs. Following a laminectomy and
spinal fusion, it is important that the back of the patient be maintained in
straight alignment and to support the entire vertebral column to promote
complete healing.
25. Answer: D
Rationale: Force fluids before and after the procedure. LP involves the removal
of some amount of spinal fluid. To facilitate CSF production, the client is
instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs
after the procedure.
26. Answer: D
Rationale: Mobility and placing the burned areas in their functional position can
help prevent contracture deformities related to burns. Pain can immobilize a
client as he seeks the position where he finds less pain and provides maximal
comfort. But this approach can lead to contracture deformities and other
complications.
27. Answer: D
Rationale: Warm compress is applied 24 hrs after tissue injury. The purpose
is to dilate blood vessels in order to increase blood to the injured area. That
promotes tissue healing and decrease edema. The temperature should be at
or slightly above body temperature
28. Answer: B
Rationale: Paget's disease is a bone disorder characterized by excessive metabolic
activity in bone, in which excessive bone reabsorption (oesteoclast activity) occurs
followed by excessive bone formation (osteoblast activity). Chronic remodeling of
the bone results in the affected bones to be larger (bone thickening on x-ray)
and softer, painful (from osteoclastic activity) and prone to fracture.
Exam Code HAAD5
29. Answer: C
Rationale: In Paget's disease, the serum phosphate level rises steadily as the
disease progresses. Normal level is 30 to 115U/L, this can reach up to 3000IU/L
in Paget's disease. The calcium level is normal to elevated awhile phosphate
and parathyroid hormone level are usually at normal levels.
30. Answer: C
Rationale: Calcium supplements are prescribed to patients at risk of developing
calcium deficiency and also to patients receiving biphosphates. Biphospahates
such as Alendronate (Fosamax), Tiludronate (Skelid) and Pamidronate ( Aredia)
inhibit osteoclastic activity. Calcitonin (whether human derived) also inhibits
reabsorption of the bone.
31. Answer: A
Rationale: Osteomalacia or adults rickets is a metabolic bone disorder that is
characterized by delayed or inadequate mineralization of bone matrix. Osteitis
deformans is Paget's disease. Hyperurecemia is associated with arthritis.
Degenerative joint disease is osteoarthritis.
32. Answer: C
Rationale: Calcium supplements are prescribed to patients at risk of developing
calcium deficiency and also to patients receiving biphosphates. Biphospahates
such as Alendronate (Fosamax), Tiludronate (Skelid) and Pamidronate ( Aredia)
inhibit osteoclastic activity. Calcitonin (whether human derived) also inhibits
reabsorption of the bone.
33. Answer: D
Rationale: This statement reflects feelings/thoughts and encourages the client
to talk about them giving the nurse an opportunity to correct misconceptions
and to provide appropriate health teachings.
34. Answer: B
Rationale: If the area distal to the operative site has no pulse and cold to
touch, it indicates compromised circulation. the nurse report this finding to the
doctor immediately.
35. Answer: D
Rationale: During administration of analgesia, and anesthesia, the priority is
maintenance of adequate respiratory function in the patient as these agents
cause respiratory depression.
36. Answer: C
Rationale: Colchicine helps prevent gout attacks by decreasing lactic acid
formation, which may promote the deposition of uric acid in the joints. It is used
in the treatment of acute attacks of gout for its anti- inflammatory effect.
37. Answer: B
Rationale: There is no special dietary requirement for patient with rheumatoid
arthritis. Alkaline ash diet is prescribed for gouty arthritis.
38. Answer: A
Rationale: Orthopneic position involves hip flexion more than 90 degrees which
puts stree on the operative site that could dislodge the prosthesis.
Exam Code HAAD5
39. Answer: B
Rationale: Advance age appears to be the most important risk factor in the
development of this condition. Other risk factors are obesity, inactivity and
decreased estrogen in menopausal women.
40. Answer: C
Rationale: Osteoporosis is a disease of the bones characterized by weak, porous
and brittle bones.
arthritis is a chronic systemic disease of the body's connective tissue
characterized by inflammatory and degenerative changes.
41. Answer: B
Rationale: The two main goals of treatment for OA are pain management and
optimizing functional ability of the joints to ensure movement of the joints.
42. Answer: A
Rationale: Obesity is a well-recognized risk factor for the development of OA and it
is modifiable in that the client can lose weight.
43. Answer: B
Rationale: Glucosamine and chondroitin are medications that improve tissue function
and retards breakdown of cartilage.
44. Answer: B
Rationale: Clients with Type 1 diabetes are insulin dependent. This
medication should be administered before the client eats.
45. Answer: A
Rationale: Posture and gait will be affected if the client is experiencing sciatica,
pain radiating down a leg resulting from pressure on the sciatic nerve.
46. Answer: D
Rationale: NSAIDs are well known for causing gastric upset and increasing the
risk for peptic ulcer disease, which could cause the client to vomit blood.
47. Answer: B
Rationale: Pain, stiffness, and functional impairment are the primary clinical
manifestations of OA.
Stiffness of the joints is commonly experienced after resting but usually lasts
less than 30 minutes and decreases with movement.
48. Answer: C
Rationale: This client is postop and now has a fever.
This client should be assessed and the health-care provider should be
notified.
49. Answer: C
Rationale: The first action is to notify the charge nurse so that a replacement can be
arranged to take over care of the clients. The nurse should notify the nurse
manager or house supervisor. An occurrence report should be completed
documenting the situation. This provides the nurse with the required
documentation to begin a worker’s compensation case for payment of medical
bills.
Exam Code HAAD5
50. Answer: C
Rationale: Alternative forms of treatment have not been proved efficacious in the
treatment of a disease. The nurse should be nonjudgmental and open
to discussions about alternative treatment, unless it interferes with the medical
regimen.
51. Answer: A
Rationale: The lumbar nerves innervate the lower abdomen. The bladder is in the
lower abdomen. The client will be required to lie flat, and this is a difficult
position for many clients, especially males, to be in to void.
52. Answer: A
Rationale: Safety should always be discussed when teaching about exercises.
Supportive shoes will prevent shin splints. Colored socks have dye that may
cause athlete’s foot, which is why white socks are recommended.
53. Answer: C
Rationale: Pain will decrease with movement, and warm or hot water will help
decrease the pain. The worse thing the client can do is not move.
54. Answer: D
Rationale: Nosebleeds are adverse effects and should be reported to the client’s
HCP.
55. Answer: C
Rationale: X-rays reveal loss of joint cartilage, which appears as a

narrowing of the joint space in clients diagnosed with OA.
56. Answer: C
Rationale: The physical therapist is able to help the client with
transferring, ambulation, and other lower-extremity difficulties.
57. Answer: C
Rationale: The legs of any client diagnosed with back pain can give out and
collapse at any time, but a large client diagnosed with back pain would be at
increased risk of injuring the assistant as well as the client. The nurse should
intervene before the client or assistant become injured.
58. Answer: D
Rationale: The client experiencing chronic pain often experiences
depression and hopelessness.
59. Answer: D
Rationale: Nighttime lights will help prevent the client from falling;
fractures are the number-one complication of osteoporosis.
60. Answer: D
Rationale: Nicotine slows the production of osteoblasts and impairs the
absorption of calcium, contributing to decreased bone density.
61. Answer: C
Rationale: Excess weight increases the workload on the vertebrae. Weight- loss
activities would help to prevent back injury.
Exam Code HAAD5
62. Answer: A
Rationale: A cold foot on a client who has had surgery may indicate a
neurovascular compromise and must be assessed first.
63. Answer: D
Rationale: Less blood supply, degeneration of the disc, and arthritis are reasons
elderly people develop back problems.
64. Answer: A
Rationale: The loss of height occurs as vertebral bodies collapse.
65. Answer: AS
Rationale: This is an example of a secondary nursing intervention, which
includes screening for early detection.
66. Answer: B
Rationale: The surgical position of the wound places the client at risk for edema of
tissues in the neck. Difficulty speaking or breathing would alert the nurse to a
potentially lifethreatening problem.
67. Answer: B
Rationale: Weight-bearing activity, such as walking, is beneficial in preventing or
slowing bone loss. The mechanical force of weight-bearing exercises promotes
bone growth.
68. Answer: B
Rationale: The prone position will help stretch the hamstring muscle, which
will help prevent flexion contractures that may lead to problems when fitting
the client for prosthesis.
69. Answer: C
Rationale: This test measures bone density in the lumbar spine or hip and is
considered to be highly accurate.
70. Answer: C
Rationale: A nonmodifiable risk factor is a factor that the client cannot do
anything to alter or change. Approximately 50% of all women will experience
an osteoporosis-related fracture in their lifetime.
71. Answer: C
Rationale: The normal capillary refill time (CRT) is less than three (3) seconds.
A prolonged refill time and increasing pain indicate circulation impairment. This
needs to be reported before compartment syndrome occurs.
72. Answer: B
Rationale: Weights from traction should be off the floor and hanging freely.
Buck’s traction is used to reduce muscle spasms preoperatively in clients who
have fractured hips.
73. Answer: B
Rationale: Looking toward the future and problem solving indicate that the
client is accepting the loss.
74. Answer: B
Exam Code HAAD5
Rationale: Determining if the client is hemorrhaging would be the first
intervention. The nurse should check for signs of hypovolemic shock,
decreased BP, and increased pulse.
75. Answer: C
Rationale: Free hydrochloric acid is needed for calcium absorption;
therefore Tums should be taken on an empty stomach.
76. Answer: A
Rationale: The best dietary sources of calcium are milk and other dairy products.
Other sources include oysters; canned sardines or salmon; beans; cauliflower; and
dark-green, leafy vegetables.
77. Answer: A
Rationale: The National Institutes of Health (NIH) recommend a daily calcium intake
of 1200 to 1500 mg per day for adolescents, young adults, and pregnant and
lactating women.
78. Answer: D
Rationale: The nursing assistant could take a client to another department in the
hospital.
79. Answer: A
Rationale: For wound healing, a balanced diet with adequate protein and
vitamins is essential, along with meals appropriate for Type 2 diabetes.
80. Answer: A
Rationale: The Jewish faith believes that all body parts must be buried
together. Therefore many synagogues will keep amputated limbs until death
occurs.
81. Answer: C
Rationale: The large tourniquet can be used if the residual limb begins to
hemorrhage either internally or externally.
82. Answer: B
Rationale: Phantom pain is caused by severing the peripheral nerves. The pain is
real to the client, and the nurse needs to medicate the client immediately.
83. Answer: A
Rationale: Applying pressure to the end of the residual limb will help toughen
the limb. Gradually pushing the residual limb against harder and harder surfaces
is done in preparation for prosthesis training.
84. Answer: B
Rationale: Encouraging the client to take deep breaths and cough would aid in
the exchange of gases. Mental changes are early signs of hypoxia in the
elderly client.
85. Answer: D
Rationale: Placing the thumb in a plastic bag will protect it and then placing
the plastic bag on ice will help preserve the thumb so that it may be
reconnected in surgery. Do not place the amputated part directly on ice because
this will cause necrosis of viable tissue.
Exam Code HAAD5
86. Answer: C
Rationale: The definition of an open fracture is a bone that has penetrated the
skin. The highest priority problem is infection because the skin is the barrier that
keeps bacteria from entering the surrounding tissue.
87. Answer: A
Rationale: The expected outcome for a client with a fracture is
maintaining the function of the extremity.
88. Answer: D
Rationale: The urinary output is not adequate; therefore the surgeon needs to be
notified. This is only 20 mL per hour. The minimum should be
30 mL per hour.
89. Answer: C
Rationale: Applying direct pressure to the artery above the amputated parts will
help decrease the bleeding immediately and is the first intervention the nurse
should implement. Then the nurse should instruct the client to hold the hand
above the head, apply towels, and call 911.
90. Answer: A
Rationale: The nurse should assess the client for signs of hypoxia from a fat
embolism. The symptoms listed in this question indicate a fat embolism. Dyspnea,
adventitious breath sounds, and confusion indicate hypoxia. Young males are more
likely to suffer from a fat embolism, especially from fractured femurs.
91. Answer: D
Rationale: The immobilizer should be kept on at all times. This indicates that the
client does not understand the teaching and needs the nurse to provide more
instruction.
92. Answer: D
Rationale: The hip should have functional motion.
93. Answer: C
Rationale: Assessing the bowel sounds should be the first intervention to
determine if an ileus has occurred. This is a common complication of a
fractured pelvis.
94. Answer: C
Rationale: Applying ice packs to the cast will relieve itching and nothing should
be placed down a cast to scratch. Skin becomes fragile inside the cast and is torn
easily. Alteration in the skin’s integrity can become infected.
95. Answer: D
Rationale: Modification of the home is essential to the rehabilitation of the
client using assistive devices for ambulation. The postoperative goals for this
client are to maximize mobility and promote health.
96. Answer: C
Rationale: Groin pain or increasing discomfort in the affected leg and the
“popping sound” indicate that the leg has dislocated and should be reported
immediately to the HCP for a possible closed reduction.
Exam Code HAAD5

97. Answer: C
Rationale: Clients should participate in care, in decision- making, and in
activities that promote mobility and adaptation to the life changes
postoperatively.
98. Answer: D
Rationale: Using a high-seated toilet and chair will help prevent
dislocation by limiting the flexion to less than 90 degrees.
99. Answer: B
Rationale: Pain with dorsiflexion of the ankle indicates deep vein thrombosis. This
can be from immobility or surgery; therefore pain should be assessed on both
legs.
100. Answer: C
Rationale: Fluid-filled blisters are from a reaction to the tape and usually occur
along the edge of the tape.
Exam Code HAAD5

CODE HAAD6
1. Answer: D
Rationale: Discomfort or pain is a problem that originates in the kidney. It is
felt at the costovertebral angle on the affected side.
2. Answer: A
Rationale: After nephrectomy, it is necessary to measure urine output hourly.
This is done to assess the effectiveness of the remaining kidney also to detect
renal failure early.
3. Answer: A
Rationale: Perfusion can be best estimated by blood pressure, which is an indirect
reflection of the adequacy of cardiac output.
4. Answer: C
Rationale: Semi-fowlers position will localize the spilled stomach contents in the
lower part of the abdominal cavity.
5. Answer: A
Rationale: Gravity speeds up digestion and prevents reflux of stomach
contents into the esophagus.
6. Answer: B
Rationale: Abdominal distension may be associated with pain, may indicate
perforation, a complication that could lead to peritonitis.
7. Answer: D
Rationale: It may take 4 to 6 months to eat anything, but most people can
eat anything they want.
8. Answer: D
Rationale: One cup of cottage cheese contains approximately 225 calories,
27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins
of high biologic value (HBV) contain optimal levels of amino acids essential for
life.
9. Answer: B
Rationale: This indicates that the bladder is distended with urine,
therefore palpable.
10. Answer: C
Rationale: Elevation increases lymphatic drainage, reducing edema and pain.
11. Answer: A
Rationale: In the diuretic phase fluid retained during the oliguric phase is
excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids
should be replaced.
12. Answer: C
Rationale: Patency of the catheter promotes bladder decompression, which
prevents distention and bleeding. Continuous flow of fluid through the bladder
limits clot formation and promotes hemostasis
Exam Code HAAD6
13. Answer: A
Rationale: It decreases serum phosphate. Aluminum binds phosphates that tend to
accumulate in the patient with chronic renal failure due to decreased filtration
capacity of the kidney. Antacids such as Amphojel are commonly used to
accomplish this.
14. Answer: A
Rationale: Institute seizure precautions. The severity of the acute phase of AGN
is variable and unpredictable; therefore, a child with edema, hypertension, and
gross hematuria may be subject to complications and anticipatory preparation
such as seizure precautions are needed.
15. Answer: A
Rationale: Circumcision is delayed so the foreskin can be used for the surgical
repair. Even if mild hypospadias is suspected, circumcision is not done in order
to save the foreskin for surgical repair, if needed.
16. Answer: B
Rationale: Ambulate. Free unattached stones in the urinary tract can be passed
out with the urine by ambulation which can mobilize the stone and by
increased fluid intake which will flush out the stone during urination.
17. Answer: B
Rationale: Cholecystectomy requires a subcostal incision. To minimize pain, clients
have a tendency to take shallow breaths which can lead to respiratory
complications like pneumonia and atelectasis. Deep breathing and coughing
exercises can help prevent such complications.
18. Answer: C
Rationale: Infection is responsible for one third of the traumatic or surgically
induced death of clients with renal failure as well as medical induced acute
renal failure (ARF)
19. Answer: C
Rationale: Menorrhagia is a type of abnormal uterine bleeding defined as
excessive bleeding at the usual time of menstrual flow. Amenorrhea refers to the
absence of menstruation. Dysmenorrhea is defined as painful menstruation.
Metrorrhagia is a type of abnormal bleeding defined as bleeding between periods
or after menopause.
20. Answer: C
Rationale: The client's complaints in conjunction with the results of the physical
examination and urinalysis suggest prostatitis, which is associated with fever,
dysuria, urgency, frequency, and such urinalysis results as bacteria and WBCs; other
findings include perineal or lower back pain and a swollen prostate on exam.
21. Answer: B
Rationale: The most common complications associated with transurethral
resection are bleeding and infection. Pulmonary complications are associated
with all types of surgeries and are not specific for transurethral resections.
22. Answer: C
Exam Code HAAD6

Rationale: Abstinence is encouraged during antibiotic therapy in acute
prostatitis, although in chronic prostatitis, sexual intercourse is encouraged. An
indwelling urinary catheter, such as a Foley catheter, is not required for the
client with acute prostatitis. A client with acute prostatitis is being treated with
antibiotics and is not required to maintain bedrest.
23. Answer: D
Rationale: The client with a rectovaginal fistula may experience fecal drainage
via the vagina; preventing infection by keeping the vaginal area clean with
irrigation, douches, and sitz baths would be most important.
24. Answer:
Rationale: Urinary drainage will be dependent on a urethral catheter for
24 hours. An indwelling urethral catheter is used, because surgical trauma can
cause urinary retention leading to further complications such as bleeding.
25. Answer: B
Rationale: Milking the tubing will usually dislodge the plug and will not harm
the client. A physician’s order is not necessary for a nurse to check catheter
patency.
26. Answer: B
Rationale: Provide hemostasis
The pressure of the balloon against the small blood vessels of the
prostate creates a tampon-like effect that causes them to constrict
thereby preventing bleeding.
27. Answer: B
Rationale: After transurethral surgery, hemorrhage is common because of venous
oozing and bleeding from many small arteries in the prostatic bed.
28. Answer: C
Rationale: Promoting hydration, maintains urine production at a higher rate,
which flushes the bladder and prevents urinary stasis and possible infection
29. Answer: D
Rationale: Membranes ruptured over 24 hours prior to birth greatly
increases the risk of infection to both mother and the newborn.
30. Answer: C
Rationale: Administer a laxative to the client the evening before the
examination. Bowel prep is important because it will allow greater
visualization of the bladder and ureters.
31. Answer: D
Rationale: No measurable voiding in 4 hours. The concern is possible
hyperkalemia, which could occur with continued potassium administration and a
decrease in urinary output since potassium is excreted via the kidneys.
32. Answer: B
Exam Code HAAD6

Rationale: The nurse’s first action should be to massage the fundus until it is
firm as uterine atony is the primary cause of bleeding in the first hour after
delivery.
33. Answer: B
Rationale: Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L. Chronic
renal failure is usually the end result of gradual tissue destruction and loss of
renal function. With the loss of renal function, the kidneys ability to regulate
fluid and electrolyte and acid base balance results. The serum Ca decreases as the
kidneys fail to excrete phosphate, potassium and hydrogen ions are retained.
34. Answer: C
Rationale: Hypovolemia, wide fluctuations in serum sodium and potassium levels.
The second phase of ARF is the diuretic phase or high output phase. The
diuresis can result in an output of up to 10L/day of dilute urine. Loss of fluids
and electrolytes occur.
35. Answer: B
Rationale: Avoid taking blood pressure measurements or blood samples from
the affected arm. In the client with an external shunt, don’t use the arm with
the vascular access site to take blood pressure readings, draw blood, insert IV
lines, or give injections because these procedures may rupture the shunt or
occlude blood flow causing damage and obstructions in the shunt.
36. Answer: D
Rationale: Surgical interventions involve an experience of pain for the client
which can come in varying degrees. Telling the pain that he will be pain free
is giving him false reassurance.
37. Answer: C
Rationale: It is important for the nurse to remember that the implant be kept
intact in the cervix during therapy. Mobility and vaginal irrigations are not done.
A low residue diet will prevent bowel movement that could lead to dislodgement
of the implant. Patient is also strictly isolated to protect other people from the
radiation emissions
38. Answer: B
Rationale: These crystals are uremic frost resulting from irritating toxins
deposited in the client’s tissues. Bathing in cool water will remove the crystals,
promote client comfort, and decrease the itching that occurs from uremic frost.
39. Answer: C
Rationale: Renal failure causes an imbalance of electrolytes (potassium, sodium,
calcium, phosphorus). Therefore the desired client outcome would be that all the
electrolytes are within normal limit
40. Answer: A
Rationale: The assistant can collect specimens. Collecting a midstream urine
specimen requires the client to clean the perineal area, to urinate a little, and
then collect the rest of the urine output in a sterile container.
41. Answer: A
Exam Code HAAD6

Rationale: The nurse should place the client’s chair with the head lower than
the body, which will shunt blood to the brain; this is the Trendelenburg position.
42. Answer: D
Rationale: Excess fluid volume is priority because of the stress placed on the
heart and vessels, which could lead to heart failure, pulmonary edema, and
death.
43. Answer: C
Rationale: Uremic frost, which results when the skin attempts to take over
the function of the kidneys, causes itching, which can lead to scratching that
results in a break in the skin.
44. Answer: B
Rationale: This client’s dialysis access is compromised and should be
assessed first.
45. Answer: C
Rationale: Carbohydrates are increased to provide for the client’s caloric intake
and protein is restricted to minimize protein breakdown and to prevent
accumulation of toxic end products.
46. Answer: A
Rationale: Preventing and treating shock with blood and fluid replacement will
prevent acute renal failure from hypoperfusion of the kidneys.
Significant blood loss would be expected in the client with a gunshot
wound.
47. Answer: D
Rationale: Because the client is in ESRD, fluid must be removed from the body so
the output should be more than the amount instilled. These assessment data
require intervention by the nurse.
48. Answer: A
Rationale: Carrying heavy objects in the left arm could cause the fistula to clot
by putting undue stress on the site, so the client should carry objects in the
right arm.
49. Answer: C
Rationale: After the initial administration of erythropoietin, a client’s
antihypertensive medications may need to be adjusted. Therefore, this
complaint requires notification of the HCP. Erythropoietin therapy is
contraindicated in clients with hypertension that cannot be controlled.
50. Answer: D
Rationale: Normal potassium level is 3.5–5.5 mEq/L.
A level of a 6.8 mEq/L is life threatening and could lead to cardiac
dysrhythmias. Therefore, the client may be dialyzed to decrease the
potassium level quickly. This would be done with an order from a
healthcare provider, so it is a collaborative intervention.
51. Answer: B
Exam Code HAAD6
Rationale: Reflecting the client’s feelings and restating them are therapeutic
responses that the nurse should use when addressing the client’s issues.
52. Answer: C
Rationale: Regular insulin, along with glucose, will drive potassium into the
cells, thereby lowering serum potassium levels temporarily.
53. Answer: B
Rationale: Bed rest reduces exertion and the metabolic rate, thereby reducing
catabolism and subsequent release of potassium and accumulation of endogenous
waste products (urea and creatinine).
54. Answer: B
Rationale: The African American culture believes that the body must be kept
intact after death, and organ donation is rare among African Americans. This is
also why a client of African American descent will be on a transplant waiting
list longer than people of other races. This is because of tissuetyping
compatibility.
55. Answer: D
Rationale: Noncompliance is a choice the client has a right to make, but the
nurse should determine the reason for the noncompliance and then take
appropriate actions based on the client’s rationale. For example, if the client has
financial difficulties, the nurse may suggest how the client can afford the proper
foods along with medications, or the nurse may be able to refer the client to a
social worker.
56. Answer: B
Rationale: Hypotension, which causes a decreased blood supply to the kidney, is one
of the most common causes of pre-renal failure (before the kidney).
57. Answer: B
Rationale: These are signs and symptoms of hypocalcemia, and the nurse can
confirm this by tapping the cheek to elicit the Chvostek’s sign. If the muscles of
the cheek begin to twitch, then the HCP should be notified immediately because
hypocalcemia is a medical emergency.
58. Answer: B
Rationale: The client has signs of phlebitis and the IV must be removed to
prevent further complications.
59. Answer: C
Rationale: Dehydration results in concentrated serum that causes lab values
to increase because the blood has normal constituents but not enough
volume to dilute the values to within normal range or possibly lower.
60. Answer: C
Rationale: The lungs attempt to increase the blood pH level by blowing off the
carbon dioxide (carbonic acid).
61. Answer: D
Exam Code HAAD6

Rationale: Clients with sodium levels less than 120 mEq/L are at risk for seizures
as a complication. The lower the sodium level, the greater the risk of a seizure.
62. Answer: D
Rationale: Unless the nurse can determine that the catheter has been inserted
within a few days, the nurse should replace the catheter and then get a
specimen. This will provide the most accurate specimen for analysis.
63. Answer: C
Rationale: A long-term complication of glomerulonephritis is that it can
become chronic if unresponsive to treatment and this can lead to end- stage
renal disease. Maintaining renal function would be an appropriate long-term
goal.
64. Answer: C
Rationale: These are symptoms of cystitis, a bladder infection that may be
caused by sexual intercourse resulting from the introduction of bacteria into the
urethra during the physical act. A teenager may not want to divulge this
information in front of the parent.
65. Answer: A
Rationale: A pregnant client diagnosed with a UTI will be admitted for aggressive
IV antibiotic therapy. After symptoms subside the client will be sent home to
complete the course of treatment with oral medications. The mother and child
need aggressive treatment to prevent systemic bacteremia.
66. Answer: C
Rationale: Clients lose potassium from the GI tract or through the use of diuretic
medications.
Potassium imbalances can lead to cardiac arrhythmias.
67. Answer: B
Rationale: Fluid volume excess refers to an isotonic expansion of the
extracellular fluid by an abnormal expansion of water and sodium.
Therefore sodium is restricted to allow the body to excrete the extra
volume.
68. Answer: C
Rationale: Crackles and rales in all lung fields indicate that the body is not able
to process the amounts of fluids being infused. This should be brought to the
HCP’s attention.
69. Answer: A
Rationale: A client with a peaked wave could be experiencing
hyperkalemia. Changes in potassium levels can initiate cardiac
dysrhythmias and instability.
70. Answer: A
Rationale: Blood urea nitrogen (BUN) levels reflect the balance between the
production and excretion of urea from the kidneys. Creatinine is a byproduct of
the metabolism of the muscles and is excreted by the kidneys. Creatinine is the
ideal substance for determining renal clearance
Exam Code HAAD6

because it is relatively constant in the body and is the laboratory value most
significant in diagnosing renal failure.
71. Answer: C
Rationale: The client should be taught to take all the prescribed
medication any time a prescription is written for antibiotics.
72. Answer: A
Rationale: Fever, chills, and costovertebral pain are symptoms of a urinary
tract infection (acute pyelonephritis), which requires a urine culture first to
confirm the diagnosis.
73. Answer: D
Rationale: Coffee, tea, cola, and alcoholic beverages are urinary tract irritants.
74. Answer: B
Rationale: Some clients develop a chronic infection and must receive antibiotic
therapy as a routine daily medication to suppress the bacterial growth. The
prescription will be refilled after the 90 days and continued.
75. Answer: C
Rationale: The nurse cannot delegate teaching.
76. Answer: C
Rationale: This is usually the length of time clients need to wait prior to having
sexual intercourse; this is the information that the client wants to know.
77. Answer: C
Rationale: Glomerular filtration rate (GFR) is approximately 120 mL per minute.
If the GFR is decreased to 40 mL per minute, the kidneys are functioning at
about one-third filtration capacity.
78. Answer: B
Rationale: Increasing the irrigation fluid will flush out the clots and blood.
79. Answer: B
Rationale: Fatigue, headache, and polyuria as well as loss of weight,
anorexia, and excessive thirst are symptoms of chronic pyelonephritis.
80. Answer: C
Rationale: This is the correct scientific rationale for metabolic acidosis
occurring in the client with ESRD.
81. Answer: D
Rationale: Clients with acute bacterial prostatitis will frequently
experience a sudden onset of fever and chills. Clients with chronic
prostatitis have milder symptoms.
82. Answer: A
Rationale: The client should sit in a warm sitz bath for 10–20 minutes several
times each day to provide comfort and assist with healing.
83. Answer: D
Rationale: This is a potential life-threatening problem.
Exam Code HAAD6

84. Answer: A
Rationale: Clients who have urinary incontinence are hesitant to discuss this
problem because they may be embarrassed. Many clients will try to hide this
condition from others, so it is the responsibility of the nurse to approach this
subject with respect and consideration.
85. Answer: B
Rationale: Elevating the scrotum on a towel for support is an intervention that
can be delegated to the UAP.
86. Answer: D
Rationale: The nurse should always assess any complaint before dismissing it as a
commonly occurring problem.
87. Answer: A
Rationale: An elevated PSA can be from urinary retention, BPH, prostate cancer,
or prostate infarct.
88. Answer: B
Rationale: Bladder spasms are common, but being relieved with medication
indicates the condition is improving.
89. Answer: C
Rationale: Dietary changes for preventing renal stones include reducing the
intake of the primary substance forming the calculi. In this case, limiting
vitamin D will inhibit the absorption of calcium from the gastrointestinal tract.
90. Answer: B
Rationale: Assessment is the first part of the nursing process and is always
priority. The intensity of the renal colic pain can be so intense it can cause a
vasovagal response, with resulting hypotension and syncope.
91. Answer: D
Rationale: No special preparation is needed for this noninvasive, nonpainful test. A
conductive gel is applied to the back or flank and then a transducer is applied
that produces sound waves that produce a picture.
92. Answer: B
Rationale: The severe flank pain associated with a stone in the ureter often
causes a sympathetic response with associated nausea; vomiting; pallor; and
cool, clammy skin.
93. Answer: D
Rationale: Pain is priority. The pain can be so severe that a sympathetic
response may occur, causing nausea; vomiting; pallor; and cool, clammy skin.
94. Answer: C
Rationale: The NA could assist the client to the car once the discharge has
been completed.
95. Answer: A
Exam Code HAAD6

Rationale: An increased fluid intake that ensures 2–3 L of urine a day prevents
the stone-forming salts from becoming concentrated enough to precipitate.
96. Answer: B
Rationale: Passing a renal stone may negate the need for the client to have
lithotripsy or a surgical procedure. Therefore, all urine must be strained, and
a stone, if found, should be sent to the laboratory to determine what caused
the stone.
97. Answer: C
Rationale: A urinalysis can assess for hematuria (red blood cells in the urine),
the presence of white blood cells, crystal fragments, or all three, which can
determine if the client has a urinary tract infection or possibly a renal stone,
with accompanying signs/symptoms of UTI.
98. Answer: D
Rationale: This white blood cell count is elevated; normal is 5,000–10,000 mm.
99. Answer: C
Rationale: Venison, sardines, goose, organ meats, and herrings are high purine
foods, which should be eliminated from the diet to help prevent uric acid
stones.
100. Answer: B
Rationale: The client or family needs to contact the surgeon if the client
develops chills, flank pain, decreased urinary output, or fever.
Exam Code HAAD6

CODE HAAD7
1. Answer: A
Rationale: Exercising the triceps, finger flexors, and elbow extensors. These sets of
muscles are used when walking with crutches and therefore need strengthening
prior to ambulation.
2. Answer: D
Rationale: Coordinate her meal schedule with the peak effect of her medication,
Mestinon. Dysphagia should be minimized during peak effect of Mestinon, thereby
decreasing the probability of aspiration. Mestinon can increase her muscle
strength including her ability to swallow.
3. Answer: A
Rationale: Scleroderma occurs initially in the skin but also occurs in blood
vessels, major organs, and body systems, potentially resulting in death.
4. Answer: D
Rationale: The goals of all HIV-related conditions include improvement of CD4
count and lowering of viral load. Initiation of HAART (highly active antiretroviral
therapy) will help improve most skin conditions related to HIV disease.
Symptomatic relief will be required until the skin condition improves.
5. Answer: C
Rationale: Risk factors for pressure ulcers include: immobility, absence of
sensation, decreased LOC, poor nutrition and hydration, skin moisture,
incontinence, increased age, decreased immune response. This client has the
greatest number of risk factors.
6. Answer: A
Rationale: Cover the wound with sterile, moist saline dressing Dehiscence is the
partial or complete separation of the surgical wound
edges. When this occurs, the client is placed in low Fowler’s position and
instructed to lie quietly. The wound should be covered to protect it from
exposure and the dressing must be sterile to protect it from infection and moist
to prevent the dressing from sticking to the wound which can disturb the healing
process.
7. Answer: A
Rationale: The graft covers the nerve endings, which reduces pain and
provides framework for granulation
8. Answer: B
Rationale: Meat provides proteins and the fruit proteins vitamin C that both
promote wound healing.
9. Answer: B
Rationale: A stage II pressure ulcer appears as a break in the skin through the
epidermis or dermis; an abrasion, blister, or shallow crater may be present. A
stage I ulcer appears as an area of nonblanchable erythema, tissue edema, and
congestion; the client typically complains of pain in the area. A stage III ulcer
extends into the subcutaneous tissue,
EXAM CODE HAAD7

usually with a deep crater. A stage IV ulcer extends into the underlying
structures, including the muscle and, possibly, the bone.
10. Answer: A
Rationale: Clients with pruritus need moisture in the environment to reduce drying
effects such as itching; therefore, keeping rooms humidified helps to reduce the
itch. Excess bedding and clothing add heat to the area, which increases pruritus;
the client should remove heavy bedding and wear lightweight cotton clothing to
allow moisture and heat to evaporate
11. Answer: D
Rationale: Turning the client frequently, such as every 2 hours, is one of the
single most important interventions in preventing pressure ulcers because it helps
to minimize the effects of pressure on the skin, allowing pressure to be
redistributed with each turn.
12. Answer: D
Rationale: Daily bathing with bactericidal soap will help to decrease the amount
of bacteria on the skin, thereby helping to prevent bacterial infections. A
topical antibiotic ointment may be used, but an antifungal agent would be used
to treat a fungal infection of the skin. A boil or pimple should not be squeezed
because this action increases the risk of spreading the infection. Using a
sunblock with an SPF of at least 30 would help prevent skin cancer, not
bacterial skin infections.
13. Answer: D
Rationale: The exact cause of acne is not known, but evidence has shown that
acne involves multiple factors, such as genetics, hormonal factors, and bacterial
infections. Excess production of sebum results in seborrhea.
14. Answer: B
Rationale: Herpes zoster is an infection caused by the varicella-zoster virus. It
is manifested by painful vesicular eruptions along the route of inflamed
nerves. Usually unilateral, the inflammation appears as a band typically
involving the thoracic, cervical, or cranial nerves. Itching may precede or
accompany the eruption.
15. Answer: B
Rationale: The client should wash his hands before and after application of any
topical medication. Because systemic absorption of topical steroid ointment is
extremely small, there is no need to gradually decrease the amount (dosage)
when discontinuing the medication; gradual dosage decrease is appropriate for
oral steroid medication therapy. Any topical ointment should be applied in a
thin layer with the understanding that more is not better; using a thick layer of
ointment increases the risk of possible systemic absorption.
16. Answer: D
Rationale: The client needs instructions about rinsing the mouth with water prior
to taking the medication; typically, the medication is prescribed as "swish and
swallow" to coat the oral mucosa. Serum peak and trough levels are usually
obtained for clients receiving aminoglycoside antibiotics
17. Answer: D
EXAM CODE HAAD7

Rationale: A full-thickness burn involves destruction of the entire epidermis and
dermis. The area appears dry and leathery, and ranges in color from white to
cherry red to black. Pain is absent because all superficial nerve endings have
been destroyed
18. Answer: B
Rationale: Treatment for psoriasis may include coal tar therapy,
photochemotherapy, and cytotoxic therapy. Antibiotics and silver nitrate
compresses are used to treat toxic epidermal neurolysis; steroids also may be
used. Immunosuppressive agents and plasmapheresis are used to treat pemphigus
vulgaris. Systemic steroids and antibiotics are used to treat exfoliative dermatitis.
19. Answer: B
Rationale: Lindane (Kwell) shampoo is the treatment of choice for pediculosis capitis
(head lice); a single application is usually sufficient. Head lice are highly
contagious; for the child with head lice, all bedding and clothing should be
washed in hot water and dried using the hot cycle of a clothes dryer to destroy
the parasite.
20. Answer: A
Rationale: Shearing force occurs when 2 surfaces move against each other;
when the bed is at an angle greater than 30 degrees, the torso tends to slide
and causes this phenomenon. Shearing forces are good contributory factors of
pressure sores.
21. Answer: D
Rationale: Coronary artery aneurysms Kawasaki Disease involves all the small
and medium-sized blood vessels. There is progressive inflammation of the small
vessels which progresses to the medium-sized muscular arteries, potentially
damaging the walls and leading to coronary artery aneurysms.
22. Answer: D
Rationale: Discontinue a new food that was added to the infant''s diet just
prior to the rash
The addition of new foods to the infant''s diet may be a cause of diaper
dermatitis.
23. Answer: C
Rationale: Using the Rule of Nine in the estimation of total body surface burned,
we allot the following: 9% – head; 9% – each upper extremity; 18%- front
chest and abdomen; 18% – entire back; 18% – each lower extremity and 1% –
perineum.
24. Answer: C
Rationale: Burns located in the upper torso, especially resulting from thermal
injury related to fires can lead to inhalation burns. This causes swelling of the
respiratory mucosa and blistering which can lead to airway obstruction
manifested by hoarseness, noisy and difficult breathing. Maintaining a patent
airway is a primary concern.
25. Answer: B
Rationale: A person grieves to a loss of a significant object. The initial stage in
the grieving process is denial, then anger, followed by
EXAM CODE HAAD7

bargaining, depression and last acceptance. The nurse should show
acceptance of the patient’s feelings and encourage verbalization.
26. Answer: A
Rationale: Sulfamylon is effective against a wide variety of gram positive and
gram negative organisms including anaerobes
27. Answer: C
Rationale: Relieve pain and promote rapid epithelialization. The graft covers
nerve endings, which reduces pain and provides a framework for granulation
that promotes effective healing.
28. Answer: B
Rationale: 28 gtt/min. This is the correct flow rate; multiply the amount to be
infused (2000 ml) by the drop factor (10) and divide the result by the amount
of time in minutes (12 hours x 60 minutes)
29. Answer: D
Rationale: When wounds dehisce, they will be allowed to heal by secondary
intention. Primary or first intention healing is the method of healing in which
wound edges are surgically approximated and integumentary continuity is
restored without granulating. Third intention healing is a method of healing in
which surgical approximation of wound edges is delayed and integumentary
continuity is restored by bringing apposing granulations together.
30. Answer: B
Rationale: The use of fragrant soap is very drying to skin hence causing the
pruritu
31. Answer: C
Rationale: Clients should be turned at least every 1 to 2 hours to prevent pressure
areas on the skin.
32. Answer: C
Rationale: Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce
renal buffering and can cause metabolic acidosis. These ABGs indicate metabolic
acidosis and therefore require immediate intervention.
33. Answer: D
Rationale: Fluid and electrolyte balance is the priority for a client with a severe burn.
Fluid resuscitation must be maintained to keep a urine output of 30 mL/hour.
Therefore a 25 mL/ hour output would warrant immediate intervention.
34. Answer: C
Rationale: The client has a fever indicating an infection. Clients with pressure
ulcers frequently develop infections in the wounds, which can lead to further
complications.
35. Answer: D
Rationale: This is a stage III ulcer and is a worsening of the client’s
condition.
36. Answer: B
EXAM CODE HAAD7

Rationale: Altered nutrition is a collaborative problem involving the nurse,
dietitian, and HCP. The client will need a diet high in protein and vitamins if
there is a chance for the client to heal.
37. Answer: B
Rationale: Cool water gives immediate and striking relief from pain and limits
local tissue edema and damage.
38. Answer: B
Rationale: Deep partial-thickness burns are scalds and flash burns that injure
the epidermis, upper dermis, and portions of the deeper dermis. This causes
pain, blistered and mottled red skin, and edema.
39. Answer: A
Rationale: The client needs sufficient nutrients for wound healing and increased
metabolic requirements, and homemade nutritious foods are usually better than
hospital food. This also allows the family to feel part of the client’s recovery.
40. Answer: B
Rationale: This is restating and clarifying, both therapeutic responses.
41. Answer: D
Rationale: A fecal diversion is changing the normal exit of the stool from the
body. A colostomy is created to keep stool from contaminating the wounds and
causing infection.
42. Answer: D
Rationale: Lifting the client with a “lift” pad rather than pulling the client
against the sheets helps to prevent skin damage from friction shearing.
43. Answer: A
Rationale: Using a pillow to suspend the heels of the bed when a client is
supine prevents the development of pressure ulcers on the heels.
44. Answer: A
Rationale: The Braden and Norton scales are tools that identify clients at risk for
skin problems. This client should be ranked on this scale, and appropriate
measures should be initiated for controlling further damage to the skin.
45. Answer: C
Rationale: The client needs to know that it will take time to adjust to life after
burns and that returning to work, family role, sexual intimacy, and body image
will take time.
46. Answer: A
Rationale: All the skin should be kept free of moisture. This is within the realm of
nursing to provide this service. Clients with constant moisture on the skin are at
high risk for impaired skin integrity.
47. Answer: C
Rationale: A xenograft or heterograft consists of skin taken from animals, usually
porcine.
EXAM CODE HAAD7

48. Answer: B
Rationale: It is important to turn bedfast clients every 1 to 2 hours and to
encourage them, if they are able, to make minor readjustments to their position
at least every 15 minutes. Allowing the client to lie in the same position for at
least another 30 minutes before being turned should not be allowed.
49. Answer: A
Rationale: Cellulitis is a bacterial infection of the subcutaneous tissue usually
associated with a break in the skin, and the nurse would suspect this with
these signs/symptoms.
50. Answer: B
Rationale: Warm, moist compresses increase vascularization and hastens the
resolution of the furuncle.
51. Answer: B
Rationale: This action could result in the client developing a skin infection and
should be stopped immediately; therefore, stopping the behavior is the first
intervention.
52. Answer: A
Rationale: Although this is a potential problem, it is priority because the body’s
protective barrier, the skin, has been compromised and there is an impaired
immune response.
53. Answer: A
Rationale: People with dark skin suffer the same skin conditions as people with light
skin. This is the correct information.
54. Answer: A
Rationale: After airway, the most urgent need is preventing irreversible shock
by replacing fluids and electrolytes.
55. Answer: A
Rationale: This disease is a bacterial inflammatory reaction that occurs
predominantly on the faces and necks of curly-haired men as a result of
shaving. African American menwho are in the military are allowed not to shave
if this occurs. The sharp ingrowing hairs have a curved root that grows at a
more acute angle and pierces the skin. The only treatment is to not shave.
56. Answer: B
Rationale: Daily cleaning reduces bacterial colonization.
57. Answer: B
Rationale: Lesions are extremely contagious and should not be touched, except
when wearing gloves.
58. Answer: D
Rationale: A carbuncle is an abscess of the skin and subcutaneous tissue and is an
extension of a furuncle. These are more likely to occur in clients with underlying
systemic diseases such as diabetes and hematologic malignances and in clients
who are immunosuppressed.
59. Answer: D
EXAM CODE HAAD7

Rationale: A major complication of pruritus (itching) is the development of a
bacterial skin infection, which is secondary to the client scratching and allowing
bacteria from the dirty hands or nails to enter compromised tissue.
60. Answer: C
Rationale: The nurse can delegate the setup of equipment to the
assistant.
61. Answer: D
Rationale: Sharing brushes is one of the main ways that lice are spread.
Therefore this indicates the teacher did not comply with the instructions.
62. Answer: A
Rationale: Diversionary techniques, including music and television, are often
used in conjunction with medication to manage pain. Shutting the blinds will
help provide a calm, quiet atmosphere
63. Answer: B
Rationale: Because of the close living quarters, clients in long-term care facilities
are at a high risk for developing scabies. Clients may have poor hygiene as a
result of limited physical ability and the nursing staff may transmit the parasite.
Therefore, the nursing staff should wear gloves to provide a barrier to the
mites.
64. Answer: C
Rationale: Valtrex is an antiviral medication that suppresses the virus replication,
but herpes is a retrovirus, which means it never dies as long as the host body
is alive.
65. Answer: C
Rationale: Deer ticks (Ixodes dammini) are responsible for the spread of Lyme
disease, which is what this client is experiencing based on the signs/symptoms.
66. Answer: D
Rationale: The client being unable to remove the wedding ring indicates that
the arm is edematous and the ring must be removed immediately or it may
cause impaired circulation to the left ring finger. This is a dangerous situation.
67. Answer: B
Rationale: Herpes varicella is the causative agent for chickenpox, and
pneumonia is a potential complication in adults.
68. Answer: D
Rationale: Tinea cruris (jock itch) results from a fungal infection in warm,
moist areas of the body. When such an infection occurs in the groin area, it
is called tinea cruris.
69. Answer: D
Rationale: The client’s description of the pain suggests shingles. Shingles is
caused by herpes zoster, which is the same virus as herpes varicella, which
causes chickenpox. This virus is a retrovirus that never dies; it becomes
dormant and lives in the body along nerve pathways. During times of stress, it
can erupt as herpes zoster, or shingles. The pain usually occurs prior to the
eruption of the vesicles.
EXAM CODE HAAD7

70. Answer: B
Rationale: The lesions are very irritating and the client will want to scratch them.
Clients with chickenpox should use calamine lotion, soak in oatmeal baths, and
apply Benadryl topical cream or take oral Benadryl.
71. Answer: C
Rationale: Acne occurs on the face and neck. This is the first impression that
people get when looking at the client; therefore body-image disturbance is the
priority.
72. Answer: C
Rationale: Staying on paths and avoiding dense undergrowth will help the person
keep away from tick-invested areas where the person is more likely to be bitten
by a tick and perhaps subsequently develop Lyme disease.
73. Answer: C
Rationale: Periorbital lesions may extend into the client’s eyes, which is an
ophthalmic emergency, especially if it is herpes zoster
74. Answer: B
Rationale: Herpes simplex 1 and 2 are caused by the same virus. Herpes simplex
1 refers to orolabial lesions and herpes simplex 2 refers to genital lesions, which
can be transferred from one area to the other.
75. Answer: A
Rationale: Soaking the feet will help remove the crust, scales, and debris to
reduce the inflammation in a client diagnosed with athlete’s foot.
Vinegar is mildly acidic, which helps remove crusts.
76. Answer: C
Rationale: A magnifying glass and a penlight are held at an oblique angle to the
skin while a search is made for small raised burrows, which indicate scabies.
77. Answer: B
Rationale: The application of Kwell lotion on wet skin can lead to increased
absorption of the lotion, which increases the possibility of central nervous
system abnormalities, including seizures.
78. Answer: D
Rationale: Scabies occurs around the waist, around the wrist, between the fingers,
and in the axilla area.
79. Answer: C
Rationale: Scabies is an infestation of the skin by the itch mite (Sarcoptes
scabiei). The female burrows into the superficial layer of skin, and burrows are
found between the fingers and on the wrist.
80. Answer: A
Rationale: Most clients with psoriasis have red raised plaques with silvery white
scales.
81. Answer: A
EXAM CODE HAAD7

Rationale: Chickenpox starts out with a macular rash. The lesions appear in crops
first on the trunk and scalp, and then lesions move to the extremities. Then, they
change to tear- drop vesicles with an erythematous base and become pustular.
Finally, they dry.
82. Answer: A
Rationale: The assistant could use a fine-toothed comb dipped in vinegar to
remove any nits in the hair of the client with lice.
83. Answer: A
Rationale: Systemic antibiotics are the treatment of choice for impetigo.
Therefore the teacher must go to the HCP to get the prescription today because
impetigo is highly contagious.
84. Answer: C
Rationale: This is a condition of ringworm of the toenail. The nurse must tell the
client that the toenail will fall off if the client does not take the medication
and it might it fall off anyway.
85. Answer: D
Rationale: The client’s legs should have pedal pulses and be warm to the touch,
and the client must be able to move the toes.
86. Answer: C
Rationale: IgE is a protein responsible for allergic reactions.
87. Answer: B
Rationale: Covering the affected area with an occlusive dressing enhances the
steroid’s effectiveness. This intervention should be limited to
12 hours to reduce systemic and local side effects.
88. Answer: A
Rationale: Skin care must be meticulous. Minimal soap and tepid water should
be used when showering or bathing. Lotions that do not irritate should be used
to keep the skin hydrated.
89. Answer: B
Rationale: To control the disorder by following the medical protocols would
be realistic and appropriate.
90. Answer: C
Rationale: Many people dispose of the poison oak plant in ways that spread
the sap. Burning or pulling the plant without gloves can cause another
allergic reaction. Pets can spread the allergen on fur. Tools should be
cleaned prior to touching the skin.
91. Answer: B
Rationale: The nurse allows the client to express fears and concerns to assist the
client to have a positive self-image.
92. Answer: C
Rationale: The decrease in sensation of the lesions is the result of peripheral nerve
damage. Leprosy is a peripheral nervous system disease.
93. Answer: C
EXAM CODE HAAD7
Rationale: The client should discuss any suspicious area with the health- care
provider. This is not an emergency, but it should be assessed.
94. Answer: D
Rationale: Coal tar comes in lotions, ointments,v shampoos, and gels. They are
used more in the hospital setting than in home settings because of the staining
and mess associated with their use.
95. Answer: A
Rationale: Contact dermatitis presents with erythema and small oozing
vesicles.
96. Answer: A
Rationale: After the first six (6) to eight (8) hours, the client will have extreme
edema that can cause the eyes to swell. This is expected.
97. Answer: D
Rationale: It is important to assess the rash as it appeared. If the client treated
the rash with an ointment or cream, its appearance may have changed. Many
times the appearance has changed from first onset and from the treatment.
98. Answer: D
Rationale: Soothing baths, such as colloidal baths or emollient baths, are helpful
in treating pruritus. Balneotherapy is a term used to refer to therapeutic baths.
99. Answer: A
Rationale: A loss of self-esteem can occur after a\ change in facial appearance
through injury or disease. Age-related changes also cause a loss in self-esteem.
This would be a nursing diagnosis that applies to the preoperative client.
100. Answer: B
Rationale: The client should take the medication exactly as instructed. The
number of pills should be taken in a descending (tapering) manner.
EXAM CODE HAAD7

CODE HAAD8
1. Answer: C
Rationale: The availability and efficiency of the sterilizing agent are the most
important criteria in selecting chemical agents for disinfection/sterilization. The
other criteria are: compatibility, physical properties of the item, hazard of toxic
residue, infection control, manufacturer
2. Answer: D
Rationale: In a vasoocclusive crisis tissue perfusion to the vital organs is
threatened. Vital organs require perfusion of blood and oxygen in order to
perform their functions and maintain homeostasis. All the other options are
important concerns when planning care for an adolescent with Sickle Cell
Disease, but are not life threatening.
3. Answer: C
Rationale: The main general objectives in the treatment of a sickle cell crisis is
bed rest, hydration, electrolyte replacement, analgesics for pain, blood
replacement and antibiotics to treat any existing infection.
4. Answer: A
Rationale: Normal hemoglobin for males is 13.0 - 18 g/100 ml. Normal
hemotocrit for males is 42 - 52%. These values are below normal and indicate
mild anemia. The first thing the nurse should do is ask the client if he''s noticed
any bleeding or change in stools that could indicate bleeding from the GI tract.
5. Answer: A
Rationale: "Nursing will help contract the uterus and reduce your risk of
bleeding." Stimulation of the breast during nursing releases oxytocin, which
contracts the uterus. This contraction is especially important following
hemorrhage.
6. Answer: B
Rationale: Heparin is an anticoagulant. It prevents the conversion of
prothrombin to thrombin. It does not dissolve a clot.
7. Answer: C
Rationale: Instruct the client about the need for bed rest. In a client with
thrombophlebitis, bedrest will prevent the dislodgment of the clot in the
extremity which can lead to pulmonary embolism.
8. Answer: B
Rationale: The marks made by the radiation oncologist guide the technician in
configuring the external beam to irradiate the area in question without causing
damage to other tissues. These marks must remain in place and should not be
washed off. Ointments, which are petroleum-based, could cause a radiation
burn to the area. The client should be encouraged to use a hat or scarf when
in the sun to prevent damage to the scalp skin and at night to prevent loss of
body heat through the scalp; hats and scarves also help to foster a positive
body image
EXAM CODE HAAD8

9. Answer: D
Rationale: Hemolytic jaundice results because, although the liver is functioning
normally, it cannot excrete the bilirubin as quickly as it is formed.
10. Answer: D
Rationale: “Does it help you to joke about your illness?” This non- judgmentally
on the part of the nurse points out the client’s behavior.
11. Answer: C
Rationale: Pernicious anemia is caused by the inability to absorb vitamin B12 in
the stomach due to a lack of intrinsic factor in the gastric juices. In the
Schilling test, radioactive vitamin B12 is administered and its absorption and
excretion can be ascertained through the urine.
12. Answer: D
Rationale: Performing active-assistive leg exercises. Inactivity causes venous stasis,
hypercoagulability, and external pressure against the veins, all of which lead to
thrombus formation. Early ambulation or exercise of the lower extremities
reduces the occurrence of this phenomenon
13. Answer: C
Rationale: IM injections once a month will maintain control. Deep IM injections
bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the
transport carrier component of gastric juices. A monthly dose is usually sufficient
since it is stored in active body tissues such as the liver, kidney, heart, muscles,
blood and bone marrow
14. Answer: D
Rationale: Since the intrinsic factor does not return to gastric secretions even
with therapy, B12 injections will be required for the remainder of the client’s
life.
15. Answer: D
Rationale: First convert milligrams to micrograms and then use ratio and
proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X=
200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.
16. Answer: B
Rationale: Immunodeficiency is an absent or depressed immune response that
increases susceptibility to infection. So it is the nurse’s primary responsibility
to protect the patient from infection.
17. Answer: C
Rationale: Children who have a depressed immune system related to HIV or
chemotherapy should not be given routine immunizations.
18. Answer: A
Rationale: In hypovolemia, one of the compenasatory mechanisms is activation of
the sympathetic nervous system that increases the RR & PR and helps restore the
BP to maintain tissue perfusion but not cause a hypertension. The SNS
stimulation constricts renal arterioles that increases release of aldosterone,
decreases glomerular filtration and increases sodium & water reabsorption that
leads to oliguria.
EXAM CODE HAAD8
19. Answer: A
Rationale: Polycythemia vera or primary polycythemia is a profilerative disorder in
which the myeloid stem cells seem to have escaped normal control mechanism.
The bone marrow is hypercellular and the erythrocyte, leukocyte and platelet
counts in the peripheral blood are elavated.
Hyperviscosity of the blood occurrs with polycythemia vera and this may lead to
thromboembolism. Thromboembolism may result to complications like CVA and
pulmonary embolism.
20. Answer: D
Rationale: Anemia is a hematologic condition characterized by reduced RBC and
hemoglobin level, the substance in the blood that carries oxygen with reduced
hemoglobin, less oxygen is delivered to tissues.
21. Answer: A
Rationale: The nurse, veurse who is taking care of a client placed on neutropenic
precautions should perform thorough hand hygiene before entering patient’s room
each and everytime. Fresh fruits, vegetables, fresh plants and flowers should be
removed from the client’s room to prevent infection. If the client needs to go
out of the room, it is advised that a mask should be worn at all times to
protect the client.
22. Answer: C
Rationale: A hemolytic transfusion reaction This results from a recipient’s
antibodies that are incompatible with transfused RBC’s; also called type II
hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary
plugging that can damage renal function, thus the flank pain and hematuria and
the other manifestations.
23. Answer: C
Rationale: Aplastic anemia decreases the bone marrow production of RBC’s, white
blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
24. Answer: A
Rationale: The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of
age. It is uncommon after 15 years of age
25. Answer: B
Rationale: Dye is injected between the toes of both feet and then scans are
performed in a few hours, at 24 hours, and then possibly once a day for several
days.
26. Answer: D
Rationale: A biopsy is the removal of cells from a mass and examination of the
tissue under a microscope to determine if the cells are cancerous. Reed-Sternberg
cells are diagnostic for Hodgkin’s disease. If these cells are not found in the
biopsy, the HCP can rebiopsy to make sure the specimen provided the needed
sample or, depending on involvement of the tissue, diagnose a non- Hodgkin’s
lymphoma.
27. Answer: A
Rationale: Clients in late stages of Hodgkin’s disease experience drenching
diaphoresis, especially at night; fever without chills; and unintentional weight
loss. Early-stage disease is indicated by a painless enlargement of a lymph node
on one side of the neck (cervical area). Pruritus is also a common symptom.
EXAM CODE HAAD8

28. Answer: C
Rationale: Clients who have received a transplant must take immunosuppressive
medications to prevent rejection of the organ. This immunosuppression blocks
the immune system from protecting the body against cancers and other
diseases. There is a high incidence of lymphoma among transplant recipients.
29. Answer: A
Rationale: Up to 90% of clients respond well to standard treatment with
chemotherapy and radiation therapy, and those that relapse usually respond to a
change of chemotherapy medications. Survival depends on the individual client
and the stage of disease at diagnosis.
30. Answer: D
Rationale: Collaborative interventions involve other departments of the health-
care facility. A chaplain is a referral that can be made, and the two disciplines
should work together to provide the needed interventions.
31. Answer: D
Rationale: Cancers of all types are definitively diagnosed through biopsy
procedures. The pathologist must identify Reed-Sternberg cells for a diagnosis of
Hodgkin’s disease.
32. Answer: D
Rationale: This client is receiving blood. The nurse with experience on a
medical-surgical floor should be able to administer blood and blood products.
33. Answer: B
Rationale: The client should be taught to practice birth control during
treatment and for at least 2 years after treatment has ceased. The therapies
used to treat the cancer can cause cancer. Antineoplastic medications are
carcinogenic, and radiation therapy has proved to be a precursor to leukemia.
A developing fetus would be subjected to the internal conditions of the
mother.
34. Answer: C
Rationale: Stage I lymphoma presents with no symptoms; for this reason, clients
are usually not diagnosed until the later stages of lymphoma.
35. Answer: A
Rationale: After the first 15 minutes during which the client tolerates the blood
transfusion, it is appropriate to ask the unlicensed nursing assistant to take the
vital signs as long as the assistant has been given specific parameters for the
vital signs. Any vital sign outside the normal parameters must have an
intervention by the nurse.
36. Answer: A
Rationale: The five (5)-year mark is a time for celebration for clients diagnosed
with cancer, but the therapies can cause secondary malignancies and there may
be a genetic predisposition for the client to develop cancer. The client should
continue to be tested regularly.
37. Answer: B
EXAM CODE HAAD8

Rationale: Fresh fruits and flowers may carry bacteria or insects on the skin of
the fruit or dirt on the flowers and leaves, so they are restricted around clients
with low white blood cell counts.
38. Answer: A
Rationale: Fever and infection are hallmark symptoms of leukemia. They occur
because the bone marrow is unable to produce white blood cells of the number
and maturity needed to fight infection.
39. Answer: C
Rationale: Radiation therapy to the head and scalp area is the treatment of
choice for central nervous system involvement of any cancer.
Radiation therapy has longer-lasting side effects than chemotherapy. If the
radiation therapy destroys the hair follicle, the hair will not grow back.
40. Answer: D
Rationale: In this form of leukemia the cells seem to escape apoptosis
(programmed cell death), which results in many thousands of mature cells
clogging the body. Because the cells are mature, the client may be asymptomatic in
the early stages.
41. Answer: A
Rationale: A left shift indicates that immature white blood cells are being
produced and released into the circulating blood volume. This should be
investigated for the malignant process of leukemia.
42. Answer: C
Rationale: Epogen is a biologic response modifier that stimulates the bone
marrow to produce red blood cells. The bone marrow is the area of malignancy in
leukemia. Stimulating the bone marrow would be generally ineffective for the
desired results and would have the potential to stimulate malignant growth.
43. Answer: B
Rationale: The platelet count of 22 _ 103 indicates a platelet count of 22,000.
The definition of thrombocytopenia is a count less than 100,000. This client is at
risk for bleeding. Bleeding precautions include decreasing the risk by using soft-
bristle toothbrushes and electric razors and holding all venipuncture sites for a
minimum of 5 minutes.
44. Answer: B
Rationale: Serum albumin is a measure of the protein content in the blood
that is derived from
the foods eaten; albumin monitors nutritional status.
45. Answer: A
Rationale: The newly diagnosed client will need to be taught about the disease
and about treatment options. The registered nurse cannot delegate teaching to a
an LPN.
46. Answer: D
Rationale: Grieving is an independent problem and the nurse can assess and treat
this problem with or without collaboration.
EXAM CODE HAAD8

47. Answer: D
Rationale: Pain is expected, but it is a priority, and pain control
measures should be implemented.
48. Answer: A
Rationale: This is a major surgery but has a predictable course with no
complications identified in the stem, and a colostomy is expected with this type
of surgery. The graduate nurse could be assigned this client.
49. Answer: D
Rationale: DIC is a clinical syndrome that develops as a complication of a wide
variety of other disorders, with sepsis being the most common cause of DIC.
50. Answer: A
Rationale: The signs/symptoms of DIC result from clotting and bleeding, ranging
from oozing blood to bleeding from every body orifice and into the tissues.
51. Answer: B
Rationale: The fibrinogen level helps predict bleeding in DIC. As it
becomes lower, the risk of bleeding increases.
52. Answer: C
Rationale: Fresh frozen plasma and platelet concentrates are administered to
restore clotting factors and platelets.
53. Answer: D
Rationale: This is a true statement and explains exactly how someone gets
hemophilia A: the mother passes it to the son.
54. Answer: A
Rationale: Nosebleeds along with hemarthrosis, cutaneous hematoma
formation, bleeding gums, hematemesis, occult blood, and hematuria are all
signs/symptoms of hemophilia.
55. Answer: C
Rationale: von Willebrand’s disease is a type of hemophilia. The most common
hereditary bleeding disorder, it is caused by a deficiency in von Willebrand’s
(vW) factor and is often diagnosed after prolonged bleeding following surgery or
dental extraction.
56. Answer: B
Rationale: Hemarthrosis is bleeding into the joint. Applying ice to the area
can cause vasoconstriction, which can help decrease bleeding.
57. Answer: A
Rationale: ITP is due to bleeding from small vessels and mucous membranes.
Petechiae, tiny purple or red spots that appear on the skin as a result of
minute hemorrhages within the dermal or submucosal layers, and purpura,
hemorrhaging into the tissue beneath the skin and mucous membranes, are
the first signs of ITP.
58. Answer: C
EXAM CODE HAAD8

Rationale: A platelet count of less than 100,000 per milliliter of blood
indicates thrombocytopenia.
59. Answer: B
Rationale: The first action in a situation in which the nurse suspects the client
has a fluid volume loss is to replace the volume as quickly as possible.
60. Answer: C
Rationale: The client cannot donate blood for 6 months after a pregnancy
because of the nutritional demands on the mother.
61. Answer: A
Rationale: O (O negative) blood is considered the universal donor because it does
not contain the antigens A, B, or Rh. (AB_ is considered the universal recipient
because a person with this blood type has all the antigens on the blood).
62. Answer: D
Rationale: Epogen or Procrit are forms of erythropoietin, the substance in the
body that stimulates the bone marrow to produce red blood cells. A client may
be prescribed iron preparations to prevent depletion of iron stores and
erythropoietin to increase RBC production. A unit of blood can be withdrawn
once a week beginning at 6 weeks prior to surgery. No phlebotomy will be
done within 72 hours of surgery.
63. Answer: A
Rationale: A cell saver is a device to catch the blood lost during orthopedic
surgeries to reinfuse into the client, rather than giving the client donor blood
products. The cells are washed with saline and reinfused through a filter into the
client. The salvaged cells cannot be stored and must be used within 4 hours or
discarded because of bacterial growth.
64. Answer: B
Rationale: Blood is a medium for bacterial growth, and any bacteria contaminating
the unit will begin to grow if left outside of a controlled refrigerated temperature
for longer than four (4) hours, placing the client at risk for septicemia.
65. Answer: C
Rationale: The correct procedure for administering a unit of blood over eight (8)
hours is to have the unit split into halves. Each half unit is treated as a new
unit and checked accordingly. This slower administration allows the compromised
client, such as one with heart failure, to assimilate the extra fluid volume.
66. Answer: D
Rationale: The priority in this situation is to prevent a further reaction if possible.
Stopping the transfusion and changing the fluid out at the hub will prevent any
more of the transfusion from entering the client’s bloodstream.
67. Answer: D
Rationale: The unlicensed nursing assistant can assist a client to brush the teeth.
Instructions about using soft-bristle toothbrushes and the need
EXAM CODE HAAD8

to report to the nurse any pink or bleeding should be given prior to
delegating the procedure.
68. Answer: C
Rationale: This client has a potential for hemorrhage and is reporting blood
in the vomitus. This client should be assessed first.
69. Answer: A
Rationale: The rugae in the stomach produce intrinsic factor, which allows the
body to use vitamin B12 from the foods eaten. Gastric bypass surgery reduces
the amount of rugae drastically. Clients develop pernicious anemia (vitamin B12
deficiency). Other symptoms of anemia include dizziness and the tachycardia and
dyspnea listed in the stem.
70. Answer: D
Rationale: Menorrhagia is excessive blood loss during menses. If the blood loss is
severe, then the client will not have the blood’s oxygencarrying capacity needed
for daily activities.
The most frequent symptom and complication of anemia is fatigue. It frequently
has the greatest impact on the client’s ability to function and quality of life.
71. Answer: C
Rationale: The stool will be a dark green–black and can mask the
appearance of blood in the stool.
72. Answer: B
Rationale: The unlicensed nursing assistant can take the vital signs of a client
who is stable; this client received the blood the day before.
73. Answer: A
Rationale: Most clients diagnosed with folic acid anemia have developed the
anemia from chronic alcohol abuse. Alcohol consumption increases the use of
folates, and the alcoholic diet is usually deficient in folic acid. A referral to
Alcoholics Anonymous would be appropriate.
74. Answer: C
Rationale: Pancytopenia is a situation that develops in clients diagnosed with
aplastic anemia because the bone marrow is not able to produce cells of any
kind. The client has anemia, thrombocytopenia, and leukopenia.
This client could develop an infection or hemorrhage, go into congestive heart
failure, or have a number of other complications develop. This client needs
the most experienced nurse.
75. Answer: B
Rationale: The client is experiencing dyspnea on exertion, which is common for
clients with anemia. The client needs a wheelchair to limit the exertion.
76. Answer: B
Rationale: This is approximately two (2) hours after breakfast and is the correct
dosing time for iron to achieve the best effects. Iron preparations should be
administered one (1) hour before a meal or two (2) hours after a meal. Iron can
cause gastrointestinal upset, but if administered with a meal, absorption can be
diminished by as much as 50%.
EXAM CODE HAAD8

77. Answer: C
Rationale: The client should have a complete blood count
regularly to determine the status of the anemia.
78. Answer: A
Rationale: The client’s problem is activity intolerance, and pacing
activities directly affect the diagnosis.
79. Answer: D
Rationale: Sickle cell anemia is a disorder of the red blood cells characterized by
abnormally shaped red cells that sickle or clump together, leading to oxygen
deprivation and resulting in crisis and severe pain.
80. Answer: B
Rationale: This explains the etiology in terms that a layperson could
understand. When both parents are carriers of the disease, each pregnancy has
a 25% chance of producing a child who has sickle cell anemia.
81. Answer: B
Rationale: A pulse oximeter reading of less than 93% indicates hypoxia, which
warrants oxygen administration.
82. Answer: C
Rationale: Increased intravenous fluid reduces the viscosity of blood,
thereby preventing further sickling as a result of dehydration.
83. Answer: A
Rationale: To assess for cyanosis (blueness) in individuals with dark skin, the
oral mucosa and conjunctiva should be assessed because cyanosis cannot be
assessed in the lips or fingertips.
84. Answer: C
Rationale: High altitudes have decreased oxygen, which could lead to a sickle
cell crisis.
85. Answer: C
Rationale: This is a term that means painful and constant penile erection that
can occur in male clients with SCA during a sickle cell crisis.
86. Answer: B
Rationale: An individual with SCA has a reduction in splenic activity from infarcts
occurring during crises. This situation progresses to the spleen no longer being
able to function and this increases the client’s susceptibility to infection.
87. Answer: B
Rationale: The Foundation’s mission is to provide information about the
disease and about support groups in the area. This information helps
decrease the client’s and significant others’ feelings of frustration and
helplessness.
88. Answer: C
EXAM CODE HAAD8

Rationale: Vasoocclusive crisis, the most frequent crisis, is characterized by organ
infarction, which will result in bloody urine secondary to kidney infarction.
89. Answer: D
Rationale: The elevated temperature is the first sign of bacteremia. Bacteremia
leads to a sickle cell crisis. Therefore, the bacteria must be identified so the
appropriate antibiotics can be prescribed to treat the infection. Blood cultures
assist in determining the type and source of infection so that it can be treated
appropriately.
90. Answer: D
Rationale: At best only about 20%–35% of the medication is absorbed
through the gastrointestinal tract (GI) tract.
91. Answer: B
Rationale: All the lab values are within normal limits. The
nurse should continue to monitor the client.
92. Answer: A
Rationale: The pulse of 116 and BP of 88/62 in addition to the other
symptoms indicate the client is in shock. This is an emergency situation.
93. Answer: C
Rationale: General complications of severe anemia include heart failure,
paresthesias, and confusion. The heart tries to compensate for the lack of oxygen
in the tissues by becoming tachycardic. The heart will be able to maintain this
compensatory mechanism for only so long and then will show evidence of
failure.
94. Answer: B
Rationale: The client with activity intolerance will need assistance to perform
activities of daily living.
95. Answer: B
Rationale: Anemia causes the client to experience
dyspnea and fatigue. Teaching the client to pace activities and rest often, to eat a
balanced diet, and to cope with changes in lifestyle is needed.
96. Answer: A
Rationale: After a bone marrow biopsy, it is important that the client form a clot
to prevent bleeding. The nurse should hold direct pressure on the site for five
(5) to ten (10) minutes.
97. Answer: D
Rationale: Erythropoietin is a biologic response modifier produced by the kidneys
in response to a low red blood cell count in the body. It stimulates the body to
produce more RBCs.
98. Answer: D
Rationale: Morphine is the drug of choice for a crisis; it does not have a ceiling
effect and can be given in large amounts and frequent doses.
99. Answer: B
Rationale: Hereditary spherocytosis is a relatively common hemolytic anemia
(1:5000 people) characterized by an abnormal permeability of the
EXAM CODE HAAD8
red blood cell, which permits it to become spherical in shape. The spheres are
then destroyed by the spleen. A splenectomy is the treatment of choice.
100. Answer: C
Rationale: The primary goal for any client coping with a chronic illness is that the
client will be able to maintain as normal a life as possible.
EXAM CODE HAAD8

EXAM CODE HAAD9
1. Answer: C
Rationale: Patients with cancer and bone metastasis experience severe
pain especially when moving. Bone tumors weaken the bone to appoint at
which normal activities and even position changes can lead to fracture.
During nursing care, the patient needs to be supported and handled
gently.
2. Answer: D
Rationale: Fatigue is a common complaint of individuals receiving
medication therapy.
3. Answer: B
Rationale: Chemotherapeutic agents are given to destroy the actively
proliferating cancer cells. But these agents cannot differentiate the
abnormal actively proliferating cancer cells from those that are actively
proliferating normal cells like the cells of the bone marrow, thus the
effect of bone marrow depression.
4. Answer: C
Rationale: Early warning signs of laryngeal cancer can vary depending on
tumor location. Hoarseness lasting 2 weeks should be evaluated because it
is one of the most common warning signs.
5. Answer: C
Rationale: Steroids decrease the body’s immune response thus decreasing
the production of antibodies that attack the acetylcholine receptors at
the neuromuscular junction
6. Answer: A
Rationale: Progression stage is the change of tumor from the
preneoplastic state or low degree of malignancy to a fast growing tumor
that cannot be reversed.
7. Answer: D
Rationale: Intermittent pain is the classic sign of renal carcinoma. It is
primarily due to capillary erosion by the cancerous growth.
8. Answer: C
Rationale: Assessing for an open airway is the priority. The procedure
involves the neck, the anesthesia may have affected the swallowing reflex
or the inflammation may have closed in on the airway leading to
ineffective air exchange.
9. Answer: D
Rationale: Gentle oral hygiene is essential to remove debris, prevent
irritation and promote healing. Oral hygiene before meal time often makes
meals more pleasant. The best solution for oral care is normal saline.
Commercial mouthwashes are irritating to the oral mucosa therefore they
are contraindicated. An anti-emetic is not necessary in this situation as
well as keeping the client on NPO and administering the food via TPN.
EXAM CODE HAAD9

10. Answer: B
Rationale: Orchiectomy is the surgical removal of a testicle. The affected
testicle is surgically removed along with its tunica and spermatic cord
11. Answer: A
Rationale: Barium enema is the radiologic visualization of the colon using
a die. To obtain accurate results in this procedure, the bowels must be
emptied of fecal material thus the need for laxative and enema.
12. Answer: D
Rationale: Numerous aspects of diet and nutrition may contribute to the
development of cancer. A low-fiber diet, such as when fresh fruits and
vegetables are minimal or lacking in the diet, slows transport of
materials through the gut which has been linked to colorectal cancer.
13. Answer: C
Rationale: Blood pressure. Pheochromocytoma is a tumor of the adrenal
medulla that causes an increase secretion of catecholamines that can
elevate the blood pressure.
14. Answer: D
Rationale: Cigarette smoke is a carcinogen that irritates and damages the
respiratory epithelium. The irritation causes the cough which initially
maybe dry, persistent and unproductive. As the tumor enlarges,
obstruction of the airways occurs and the cough may become productive
due to infection.
15. Answer: C
Rationale: Assessment of a client with Hodgkin’s disease most often
reveals enlarged, painless lymph node, fever, malaise and night sweats
16. Answer: D
Rationale: Constipation, diarrhea, and/or constipation alternating with
diarrhea are the most common symptoms of colorectal cancer.
17. Answer: B
Rationale: The earliest and most sensitive sign of increased ICP is a
change in the level of consciousness. Elevated BP + positive Babinski
reflex due to damage to the corticospinal tract are both late signs.
Urinary incontinence` is not diagnostic of increased ICP.
18. Answer: C
Rationale: If the cancer is treatable by surgery, it is preferred over
other treatments that have multiple side effects such as chemotherapy
and radiation therapy. Bone marrow transplant is a specific treatment for
leukemia that is not applicable to other types of cancer.
19. Answer: A
Rationale: The client's platelet count is severely depressed, placing him at
risk for bleeding secondary to thrombocytopenia. Bleeding precautions
should be instituted, including the use of an electric razor and soft
toothbrush, minimizing injections, avoiding aspirin, and observing for
petechiae and ecchymosis. Typically, chemotherapy would be held if the
client developed thrombocytopenia.
20. Answer: B
EXAM CODE HAAD9

Rationale: The client is probably neutropenic due to a low neutrophil
count on the WBC count. This occurs as a result of myelosuppressive
activity of the chemotherapy and is further confirmed by the client's
symptoms of infection. Even though infection control is the top priority,
meals should be served at room temperature to cold to minimize food
odors, which can cause nausea. A client receiving chemotherapy and
having developed an infection should be served a high-protein, high-
calorie diet to ensure adequate nutrients and calories for the body to
mount a response to the infection.
21. Answer: C
Rationale: Hospice programs are designed to help with symptom control
and maintain quality of life for the client who has 6 months or less to
live; they also assist the client with the anticipation of loss and plans
for end-of-life care, such as funerals.
22. Answer: B
Rationale: The client receiving chemotherapy is at risk for infection
secondary to bone marrow suppression. A fever indicates the possibility of
an infection that could be life-threatening, so she should notify her
health care provider immediately. The client should be taught to use
birth control for at least 2 years after chemotherapy to prevent possible
birth defects and to pace herself and to allow for periods of rest to
avoid fatigue and overexertion.
23. Answer: B
Rationale: Biologic response modifiers are naturally or genetically
engineered agents that can alter the immunologic relationship between the
tumor and the client with cancer in an attempt to destroy or stop the
malignant growth by stimulating the body's natural immune defenses.
Destroying or stopping malignant growth, not stimulating the production of
cancer cells, is the goal of therapy when using BRMs.
24. Answer: C
Rationale: Intellectualization. People use defense mechanisms to cope with
stressful events. Intellectualization is the use of reasoning and thought
processes to avoid the emotional upsets.
25. Answer: B
Rationale: Children have cells that are normally actively dividing in the
process of growth. Radiation acts not only against the abnormally
actively dividing cells of cancer but also on the normally dividing cells
thus affecting the growth and development of the child and even causing
cancer itself.
26. Answer: D
Rationale: Elevating the arm above the level of the heart promotes good
venous return to the heart and good lymphatic drainage thus preventing
swelling.
27. Answer: B
Rationale: One of the oncologic emergencies, the tumor lysis syndrome, is
caused by the rapid destruction of large number of tumor cells. .
Intracellular contents are released, including potassium and purines, into
the bloodstream faster than the body can eliminate them. The purines are
converted in the liver to uric acid and released into the blood causing
EXAM CODE HAAD9

hyperuricemia. They can precipitate in the kidneys and block the tubules
causing acute renal failure.
28. Answer: B
Rationale: Assessing the client’s expectations and doubts will help lessen
her fears and anxieties. The nurse needs to encourage the client to
verbalize and to listen and correctly provide explanations when needed.
29. Answer: B
Rationale: A person grieves to a loss of a significant object. The initial
stage in the grieving process is denial, then anger, followed by
bargaining, depression and last acceptance. The nurse should show
acceptance of the patient’s feelings and encourage verbalization.
30. Answer: D
Rationale: The client is showing signs of anxiety reaction to a stressful
event. Recognizing the client’s anxiety conveys acceptance of his behavior
and will allow for verbalization of feelings and concerns.
31. Answer: C
Rationale: Patients with cancer and bone metastasis experience severe
pain especially when moving. Bone tumors weaken the bone to appoint at
which normal activities and even position changes can lead to fracture.
During nursing care, the patient needs to be supported and handled
gently.
32. Answer: C
Rationale: Pheochromocytoma is a tumor of the adrenal medulla that
causes an increase secretion of catecholamines that can elevate the blood
pressure.
33. Answer: A
Rationale: Malignant melanomas are the most deadly of the skin cancers.
Asymmetry, irregular borders, variegated color, and rapid growth are
characteristic of them.
34. Answer: B
Rationale: This is part of assessing the lesion and should be completed.
The ABCDs of skin cancer detection include the following: 1) Asymmetry—
Is the lesion balanced on both sides with an even surface? 2) Borders—
are the borders rounded and smooth or notched and indistinct? 3) Color—
Is the color a uniform light brown or is it variegated and darker or
reddish purple? 4) Diameter—A diameter exceeding 4–6 mm is considered
suspicious.
35. Answer: B
Rationale: This is the most commonly written therapeutic communication
goal. This addresses the client’s concerns.
36. Answer: A
Rationale: The client should be aware of symptoms that indicate
development of another skin cancer. Squamous cell carcinoma can develop
EXAM CODE HAAD9

37. Answer: A
Rationale: This client has an unexpected situation occurring and should be
assessed before any stable client.
38. Answer: C
Rationale: This is part of assessing the client and cannot be delegated.
39. Answer: D
Rationale: Clients with very little melanin in the skin (fair-skinned) have
an increased risk as a result of the UV damage to the underlying
membranes. Damage to the underlying membranes never completely
reverses itself; a lifetime of damage causes changes at the cellular level
that can result in the development of cancer.
40. Answer: D
Rationale: Sunscreen products range in numerical value from 4 to 50; the
higher the number of the sunscreen, the greater the UV protection.
41. Answer: C
Rationale: The American Cancer Society recommends a monthly skin check
using mirrors to identify any suspicious skin lesion for early detection.
42. Answer: C
Rationale: Pain is a physiological problem; this is an appropriate
physiological goal.
43. Answer: D
Rationale: On discharge, all clients should receive instructions in the care
of surgical incisions.
44. Answer: D
Rationale: An ileal conduit is a procedure that diverts urine from the
bladder and provides an alternate cutaneous pathway for urine to exit
the body. Urinary output should always be at least 30 mL per hour. This
client should be assessed to make sure that the stents placed in the
ureters have not become dislodged or to ensure that edema of the ureters
is not occurring.
45. Answer: C
Rationale: Cigarette smoke contains more than 400 chemicals, 17 of which
are known to cause cancer. The risk is directly proportional to the
amount of smoking.
46. Answer: B
Rationale: A urinary diversion procedure involves the removal of the
bladder. In a cutaneous procedure the ureters are implanted in some way
to allow for stoma formation on the abdominal wall, and the urine then
drains into a pouch. There are numerous methods used for creating the
stoma.
47. Answer: A
Rationale: The client will have medication instilled in the bladder that
must remain in the bladder for a prescribed length of time. For this
reason, the client must remain NPO before the procedure.
48. Answer: A
EXAM CODE HAAD9

Rationale: Urine is acidic and the abdominal wall tissue is not designed to
tolerate acidic environments. The stoma is pouched so that urine will not
touch the skin.
49. Answer: D
Rationale: It is in the scope of practice for the LPN to care for this
client.
50. Answer: B
Rationale: Paternalism is deciding for the client what is best, such as a
parent making decisions for a child. Feeding a client, as with a feeding
tube, without the client wishing to eat is paternalism.
51. Answer: C
Rationale: This is an example of restating, a therapeutic technique used
to clarify the client’s feelings and encourage a discussion of those
feelings.
52. Answer: A
Rationale: A continent urinary diversion is a surgical procedure in which a
reservoir is created that will hold urine until the client can
selfcatheterize the stoma. The nurse should observe the client’s technique
before discharge.
53. Answer: A
Rationale: Vinegar will act as a deodorizing agent in the pouch and help
prevent a strong urine smell.
54. Answer: D
Rationale: The client is drawn up in a position that takes pressure off
the abdomen; a rigid abdomen is an indicator of peritonitis, a medical
emergency.
55. Answer: A
Rationale: This client is asking for information and should be given
factual information. The surgery will not make the client sterile, but
chemotherapy can induce menopause and radiation therapy to the pelvis
can render a client sterile.
56. Answer: B
Rationale: The testicular-self examination is recommended monthly after a
warm bath or shower when the scrotal skin is relaxed. The client should
stand to examine the testicles. Using both hands, with fingers under the
scrotum and thumbs on top, the client should gently roll the testicles,
feeling for any lumps.
57. Answer: C
Rationale: Risk factors for cervical cancer include human papillomavirus
(HPV) infection, active and passive cigarette smoking, certain high-risk
sexual activities (first intercourse before 17 years of age, multiple sex
partners, or male partners with multiple sex partners). Screening via
regular gynecological exams and Papanicolaou smear (Pap test) with
treatment of precancerous abnormalities decrease the incidence and
mortality of cervical cancer.
58. Answer: D
EXAM CODE HAAD9

Rationale: The breast self-examination should be performed monthly 7
days after the onset of the menstrual period. Performing the examination
weekly is not recommended. At the onset of menstruation and during
ovulation, hormonal changes occur that may alter breast tissue.
59. Answer: A
Rationale: The client is at risk of deep vein thrombosis or
thrombophlebitis after this surgery, as for any other major surgery. For
this reason, the nurse implements measures that will prevent
thiscomplication. Range-of-motion exercises, antiembolism stockings, and
pneumatic compression boots are helpful. The nurse should avoid using the
knee gatch in the bed, which inhibits venous return, thus placing the
client more at risk for deep vein thrombosis or thrombophlebitis.
60. Answer: A
Rationale: A biopsy is done to determine whether a tumor is malignant
or benign. Magnetic resonance imaging, computed tomography scan, and
ultrasound will visualize the presence of a mass but will not confirm a
diagnosis of malignancy.
61. Answer: D
Rationale: Rationale: Multiple myeloma is a B-cell neoplastic condition
characterized by abnormal malignant proliferation of plasma cells and the
accumulation of mature plasma cells in the bone marrow.
62. Answer: A
Rationale: Findings indicative of multiple myeloma are an increased
number of plasma cells in the bone marrow, anemia, hypercalcemia
caused by the release of calcium from the deteriorating bone tissue, and
an elevated blood urea nitrogen level. An increased white blood cell
count may or may not be present and is not related specifically to
multiple myeloma.
63. Answer: A
Rationale: Hypercalcemia caused by bone destruction is a priority concern
in the client with multiple myeloma. The nurse should administer fluids in
adequate amounts to maintain a urine output of 1.5 to 2 L/day; this
requires about 3 L of fluid intake per day. The fluid is needed not only
to dilute the calcium overload but also to prevent protein from
precipitating in the renal tubules
64. Answer: B
Rationale: Hodgkin's disease is a disorder of young adults.
65. Answer: A
Rationale: Alopecia is not an assessment finding in testicular cancer.
Alopecia may occur, however, as a result of radiation or chemotherapy.
Options 2, 3, and 4 are assessment findings in testicular cancer. Back
pain may indicate metastasis to the retroperitoneal lymph nodes.
66. Answer: C
Rationale: In general, only the area in the treatment field is affected by
the radiation. Skin reactions, fatigue, nausea, and anorexia may occur
with radiation to any site, whereas other side effects occur only when
specific areas are involved in treatment. A client receiving radiation to
the larynx is most likely to experience a sore throat.
EXAM CODE HAAD9

67. Answer: B
Rationale: The time that the nurse spends in a room of a client with an
internal radiation implant is 30 minutes per 8-hour shift. The dosimeter
badge must be worn when in the client's room. Children younger than 16
years of age and pregnant women are not allowed in the client's room.
68. Answer: A
Rationale: The client with a cervical radiation implant should be
maintained on bed rest in the dorsal position to prevent movement of the
radiation source. The head of the bed is elevated to a maximum of 10 to
15 degrees for comfort. The nurse avoids turning the client on the side.
If turning is absolutely necessary, a pillow is placed between the knees
and, with the body in straight alignment, the client is log rolled.
69. Answer: D
Rationale: A lead container and long-handled forceps should be kept in
the client's room at all times during internal radiation therapy. If the
implant becomes dislodged, the nurse should pick up the implant with long-
handled forceps and place it in the lead container.
70. Answer: C
Rationale: In the neutropenic client, meticulous hand hygiene education is
implemented for the client, family, visitors, and staff.
Not all visitors are restricted, but the client is protected from persons
with known infections. Fluids should be encouraged. Invasive measures
such as an indwelling urinary catheter should be avoided to prevent
infections.
71. Answer: A
Rationale: Rationale: The client's self-report is a critical component of
pain assessment. The nurse should ask the client about the description of
the pain and listen carefully to the client's words used to describe the
pain. The nurse's impression of the client's pain is not appropriate in
determining the client's level of pain. Nonverbal cues from the clientare
important but are not the most appropriate pain assessment measure.
Assessing pain relief is an important measure, but this option is not
related to the subject of the question.
72. Answer: A
Rationale: Rationale: The client is kept NPO until peristalsis returns,
usually in 4 to 6 days. When signs of bowel function return, clear fluids
are given to the client. If no distention occurs, the diet is advanced as
tolerated. The most important assessment is to assess bowel sounds before
feeding the client.
73. Answer: D
Rationale: Hodgkin's disease is a chronic progressive neoplastic disorder of
lymphoid tissue characterized by the painless enlargement of lymph nodes
with progression to extralymphatic sites, such as the spleen and liver.
Weight loss is most likely to be noted. Fatigue and weakness may occur
but are not related significantly to the disease.
74. Answer: D
EXAM CODE HAAD9

Rationale: Clinical manifestations of ovarian cancer include abdominal
distention, urinary frequency and urgency, pleural effusion, malnutrition,
pain from pressure caused by the growing tumor and the effects of
urinary or bowel obstruction, constipation,
ascites with dyspnea, and ultimately general severe pain. Abnormal
bleeding, often resulting in hypermenorrhea, is associated with uterine
cancer.
75. Answer: B
Rationale: Hypercalcemia is a serum calcium level higher than 10 mg/dL,
most often occurs in clients who have bone metastasis, and is a late
manifestation of extensive malignancy. The presence of cancer in the bone
causes the bone to release calcium into the bloodstream.
76. Answer: D
Rationale: Testicular cancer almost always occurs in only one testicle and
is usually a pea-sized painless lump. The cancer is highly curable when
found early. The finding should be reported to the physician.
77. Answer: C
Rationale: Denial, bargaining, anger, depression, and acceptance are
recognized stages that a person facing a life-threatening illness
experiences. Bargaining identifies a behavior in which the individual is
willing to do anything to avoid loss or change prognosis or fate. Denial is
expressed as shock and disbelief and may be the first response to hearing
bad news. Depression may be manifested by hopelessness, weeping openly,
or remaining quiet or withdrawn.
Anger also may be a first response to upsetting news and the
predominant theme is “why me?” or the blaming of others.
78. Answer: B
Rationale: Arm edema on the operative side (lymphedema) is a
complication following mastectomy and can occur immediately
postoperatively or may occur months or even years after surgery.
79. Answer: B
Rationale: The most common risk factor associated with laryngeal cancer
is cigarette smoking. Heavy alcohol use and the combined use of tobacco
increase the risk. Another risk factor is exposure to environmental
pollutants.
80. Answer: B
Rationale: A vesicovaginal fistula is a genital fistula that occurs between
the bladder and vagina. The fistula is an abnormal opening between these
two body parts and, if this occurs, the client may experience drainage of
urine through the vagina.
81. Answer: D
Rationale: Allopurinol decreases uric acid production and reduces uric acid
concentrations in serum and urine. In the client receiving chemotherapy,
uric acid levels increase as a result of the massive cell destruction that
occurs from the chemotherapy. This medication prevents or treats
hyperuricemia caused by chemotherapy.
Allopurinol is not used to prevent alopecia, nausea, or vomiting.
EXAM CODE HAAD9

82. Answer: D
Rationale: An acidic environment in the mouth is favorable for bacterial
growth, particularly in an area already compromised from chemotherapy.
Therefore, the client is advised to rinse the mouth before every meal and
at bedtime with a weak salt and sodium bicarbonate mouth rinse. This
lessens the growth of bacteria and limits plaque formation. The other
substances are irritating to oral tissue. If hydrogen peroxide must be
used because of severe plaque, it should be a weak solution because it
dries the mucous membranes.
83. Answer: B
Rationale: A high-fat diet plays a role in the development of cancer of
the pancreas. Options 1, 3, and 4 are risk factors related to gastric
cancer.
84. Answer: D
Rationale: Following gastrectomy, drainage from the nasogastric tube is
normally bloody for 24 hours postoperatively, changes to brown-tinged,
and is then to yellow or clear. Because bloody drainage is expected in
the immediate postoperative period, the nurse should continue to monitor
the drainage. The nurse does not need to notify the physician at this
time. Measuring abdominal girth is performed to detect the development
of distention. Following gastrectomy, a nasogastric tube should not be
irrigated unless there are specific physician orders to do so.
85. Answer: A
Rationale: Colorectal cancer risk factors include age older than 50 years,
a family history of the disease, colorectal polyps, and chronic
inflammatory bowel disease.
86. Answer: C
Rationale: To reduce the risk of contamination at the time of surgery,
the bowel is emptied and cleansed. Laxatives and enemas are given to
empty the bowel. Intestinal anti-infectives such as neomycin or kanamycin
(Kantrex) are administered to decrease the bacteria in the bowel.
87. Answer: C
Rationale: Immediately after surgery, profuse serosanguineous drainage
from the perineal wound is expected. The nurse does not need to notify
the physician at this time. A Penrose drain should not be clamped
because this action will cause the accumulation of drainage within the
tissue. Penrose drains and packing are removed gradually over a period of
5 to 7 days as prescribed. The nurse should not remove the perineal
packing.
88. Answer: B
Rationale: Following abdominal perineal resection, the nurse would expect
the colostomy to begin to function within 72 hours after surgery,
although it may take up to 5 days. The nurse should assess for a return
of peristalsis, listen for bowel sounds, and check for the passage of
flatus. Absent bowel sounds would not indicate the return of peristalsis.
The client would remain NPO until bowel sounds return and the colostomy
is functioning. Bloody drainage is not expected from a colostomy.
89. Answer: C
EXAM CODE HAAD9

Rationale: Air conditioners need to be avoided to protect from excessive
coldness. A humidifier in the home should be used if excessive dryness is
a problem.
90. Answer: A
Rationale: Cytoreductive or “debulking” surgery may be used if a large
tumor cannot be completely removed as is often the case with late-stage
ovarian cancer (e.g., the tumor is attached to a vital organ or spread
throughout the abdomen). When this occurs, as much tumor as possible is
removed and adjuvant chemotherapy or radiation may be prescribed.
91. Answer: C
Rationale: Hormone therapy (androgen deprivation) is a mode of treatment
for prostatic cancer. The goal is to limit the amount of circulating
androgens because prostate cells depend on androgen for cellular
maintenance. Deprivation of androgen often can lead to regression of
disease and improvement of symptoms.
92. Answer: D
Rationale: Small pieces of tissue or blood clots can be passed during
urination for up to 2 weeks after surgery. Driving a car and sitting for
long periods of time are restricted for at least 3 weeks. A high daily
fluid intake should be maintained to limit clot formation and prevent
infection. Option 3 is an accurate discharge instruction following
prostatectomy.
93. Answer: A
Rationale: The incidence of bladder cancer is greater in men than in
women and affects the white population twice as often as blacks.
94. Answer: B
Rationale: The most common symptom in clients with cancer of the
bladder is hematuria. The client also may experience irritative voiding
symptoms such as frequency, urgency, and dysuria, and these symptoms
often are associated with carcinoma in situ.
95. Answer: C
Rationale: Normally, the medication is injected into the bladder through a
urethral catheter, the catheter is clamped or removed, and the client is
asked to retain the fluid for 2 hours. The client changes position every
15 to 30 minutes from side to side and from supine to prone or resumes
all activity immediately. The client then voids and is instructed to drink
water to flush the bladder.
96. Answer: D
Rationale: Following ureterostomy, the stoma should be red and moist. A
pale stoma may indicate an inadequate amount of vascular supply. A dry
stoma may indicate a body fluid deficit. Any sign of darkness or
duskiness in the stoma may indicate a loss of vascular supply and must
be reported immediately or necrosis can occur.
97. Answer: B
Rationale: Following mastectomy, the arm should be elevated above the
level of the heart. Simple arm exercises should be encouraged.
EXAM CODE HAAD9

No blood pressure readings, injections, intravenous lines, or blood draws
should be performed on the affected arm. Cool compresses are not a
suggested measure to prevent lymphedema from occurring.
98. Answer: C
Rationale: Superior vena cava syndrome occurs when the superior vena
cava is compressed or obstructed by tumor growth. Early signs and
symptoms generally occur in the morning and include edema of the face,
especially around the eyes, and client complaints of tightness of a shirt
or blouse collar. As the compression worsens, the client experiences edema
of the hands and arms. Mental status changes and cyanosis are late
signs.
99. Answer: D
Rationale: Rationale: Hypercalcemia is a late manifestation of bone
metastasis in late-stage cancer. Headache and dysphagia are not
associated with
hypercalcemia. Constipation may occur early in the process.
Electrocardiogram changes include shortened ST segment and a widened T
wave.
100. Answer: C
Rationale: During the period of greatest bone marrow suppression (the
nadir), the platelet count may be low, less than 20,000 cells/mm3.
Aspirin and nonsteroidal anti-inflammatory drugs and product that contain
aspirin should be avoided because of their antiplatelet activity, thus
further teaching is needed.
EXAM CODE HAAD9

EXAM CODE HAAD10
1. Answer: C
Rationale: Nausea is one of the common complaints of a patient after
receiving general anesthesia. But this complaint could be aggravated by
gastric distention especially in a patient who has undergone abdominal
surgery. Insertion of the NGT helps relieve the problem. Checking on the
patency of the NGT for any obstruction will help the nurse determine the
cause of the problem and institute the necessary intervention.
2. Answer: D
Drains are usually inserted into the splenic bed to facilitate removal of
fluid in the area that could lead to abscess formation.
3. Answer: C
Rationale: The nurse’s priority at this time is to alleviate the chest pain
of the client. Obtaining chest radiograph, ECG and blood work are all
important and can be done after administering morphine.
4. Answer: B
Rationale: There are many possible causes for a childhood seizure. These
include fever, central nervous system conditions, trauma, metabolic
alterations and idiopathic
5. Answer: B
Rationale: Croup is an upper airway obstruction and the signs and
symptoms are because of difficulty getting air past the upper airway.
Wheezing is found with Asthma, decreased aeration in lung fields is found
with Pneumonia. Shallow respirations are unlikely; the child may exhibit
retractions, but not shallow respirations.
6. Answer: B
Rationale: This patient is suffering from frostbite, due to prolonged
exposure to sub-freezing temperatures without proper protection.
Frostbite is a condition in which there is trauma to the tissues without
actual freezing of tissue fluids. Exposed areas of the body such as
hands, feet, earlobes, etc. are all subject to this. The affected part
becomes hard, cold, and is not sensitive to touch, and mottled bluish-
white in color. The aim of nursing care is to restore normal temperature
and circulation to the part.
7. Answer: A
Rationale: When dealing with an emergency, the ABCs — airway,
breathing, and circulation — are the priorities and must be maintained
first. Blood pressure, neurological, and neurovascular assessments are
important, but in this case, airway is the priority.
8. Answer: B
Rationale: Infection is a priority for all types of burns. Airway is a
priority only for burns to the face and neck. Pain is a second priority
for 1st and 2nd degree burns. Fluid and electrolyte balance is a second
priority for 3rd and 4th degree burns [no pain because nerve endings are
damaged].
9. Answer: C
EXAM CODE HAAD10

Rationale: Regardless of the cause, the priority in an emergency situation
is the ABCs — airway, breathing, and circulation; thus, the priority would
be to provide support for breathing and circulation. Eliminating the drug
from the body is important, but only after respiratory and cardiovascular
support is provided.
10. Answer: B
Rationale: The client is probably experiencing autonomic hyperreflexia, a
medical emergency usually triggered by a distended bladder; a distended
bowel or pain also may lead to autonomic hyperreflexia
11. Answer: C
Rationale: Because of the effects of the electrical current on the
cardiovascular system, all clients experiencing electrical burns should be
placed on a cardiac monitor. Applying ice is inappropriate for any type of
burn. Only chemical burns should be flushed with large amounts of water.
Chemical antidotes may be used for chemical burns for which an antidote
has been identified.
12. Answer: D
Rationale: Respiratory and cardiovascular functions are essential for
oxygenation. These are top priorities to trauma management. Basic life
functions must be maintained or reestablished
13. Answer: C
Rationale: Acute asthmatic attack is characterized by severe
bronchospasm which can be relieved by the immediate administration of
bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that
causes bronchial dilation by relaxing the bronchial smooth muscles.
14. Answer: A
Rationale: Swallowing of corrosive substances causes severe irritation and
tissue destruction of the mucous membrane of the GI tract. Measures are
taken to immediately remove the toxin or reduce its absorption. For
corrosive poison ingestion, such as in muriatic acid where burn or
perforation of the mucosa may occur, gastric emptying procedure is
immediately instituted, This includes gastric lavage and the administration
of activated charcoal to absorb the poison. Administering an irritant with
the concomitant vomiting to remove the swallowed poison will further
cause irritation and damage to the mucosal lining of the digestive tract.
Vomiting is only indicated when non-corrosive poison is swallowed.
15. Answer: B
Rationale: Sudden death of a family member creates a state of shock on
the family. They go into a stage of denial and anger in their grieving.
Assisting them with information they need to know, answering their
questions and listening to them will provide the needed support for them
to move on and be of support to one another.
16. Answer: C
Rationale: Perform 5 abdominal thrusts. At this age, the most effective
way to clear the airway of food is to perform abdominal thrusts.
17. Answer: D
Rationale: Ensure an intake of at least 3000 ml of fluid per day. Gouty
arthritis is a metabolic disease marked by urate deposits that cause
EXAM CODE HAAD10

painful arthritic joints. The patient should be urged to increase his fluid
intake to prevent the development of urinary uric acid stones.
18. Answer: A
Rationale: The Heimlich maneuver is used to assist a person choking on a
foreign object. The pressure from the thrusts lifts the diaphragm, forces
air out of the lungs and creates an artificial cough that expels the
aspirated material.
19. Answer: C
Rationale: The exact and safe location to do cardiac compression is the
lower half of the sternum. Doing it at the lower third of the sternum
may cause gastric compression which can lead to a possible aspiration.
20. Answer: B
Rationale: Sudden death of a family member creates a state of shock on
the family. They go into a stage of denial and anger in their grieving.
Assisting them with information they need to know, answering their
questions and listening to them will provide the needed support for them
to move on and be of support to one another.
21. Answer: D
Rationale: Presence of abdominal drains for several days after surgery
Drains are usually inserted into the splenic bed to facilitate removal of
fluid in the area that could lead to abscess formation.
22. Answer: A
Rationale: to establish the sufficiency of fluid resuscitation, urine output
totals an index of renal perfusion. Urine output totals an index of renal
perfusion, urine output totals of 30-50 ml/hour have been used as
resuscitation goals. Other indicators of adequate fluid replacement are
systolic blood pressure exceeding 100 mmHg, a pulse rate less than110
beats/min or both.
23. Answer: B
Rationale: Emergent surgery is performed, immediately without delay to
maintain life, limb or organ, remove damage and stop bleeding. Urgent
surgery requires prompt attention and is done few hours but within 24 to
48 hours. Required surgery is done within a few weeks as surgery is
important. Elective surgery is scheduled and done at the convenience of
client as failure to have surgery is not catastrophic. Optional surgeries
are done by preference only.
24. Answer: A
Rationale: Introducing self initiates the nurse-patient interaction,
relationship and the purpose of being with the client. This prevents
confusion and let the client know what to expect, thereby reducing
anxiety.
25. Answer: A
Rationale: Awakening the client every 2 hours allows the identification of
headache, dizziness, lethargy, irritability, and anxiety—all signs of post-
concussion syndrome—that would warrant the significant other’s taking the
client back to the emergency department.
26. Answer: A
Rationale: This client has been exposed to wind and sun at the lake
EXAM CODE HAAD10

during the hours prior to being admitted to the emergency department.
This predisposes the client to dehydration and an Addisonian crisis. Rapid
IV fluid replacement is necessary.
27. Answer: D
Rationale: Keeping the fingernails short will reduce the chance of breaks
in the skin from scratching.
28. Answer: B
Rationale: This is a major abdominal surgery, and there are massive fluid
volume shifts that occur when this type of trauma is experienced by the
body. Maintaining the circulatory system without overloading it requires
extremely close monitoring.
29. Answer: A
Rationale: The client will have jaundice, clay-colored stools, and tea-
colored urine resulting from blockage of the bile drainage.
30. Answer: C
Rationale: These are symptoms of an insulin reaction (hypoglycemia). A
bedside glucose check should be done. Pancreatic islet tumors can produce
hyperinsulinemia or hypoglycemia.
31. Answer: C
Rationale: Limiting the intake of meat and fats in the diet would be an
example of primary interventions. Risk factors for the development of
cancer of the pancreas are cigarette smoking and eating a high-fat diet
that is high in animal protein. By changing these behaviors the client
could possibly prevent the development of cancer of the pancreas. Other
risk factors include genetic predisposition and exposure to industrial
chemicals.
32. Answer: B
Rationale: The most important person in the treatment of the cancer is
the client. Research has proved that the more involved a client becomes
in his or her care, the better the prognosis. Clients should have a chance
to ask all the questions that they have.
33. Answer: D
Rationale: A collaborative intervention would be to refer to the nutrition
expert, the dietitian.
34. Answer: A
Rationale: The nurse should assess the nail beds for the capillary refill
time. A prolonged time (greater than three seconds) indicates impaired
circulation to the extremity.
35. Answer: C
Rationale: This is the first intervention the nurse should implement after
finding the client unresponsive on the floor.
36. Answer: C
Rationale: The sternum should be depressed 1.5 to 2 inches during
compressions to ensure adequate circulation of blood to the body;
therefore, the nurse needs to correct the assistant.
EXAM CODE HAAD10

37. Answer: C
Rationale: This is the most important intervention.
The nurse should always treat the client based on the nurse’s assessment
and data from the monitors; an intervention should not be based on data
from the monitors without the nurse’s assessment.
38. Answer: A
Rationale: This is the correct statement explaining what an AED does
when used in a code.
39. Answer: C
Rationale: Ventricular fibrillation is the most common dysrhythmia
associated with sudden cardiac death; ventricular fibrillation is responsible
for 65% to 85% of sudden cardiac deaths.
40. Answer: A
Rationale: The chaplain should be called to help address the client’s
family or significant others.
A small community hospital would not have a 24-hour on-duty pastoral
service.
41. Answer: D
Rationale: Nurses should protect themselves against possible communicable
disease, such as HIV, hepatitis, or any types of sexually transmitted
disease.
42. Answer: C
Rationale: Unexpected death occurring within1 hour of the onset of
cardiovascular symptoms is the definition of sudden cardiac death.
43. Answer: A
Rationale: Gastric distention occurs from overventilating clients. When
compressions are performed, the pressure will cause vomiting that could
be aspirated into the lungs.
44. Answer: B
Rationale: The crash cart is the mobile unit that has the defibrillator
and all the medications and supplies needed to conduct a code.
45. Answer: D
Rationale: The chart is a legal document and the code must be
documented in the chart and provide information that may be needed in
the intensive care unit.
46. Answer: B
Rationale: The nurse should take note of any unusual illness for the time
of year or clusters of clients coming from a single geographical location
who all exhibit signs/symptoms of possible biological terrorism.
47. Answer: A
Rationale: Level A protection is worn when the highest level of
respiratory, skin, eye, and mucous membrane protection is required.
In this situation of possible inhalation of anthrax, such protection is
required.
EXAM CODE HAAD10

48. Answer: C
Rationale: The health-care providers are not guaranteed absolute protects.
The nurse should take note of any unusual illness for the time of year or
clusters of clients coming from a single geographical location who all
exhibit signs/symptoms of possible biological terrorism.ion, even with all
the training and protective equipment.
49. Answer: D
Rationale: Avoiding cross contamination is a priority for personnel and
equipment—the fewer number of people exposed, the safer the community
and area.
50. Answer: C
Rationale: This is the first step. Depending on the type of exposure, this
step alone can remove a large portion of exposure.
51. Answer: D
Rationale: Because of the variety of agents, the means of transmission,
and lethality of the agents, biological weapons, including anthrax,
smallpox, and plague, is especially dangerous.
52. Answer: B
Rationale: Exposure to anthrax bacilli via the skin results in skin lesions,
which cause edema with pruritus and the formation of macules or papules
that ulcerate, forming a 1-3 mm vesicle. Then a painless eschar develops,
which falls off in one (1) to 2 weeks.
53. Answer: A
Rationale: Cremation is recommended because the virus can stay alive in
the scabs of the body for 13 years.
54. Answer: B
Rationale: Standing up will avoid heavy exposure the chemical will sink
toward the floor or ground.
55. Answer: C
Rationale: The prodromal phase (presenting symptoms) of radiation
exposure occurs 48–72 hours after exposure and the signs/symptoms are
nausea, vomiting, diarrhea, anorexia, and fatigue. Higher exposures of
radiation signs/symptoms include fever, respiratory distress, and
excitability.
56. Answer: D
Rationale: The nurse should follow the hospital’s policy. Many times
nurses will stay at home until decisions are made as to where the
employees should report.
57. Answer: A
Rationale: The MSDS provides chemical information regarding specific
agents, health information, and spill information for a variety of
chemicals. It is required for every chemical that is found in the hospital.
58. Answer: B
Rationale: The triage nurse should see this client first because these are
symptoms of a myocardial infarction, which potentially life is
threatening.
59. Answer: D
EXAM CODE HAAD10

Rationale: This is called the immediate category. Individuals in this group
can progress rapidly to expectant if treatment is delayed.
60. Answer: D
Rationale: New settings and atypical roles for nurses may be required
during disasters; medical-surgical nurses can provide first aid and be
required to work in unfamiliar settings.
61. Answer: B
Rationale: This client has a very poor prognosis, and even with treatment,
survival is unlikely.
62. Answer: C
Rationale: Federal resources include organizations such as DHHS and the
Department of Justice. Each of these federal departments oversees
hundreds of agencies, including the American Red Cross, that respond to
disasters.
63. Answer: A
Rationale: CISM is an approach to preventing and treating the emotional
trauma that can affect emergency responders as a consequence of their
job. Performing CPR and treating a young child affects the emergency
personnel psychologically, and the death increases the traumatic
experience.
64. Answer: B
Rationale: Emergency operations plans will always have a designated
disaster plan coordinator.
All public information should be routed through this person.
65. Answer: C
Rationale: The tag should never be removed from the client until the
disaster is over or the client is admitted and the tag becomes a part of
the client’s record. The HCP needs to be informed immediately of the
action.
66. Answer: A
Rationale: This will help diffuse the escalating situation and attempt to
keep the father calm.
67. Answer: D
Rationale: Self-protection is priority, and the nurse is not required to be
injured in the line of duty.
68. Answer: D
Rationale: The Poison Control Center can assist the nurse in identifying
which chemical has been ingested by the child and the antidote.
69. Answer: A
Rationale: The primary goal for the ED nurse is to stop the action of the
poison and then maintain organ functioning.
70. Answer: C
Rationale: Airway edema or obstruction can occur as a result of the
burning action of corrosive substances.
EXAM CODE HAAD10

71. Answer: B
Rationale: These are signs and symptoms of carbon monoxide poisoning.
Symptoms include skin color from a cherry red to cyanotic and pale,
headache, muscular weakness, palpitations, dizziness, and confusion and
can progress rapidly to coma and death. Oxygen should be administered
100% at hyperbaric or atmospheric pressures to reverse hypoxia and
accelerate elimination of the carbon monoxide.
72. Answer: A
Rationale: The skin should be immediately drenched with water from a
hose or shower. A constant stream of water is applied. Time should not
be lost by removing the clothes and then proceeding to rinsing with
water.
If the person has a dry powder form of white phosphorus or lye, it is
brushed off and then the client is placed under the shower.
73. Answer: B
Rationale: Clients with botulism are at risk for respiratory paralysis, and
this is the priority problem.
74. Answer: D
Rationale: The client should lie down, all restrictive items such as rings
should be removed, the wound should be cleansed and covered with a
sterile dressing, the affected body part should be immobilized, and the
client should be kept warm.
75. Answer: B
Rationale: The lips should be pink, not bright red or blue. This indicates
a saturation of the hemoglobin with carbon monoxide. This client needs
more instruction.
76. Answer: B
Rationale: This is a sterile dressing change and should not be delegated.
77. Answer: A
Rationale: Before administering antivenin, the affected body part must be
measured and remeasured every 15 minutes during a 4- to 6-hour
procedure. The infusion is begun slowly and increased after 10 minutes.
The affected part is measured every 30–60 minutes after the infusion and
for 48 hours to detect symptoms of compartment syndrome (swelling, loss
of pulse, increased pain, and paresthesias). Allergic reactions to the
antivenin are not uncommon and are usually the result of a too-rapid
infusion of the antivenin. The most experienced nurse should be assigned
this client.
78. Answer: A
Rationale: There are many type of shock, but the one common
intervention that should be done first in all types of shock is to
establish an intravenous line with a large bore catheter. This client has
signs and symptoms of shock, and the narrowing pulse pressure indicates
the client is getting worse.
79. Answer: C
Rationale: The client must have a urinary output of at least 30 mL/hr, so
90 mL in the last four (4) hours indicates impaired renal perfusion, which
is a sign of worsening shock and warrants immediate intervention.
EXAM CODE HAAD10

80. Answer: B
Rationale: An IV antibiotic is the priority medication for the client with
an infection, which is the definition of sepsis—a systemic bacterial
infection of the blood. A new order for
an IV antibiotic should be implemented within one (1) hour of receiving
the order.
81. Answer: B
Rationale: The client will have bradycardia instead of tachycardia, which
is seen in other forms of shock.
82. Answer: C
Rationale: Any time a nurse administers a medication for the first time,
the client should be observed for a possible anaphylactic reaction,
especially with antibiotics.
83. Answer: D
Rationale: Antipyretic medication will help decrease the client’s fever,
which directly addresses the etiology of the client’s nursing diagnosis.
84. Answer: A
Rationale: Specimens should be put into biohazard bags prior to leaving
the client’s room.
85. Answer: B
Rationale: This client’s signs/symptoms would make the nurse suspect the
client is losing blood, which leads to hypovolemic shock, which is the
most common type of shock and is characterized by decreased
intravascular volume. The client’s taking of NSAID medications puts her at
risk for hemorrhage because NSAIDs inhibit prostaglandin production in
the stomach, which increases the risk of developing ulcers, which can
erode the stomach lining and lead to hemorrhaging.
86. Answer: C
Rationale: Promoting adequate oxygenation of the heart muscle and
decreasing the cardiac workload can prevent cardiogenic shock.
87. Answer: D
Rationale: A sensitivity report that indicates a resistance to the antibiotic
being given indicates the medication the client is receiving is not
appropriate for the treatment of the infectious organism, and the HCP
needs to be notified so that the antibiotic can be changed.
88. Answer: A
Rationale: The hypodynamic phase is the last and irreversible phase of
septic shock, characterized by low cardiac output with vasoconstriction.
It reflects the body’s effort to compensate for hypovolemia caused by the
loss of intravascular volume through the capillaries.
89. Answer: D
Rationale: By escorting the client to a bathroom for any reason, the
nurse can get the client to a safe area out of the hearing of the spouse.
This is the most innocuous way to get the client alone.
90. Answer: B
Rationale: The nurse should arrange for the social worker to see the
EXAM CODE HAAD10

client and family to determine if some arrangements could be made to
provide for the client’s safety and for the client to be provided with
nutritious meals while the adult children are at work. A long-term care
facility or adult day care may be needed.
91. Answer: A
Rationale: Research suggests that at least 67% of adolescents who are
runaways or homeless have been abused in the home. This represents a
learned behavior pattern that gets the female adolescent attention.
92. Answer: B
Rationale: Child Protective Services should be notified to protect the child
from further abuse and to initiate charges against the father. An
intermediate school nurse would be caring for children in the 4th, 5th,
6th, or 7th grades, depending on the school district.
93. Answer: C
Rationale: Rape is an act of violence motivated by the rapist desires to
overpower and control the victim.
94. Answer: D
Rationale: The nurse should help the client to devise a plan for safety by
giving the client the number of a safe house or a woman’s shelter.
95. Answer: B
Rationale: Many times the elderly are ashamed to report abuse because
they raised the abuser and feel responsible that their child became an
abuser. The elder parent may feel financially dependent on the child or
be afraid of being placed in a long-term care facility. Forty-seven states
have Adult Protective
Services (APS) created by the states to protect elder citizens.
96. Answer: D
Rationale: This statement assesses the abused client’s safety (or a plan
for safety).
97. Answer: A
Rationale: Clients diagnosed with PTSD are easily startled and can react
violently if awakened from sleep by being touched.
98. Answer: C
Rationale: The client should be provided the phone number of a rape
crisis counseling center or counselor to help the client deal with the
psychological feelings of being raped.
99. Answer: B
Rationale: The first step in helping a client who has been abused is to
get the client to admit that the abuse is happening.
100. Answer: C
Rationale: When a client suffers from multiple rib fractures, the client
has an increased risk for flail chest. The nurse should assess the client
for paradoxical chest wall movement and, if respiratory distress is
present forpallor and cyanosis.
EXAM CODE HAAD10


CARDIAC ANSWERS AND RATIONALES

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CARDIAC ANSWERS AND RATIONALES

Uploaded by

Copyright:

Available Formats

ANSWERS AND RATIONALES

Exam Code HAAD 1

Exam Code HAAD 1

Exam Code HAAD 1

Exam Code HAAD 1

Exam Code HAAD 1

Exam Code HAAD 1

Exam Code HAAD 1

Exam Code HAAD 1

Exam Code HAAD 1

Exam Code HAAD 1

EXAM CODE HAAD2

EXAM CODE HAAD2

EXAM CODE HAAD2

EXAM CODE HAAD2

EXAM CODE HAAD2

EXAM CODE HAAD2

EXAM CODE HAAD2

Exam Code HAAD3

Exam Code HAAD3

Exam Code HAAD3

Exam Code HAAD3

6. B. Excessive bubbling indicates an air leak which must be eliminated to

Exam Code HAAD4

Exam Code HAAD4

Exam Code HAAD4

Exam Code HAAD4

Exam Code HAAD4

Exam Code HAAD4

Exam Code HAAD4

Exam Code HAAD4

Exam Code HAAD5

Exam Code HAAD5

Rationale: X-rays reveal loss of joint cartilage, which appears as a

Exam Code HAAD5

Exam Code HAAD5

Exam Code HAAD6

Exam Code HAAD6

Exam Code HAAD6

Exam Code HAAD6

Exam Code HAAD6

Exam Code HAAD6

Exam Code HAAD6

Exam Code HAAD6

EXAM CODE HAAD7

EXAM CODE HAAD7

EXAM CODE HAAD7

EXAM CODE HAAD7

EXAM CODE HAAD7

EXAM CODE HAAD7

EXAM CODE HAAD7

EXAM CODE HAAD7

EXAM CODE HAAD7

EXAM CODE HAAD8

EXAM CODE HAAD8

EXAM CODE HAAD8

EXAM CODE HAAD8

EXAM CODE HAAD8

EXAM CODE HAAD8

EXAM CODE HAAD8

EXAM CODE HAAD8

EXAM CODE HAAD8

EXAM CODE HAAD9