NCLEX-RN Exam Pack Set 2 (75

Questions & Answers Updated

2022)
1. 1. Question
A nurse was instructed by a physician to give clarithromycin
(Biaxin) for a child whose BSA is 0.55 m2. The usual adult dose is
500 mg. Biaxin is available in an oral suspension. The 100ml
bottle is labeled 50 mg/ml. How many ml would the nurse give
per dose? Fill in the blanks. Record your answer using one
decimal place.

o Answer: (3.2) mL.

Correct answer:
o 3.2 mL.

Formula: BS
A Formula: BSA
Formula:

Rationale:
o Use the BSA formula first then the standard formula as
shown above.
o To get the child’s dose, multiply 0.55m2(child’s BSA)
to 500 mg (usual adult dose) to get 275.
o Divide 275 with 1.7 m2to get 161.76 mg.
o Use the standard formula above.
o Divide 161.76 mg (desired pedia dose) with 50 mg
(drug on hand) and multiply by 1 ml (vehicle) to get
3.2 ml.
Computation:

 2. Question
A 28-year-old male has been found wandering around in a
confusing pattern. The male is sweaty and pale. Which of the
following tests is most likely to be performed first?

o A. Blood sugar check

o B. CT scan
o C. Blood cultures
o D. Arterial blood gases

Correct Answer: A. Blood sugar check

With a history of diabetes, the first response should be to check
blood sugar levels.
o Option B: Performing a CT scan at this stage of
assessment is unnecessary. A computerized
tomography (CT) scan combines a series of X-ray
images taken from different angles around the body
and uses computer processing to create cross-
sectional images (slices) of the bones, blood vessels,
and soft tissues inside the body. CT scan images
provide more detailed information than plain X-rays
do.
o Option C: A blood culture test helps the doctor figure
out if the client has a kind of infection that is in the
bloodstream and can affect the entire body. Doctors
call this a systemic infection. The test checks a sample
of the blood for bacteria or yeast that might be
causing the infection.
o Option D: An arterial blood gas (ABG) test measures
oxygen and carbon dioxide levels in the blood. It also
measures the body’s acid-base (pH) level, which is
usually in balance when healthy.
  3. Question
A mother is inquiring about her child’s ability to potty train. Which
of the following factors is the most important aspect of toilet
training?

o A. The age of the child

o B. The child's ability to understand instruction
o C. The overall mental and physical abilities of the
child
o D. Frequent attempts with positive reinforcement

Correct Answer: C. The overall mental and physical

abilities of the child.
Age is not the greatest factor in potty training. The overall mental
and physical abilities of the child are the most important factor.
o Option A: Readiness for toilet training varies with
every age of the child.
o Option B: A child who can follow simple instructions
may start toilet training. However, it is not considered
the most important factor.
o Option D: Positive reinforcement is a great tool for
toilet training, yet, it may not be the most important
one.
 4. Question
A parent calls the pediatric clinic and is frantic about the bottle of
cleaning fluid her child drank for 20 minutes. Which of the
following is the most important instruction the nurse can give the
parent?

o A. This too shall pass

o B. Take the child immediately to the ER
o C. Contact the Poison Control Center quickly
o D. Give the child syrup of ipecac
Correct Answer: C. Contact the Poison Control Center
quickly.
The poison control center will have an exact plan of action for this
child.
o Option A: Ingestion of a chemical is an emergency
and should not be delayed.
o Option B: Taking the client to the ER may be correct,
however, they will still have to contact the Poison
Control Center.
o Option D: It should not be given to someone who
swallowed chemicals that cause burns on contact or
medicines that can cause seizures very quickly. It can
be dangerous to people with some types of medical
problems. When such poisoning victims got Ipecac
anyway, they developed serious complications or even
died.
 5. Question
A nurse is administering a shot of Vitamin K to a 30 day-old
infant. Which of the following target areas is
the most appropriate?

o A. Gluteus maximus
o B. Gluteus minimus
o C. Vastus lateralis
o D. Vastus medialis

Correct Answer: C. Vastus lateralis

Medications are injected into the bulkiest part of the vastus
lateralis thigh muscle, which is the junction of the upper and
middle thirds of this muscle.
o Option A: Intramuscular injections given at the
dorsogluteal and ventrogluteal sites are intended for
the gluteus maximus and gluteus medius muscles,
respectively. However, little research has confirmed
the reliability of these sites for the presence and
thickness of the target and other muscles, and
subcutaneous fat.
 o Option B: Never give an IM injection in the gluteal
muscles to avoid the risk of sciatica nerve damage.
o Option D: The vastus medialis muscle is a part of the
quadriceps muscle group, located on the front of the
thigh.
 6. Question
A nurse has just started her rounds delivering medication. A new
patient on her rounds is a 4-year-old boy who is non-verbal. This
child does not have any identification on. What should the nurse
do?

o A. Contact the provider

o B. Ask the child to write their name on paper
o C. Ask a coworker about the identification of the child
o D. Ask the father who is in the room the child’s
name

Correct Answer: D. Ask the father who is in the room the

child’s name.
In this case, you can determine the name of the child by the
father’s statement. You should not withhold the medication from
the child after identification.
o Option A: Contacting the provider is unnecessary and
may take time. A pediatric patient must have folks
with them inside the room, so asking the child’s folks
would be the most appropriate intervention.
o Option B: The child may have not yet developed his
writing abilities. Some children are able to write their
names at age 4, but some typically developing
children still aren’t ready until well into age.
o Option C: Asking a coworker would be inappropriate
and against the patient’s confidentiality.
 7. Question
A patient is admitted to the hospital with a diagnosis of primary
hyperparathyroidism. A nurse checking the patient’s lab results
would expect which of the following changes in laboratory
findings?
 o A. Elevated serum calcium
o B. Low serum parathyroid hormone (PTH)
o C. Elevated serum vitamin D
o D. Low urine calcium

Correct Answer: A. Elevated serum calcium

The parathyroid glands regulate the calcium level in the blood. In
hyperparathyroidism, the serum calcium level will be elevated.
The chronic excessive resorption of calcium from bone caused by
excessive parathyroid hormone can result in osteopenia.
o Option B: Parathyroid hormone levels may be high or
normal but not low. The main effects of parathyroid
hormone are to increase the concentration of plasma
calcium by increasing the release of calcium and
phosphate from bone matrix, increasing calcium
reabsorption by the kidney, and increasing renal
production of 1,25-dihydroxyvitamin D-3 (calcitriol),
which increases intestinal absorption of calcium.
o Option C: The body will lower the level of vitamin D in
an attempt to lower calcium. Vitamin D levels should
be measured in the evaluation of primary
hyperparathyroidism. Vitamin D deficiency (a 25-
hydroxyvitamin D level of less than 20 ng per milliliter)
can cause secondary hyperparathyroidism, and
repletion of vitamin D deficiency can help to reduce
parathyroid hormone levels.
o Option D: Urine calcium may be elevated, with
calcium spilling over from elevated serum levels. This
may cause renal stones. In addition, the chronically
increased excretion of calcium in the urine can
predispose to the formation of renal stones.
 8. Question
A patient with Addison’s disease asks a nurse for nutrition and
diet advice. Which of the following diet modifications
is not recommended?

o A. A diet high in grains

 o B. A diet with adequate caloric intake
o C. A high protein diet
o D. A restricted sodium diet

Correct Answer: D. A restricted sodium diet

A patient with Addison’s disease requires normal dietary sodium
to prevent excess fluid loss. Patients should eat an unrestricted
diet. Those with primary adrenal insufficiency (Addison disease)
should have ample access to salt because of the salt-wasting that
occurs if their condition is untreated. Infants with primary adrenal
insufficiency often need 2-4 g of sodium chloride per day.
o Option A: A well-balanced diet is the best way to
keep the body healthy and to regulate sugar levels.
Doctors recommend balancing protein, healthy fats,
and high-quality, nutrient-dense carbohydrates.
o Option B: High-calorie comfort food reduces
symptoms of neuroglycopenia in Addison patients,
suggesting that Addison’s disease is associated with a
deficit in cerebral energy supply that can partly be
alleviated by intake of palatable food.
o Option C: Healthy fats and high-quality proteins slow
the blood sugar rollercoaster and promote stable blood
sugar levels throughout the day.
 9. Question
A patient with a history of diabetes mellitus is on the second
postoperative day following cholecystectomy. She has
complained of nausea and isn’t able to eat solid foods. The nurse
enters the room to find the patient confused and shaky. Which of
the following is the most likely explanation for the patient’s
symptoms?

o A. Anesthesia reaction
o B. Hyperglycemia
o C. Hypoglycemia
o D. Diabetic ketoacidosis
Correct Answer: C. Hypoglycemia
A postoperative diabetic patient who is unable to eat is likely to
be suffering from hypoglycemia. Confusion and shakiness are
common symptoms. Reduction in cerebral glucose availability (ie,
neuroglycopenia) can manifest as confusion, difficulty with
concentration, irritability, hallucinations, focal impairments (eg,
hemiplegia), and, eventually, coma and death.
o Option A: An anesthesia reaction would not occur on
the second postoperative day. The adrenergic
symptoms often precede the neuroglycopenic
symptoms and, thus, provide an early warning system
for the patient. Studies have shown that the primary
stimulus for the release of catecholamines is the
absolute level of plasma glucose; the rate of decrease
of glucose is less important.
o Option B: Neuropathy affects up to 50% of patients
with type 1 DM, but symptomatic neuropathy is
typically a late development, developing after many
years of chronic prolonged hyperglycemia. Peripheral
neuropathy presents as numbness and tingling in both
hands and feet, in a glove-and-stocking pattern; it is
bilateral, symmetric, and ascending.
o Option D: Symptoms of hyperglycemia associated
with diabetic ketoacidosis may include thirst, polyuria,
polydipsia, and nocturia.
 10. Question
A nurse assigned to the emergency department evaluates a
patient who underwent fiberoptic colonoscopy 18 hours
previously. The patient reports increasing abdominal pain, fever,
and chills. Which of the following conditions poses
the most immediate concern?

o A. Bowel perforation
o B. Viral Gastroenteritis
o C. Colon cancer
o D. Diverticulitis
Correct Answer: A. Bowel perforation
Bowel perforation is the most serious complication of fiberoptic
colonoscopy. Important signs include progressive abdominal pain,
fever, chills, and tachycardia, which indicate advancing
peritonitis. One of the most serious complications of colonoscopy
is endoscopic perforation of the colon, which has been reported
as between 0.03% and 0.7%. Although colonoscopic perforation
(CP) occurs rarely, it can be associated with high mortality and
morbidity rates.
o Option B: Viral gastroenteritis is a known cause of
nausea, vomiting, diarrhea, anorexia, weight loss, and
dehydration. Isolated cases can occur, but viral
gastroenteritis more commonly occurs in outbreaks
within close communities such as daycare centers,
nursing facilities, and cruise ships. Many different
viruses can lead to symptomatology, though in routine
clinical practice the true causative virus is generally
not identified.
o Option C: If the patient is age 50 or older and at
average risk of colon cancer — he has no colon cancer
risk factors other than age — the doctor may
recommend a colonoscopy every 10 years or
sometimes sooner to screen for colon cancer.
Colonoscopy is one option for colon cancer screening.
o Option D: Diverticulitis may cause pain, fever, and
chills, but is far less serious than perforation and
peritonitis.
 11. Question
A nurse is assessing a clinic patient with a diagnosis of hepatitis
A. Which of the following is the most likely route of transmission?

o A. Sexual contact with an infected partner

o B. Contaminated food
o C. Blood transfusion
o D. Illegal drug use

Correct Answer: B. Contaminated food

Hepatitis A is the only type that is transmitted by the fecal-oral
route through contaminated food. HAV is a single-stranded,
positive-sense, linear RNA enterovirus of the Picornaviridae
family. In humans, viral replication depends on hepatocyte uptake
and synthesis, and assembly occurs exclusively in the liver cells.
Virus acquisition results almost exclusively from ingestion (eg,
fecal-oral transmission)
o Option A: Hepatitis B infection, caused by the
hepatitis B virus (HBV), is commonly transmitted via
body fluids such as blood, semen, and vaginal
secretions. [1] Consequently, sexual contact,
accidental needle sticks or sharing of needles, blood
transfusions, and organ transplantation are routes for
HBV infection.
o Option C: Before widespread screening of the blood
supply in 1992, hepatitis C was also spread through
blood transfusions and organ transplants. Now, the
risk of transmission to recipients of blood or blood
products is extremely low.
o Option D: Today, most people become infected with
hepatitis B, C, or D by sharing needles, syringes, or
any other equipment used to prepare and inject drugs.
 12. Question
A leukemia patient has a relative who wants to donate blood for
transfusion. Which of the following donor medical conditions
would prevent this?

o A. A history of hepatitis C five years previously

o B. Cholecystitis requiring cholecystectomy one year
previously
o C. Asymptomatic diverticulosis
o D. Crohn's disease in remission

Correct Answer: A. A history of hepatitis C five years

previously
Hepatitis C is a viral infection transmitted through bodily fluids,
such as blood, causing inflammation of the liver. Patients with
hepatitis C may not donate blood for transfusion due to the high
risk of infection in the recipient.
o Option B: Cholecystitis is the inflammation of the
gallbladder. This condition does not transmit through
bodily fluids.
o Option C: Diverticulosis is when pockets called
diverticula form in the wall of the digestive tract. The
inner layer of the intestine pushes through weak spots
in the outer lining. This pressure makes them bulge
out, making little pouches.
o Option D: Crohn’s disease is an inflammatory bowel
disease. It causes inflammation of the digestive tract.
This disease does not transmit through the blood.
 13. Question
A physician has diagnosed acute gastritis in a clinic patient.
Which of the following medications would be contraindicated for
this patient?

o A. Naproxen sodium (Naprosyn)

o B. Calcium carbonate
o C. Clarithromycin (Biaxin)
o D. Furosemide (Lasix)

Correct Answer: A. Naproxen sodium (Naprosyn)

Naproxen sodium is a nonsteroidal anti-inflammatory drug that
can cause inflammation of the upper GI tract. For this reason, it is
contraindicated in a patient with gastritis. Naproxen is used to
relieve pain from various conditions such as headache, muscle
aches, tendonitis, dental pain, and menstrual cramps. It also
reduces pain, swelling, and joint stiffness caused by arthritis,
bursitis, and gout attacks.
o Option B: Calcium carbonate is used as an antacid for
the relief of indigestion and is not contraindicated.
Calcium carbonate is a dietary supplement used when
the amount of calcium taken in the diet is not enough.
Calcium is needed by the body for healthy bones,
muscles, nervous system, and heart. Calcium
carbonate also is used as an antacid to relieve
 heartburn, acid indigestion, and upset stomach. It is
available with or without a prescription.
o Option C: Clarithromycin is an antibacterial often
used for the treatment of Helicobacter pylori in
gastritis. Clarithromycin is used to treat certain
bacterial infections, such as pneumonia (a lung
infection), bronchitis (infection of the tubes leading to
the lungs), and infections of the ears, sinuses, skin,
and throat. It also is used to treat and prevent
disseminated Mycobacterium avium complex (MAC)
infection [a type of lung infection that often affects
people with human immunodeficiency virus (HIV)]. It is
used in combination with other medications to
eliminate H. pylori, a bacterium that causes ulcers.
Clarithromycin is in a class of medications called
macrolide antibiotics. It works by stopping the growth
of bacteria.
o Option D: Furosemide is a loop diuretic and is NOT
contraindicated in a patient with gastritis. Furosemide
is used alone or in combination with other medications
to treat high blood pressure. Furosemide is used to
treat edema (fluid retention; excess fluid held in body
tissues) caused by various medical problems,
including heart, kidney, and liver disease. Furosemide
is in a class of medications called diuretics (‘water
pills’). It works by causing the kidneys to get rid of
unneeded water and salt from the body into the urine.
 14. Question
The nurse is conducting nutrition counseling for a patient with
cholecystitis. Which of the following information is important to
communicate?

o A. The patient must maintain a low-calorie diet.

o B. The patient must maintain a high protein/low
carbohydrate diet.
o C. The patient should limit sweets and sugary drinks.
o D. The patient should limit fatty foods.
Correct Answer: D. The patient should limit fatty foods.
Cholecystitis, inflammation of the gallbladder, is most commonly
caused by the presence of gallstones, which may block bile
(necessary for fat absorption) from entering the intestines.
Patients should decrease dietary fat by limiting foods like fatty
meats, fried foods, and creamy desserts to avoid irritation of the
gallbladder.
o Option A: The patient may maintain a moderate to a
high-calorie diet, as a very low-calorie diet may
increase the risk for gallstones that predisposes to
cholecystitis.
o Option B: Both animal fat and animal protein may
contribute to the formation of gallstones. Vitamin C,
which is abundant in plants and absent from meat
affects the rate-limiting step in the catabolism of
cholesterol to bile acids and is inversely related to the
risk of gallstones and cholecystitis. Individuals
consuming the most refined carbohydrates have a
60% greater risk for developing gallstones, compared
with those who consumed the least.
o Option C: Replacing sugary drinks with drinks high in
fiber would reduce the risk of gallbladder stones by
15%.
 15. Question
A patient admitted to the hospital with myocardial infarction
develops severe pulmonary edema. Which of the following
symptoms should the nurse expect the patient to exhibit?

o A. Slow, deep respirations

o B. Stridor
o C. Bradycardia
o D. Air hunger

Correct Answer: D. Air hunger

Patients with pulmonary edema experience air hunger, anxiety,
and agitation. Symptoms may also include coughing up blood or
bloody froth; difficulty breathing when lying down (orthopnea);
feeling of “air hunger” or “drowning” (this feeling is called
“paroxysmal nocturnal dyspnea” if it causes you to wake up 1 to
2 hours after falling asleep and struggle to catch your breath).
o Option A: Physical findings in patients with
pulmonary edema are notable for tachypnea and
tachycardia. Patients may be sitting upright, they may
demonstrate air hunger, and they may become
agitated and confused. Patients usually appear
anxious and diaphoretic.
o Option B: Auscultation of the lungs usually reveals
fine, crepitant rales, but rhonchi or wheezes may also
be present. Rales are usually heard at the bases first;
as the condition worsens, they progress to the apices.
o Option C: Cardiovascular findings are usually notable
for S3, accentuation of the pulmonic component of S2,
and jugular venous distention. Auscultation of
murmurs can help in the diagnosis of acute valvular
disorders manifesting with pulmonary edema.
 16. Question
A nurse caring for several patients in the cardiac unit is told that
one is scheduled for implantation of an automatic internal
cardioverter-defibrillator. Which of the following patients
is most likely to have this procedure?

o A. A patient admitted for myocardial infarction without

cardiac muscle damage.
o B. A postoperative coronary bypass patient, recovering
on schedule.
o C. A patient with a history of ventricular
tachycardia and syncopal episodes.
o D. A patient with a history of atrial tachycardia and
fatigue.

Correct Answer: C. A patient with a history of ventricular

tachycardia and syncopal episodes.
An automatic internal cardioverter-defibrillator delivers an electric
shock to the heart to terminate episodes of ventricular
tachycardia and ventricular fibrillation. This is necessary for a
patient with significant ventricular symptoms, such as
tachycardia resulting in syncope.
o Option A: A patient with myocardial infarction that
resolved with no permanent cardiac damage would not
be a candidate.
o Option B: A patient recovering well from coronary
bypass would not need the device.
o Option D: Atrial tachycardia is less serious and is
treated conservatively with medication and
cardioversion as a last resort.
 17. Question
A patient is scheduled for a magnetic resonance imaging (MRI)
scan for suspected lung cancer. Which of the following is a
contraindication to the study for this patient?

o A. The patient is allergic to shellfish.

o B. The patient has a pacemaker.
o C. The patient suffers from claustrophobia.
o D. The patient takes antipsychotic medication.

Correct Answer: B. The patient has a pacemaker

The implanted pacemaker will interfere with the magnetic fields
of the MRI scanner and may be deactivated by them. Patients
with cardiac implantable electronic devices or CIED are at risk for
inappropriate device therapy, device heating/movement, and
arrhythmia during MRI. These patients must be scheduled in a
CIED blocked slot or scheduled with electrophysiology nurse or
technician support. But nowadays MRI conditional cardiac
implantable electronic devices are widely available.
o Option A: Shellfish/iodine allergy is not a
contraindication because the contrast used in MRI
scanning is not iodine-based. MRI contrast agents are
gadolinium chelates with different stability, viscosity,
and osmolality. Gadolinium is a relatively very safe
contrast; however, it rarely might cause allergic
reactions in patients.
o Options C: Open MRI scanners and anti-anxiety
medications are available for patients with
 claustrophobia. Claustrophobic patients might refuse
to complete the MRI scan and need sedation. These
patients need to be well informed about the MRI scan
procedure. The recommendation is that a physician
has a discussion with them about the details in
advance. Using Larger and opener MRI systems might
be helpful in claustrophobic patients.
o Option D: Psychiatric medication is not a
contraindication to MRI scanning. MRI helps in high-
resolution investigations of soft tissues without the use
of ionizing radiation. This safe modality currently
becomes the imaging technique of choice for
diagnosing musculoskeletal, neurologic, and
cardiovascular disease. However, there are restrictions
and contraindications caused by MRI magnetic fields,
machine structure, and gadolinium contrast agents.
 18. Question
A nurse calls a physician with the concern that a patient has
developed a pulmonary embolism. Which of the following
symptoms has the nurse most likely observed?

o A. The patient is somnolent with decreased response to

the family.
o B. The patient suddenly complains of chest pain
and shortness of breath.
o C. The patient has developed a wet cough and the nurse
hears crackles on auscultation of the lungs.
o D. The patient has a fever, chills, and loss of appetite.

Correct Answer: B. The patient suddenly complains of

chest pain and shortness of breath.
Typical symptoms of pulmonary embolism include chest pain,
shortness of breath, and severe anxiety. The physician should be
notified immediately. Clinical signs and symptoms for pulmonary
embolism are nonspecific; therefore, patients suspected of having
pulmonary embolism—because of unexplained dyspnea,
tachypnea, or chest pain or the presence of risk factors for
pulmonary embolism—must undergo diagnostic tests until the
diagnosis is ascertained or eliminated or an alternative diagnosis
is confirmed.
o Option A: The patient may present atypical
symptoms based on risk factors, such as delirium or a
decreasing level of consciousness.
o Option B: The diagnosis of pulmonary embolism
should be sought actively in patients with respiratory
symptoms UNEXPLAINED by an alternative diagnosis;
symptoms may include productive cough and
wheezing.
o Option D: A patient with fever, chills, and loss of
appetite may be developing pneumonia. Fever of less
than 39°C (102.2ºF) may be present in 14% of
patients; however, a temperature higher than 39.5°C
(103.1º) F is not from a pulmonary embolism.
 19. Question
A patient comes to the emergency department with abdominal
pain. Work-up reveals the presence of a rapidly enlarging
abdominal aortic aneurysm. Which of the following actions should
the nurse expect?

o A. The patient will be admitted to the medicine unit for

observation and medication.
o B. The patient will be admitted to the day surgery unit
for sclerotherapy.
o C. The patient will be admitted to the surgical unit
and resection will be scheduled.
o D. The patient will be discharged home to follow-up with
his cardiologist in 24 hours.

Correct Answer: C. The patient will be admitted to the

surgical unit and resection will be scheduled.
A rapidly enlarging abdominal aortic aneurysm is at significant
risk of rupture and should be resected as soon as possible. No
other appropriate treatment options currently exist.
o Option A: Admitting the patient for observation will
be a delay and may result in the rupture of the
 aneurysm. Immediate surgery is the only
recommended management.
o Option B: Sclerotherapy, in which a solution is
injected into a vein, causing it to collapse, scar, and
fade, remains the primary treatment for the small-
vessel varicose disease of the lower extremities.
o Option D: The patient should not be discharged
because the abdominal aneurysm may rupture at any
time and place the patient’s life at risk.
 20. Question
A patient with leukemia is receiving chemotherapy that is known
to depress bone marrow. A CBC (complete blood count) reveals a
platelet count of 25,000/microliter. Which of the following actions
related specifically to the platelet count should be included in the
nursing care plan?

o A. Monitor for fever every 4 hours.

o B. Require visitors to wear respiratory masks and
protective clothing.
o C. Consider transfusion of packed red blood cells.
o D. Check for signs of bleeding, including
examination of urine and stool for blood.

Correct Answer: D. Check for signs of bleeding, including

examination of urine and stool for blood.
A platelet count of 25,000/microliter is severely
thrombocytopenic and should prompt the initiation of bleeding
precautions, including monitoring urine and stool for evidence of
bleeding.
o Option A: According to three retrospective case
reviews of childhood leukemia (in which 75% to 100%
of the cases were acute lymphoblastic leukemia),
common presenting signs and symptoms include fever
(17% to 77%), lethargy (12% to 39%), and bleeding
(10% to 45%).
o Option B: Requiring protective clothing is indicated to
prevent infection if white blood cells are decreased.
Protective garments consisting of gloves,
 chemotherapy gowns, eye protection e.g.; goggles,
N95 respirator, and shoe covers will be worn according
to the task being performed with a
Chemotherapy/Biotherapy agent or excreta of a
patient who has received a Chemotherapy/Biotherapy
agent within the last 48 hours.
o Option C: Transfusion of red cells is indicated for
severe anemia. Blood transfusions represent one of
the most important forms of supportive care for
patients with leukemia. Cancer is the major cause of
transfusion. One-third of transfused patients have a
malignant disease, with acute leukemia being the
malignancy in a large part of them.
 21. Question
A nurse in the emergency department is observing a 4-year-old
child for signs of increased intracranial pressure after a fall from a
bicycle, resulting in head trauma. Which of the following signs or
symptoms would be cause for concern?

o A. Bulging anterior fontanel

o B. Repeated vomiting
o C. Signs of sleepiness at 10 PM
o D. Inability to read short words from a distance of 18
inches

Correct Answer: B. Repeated vomiting

Increased pressure caused by bleeding or swelling within the skull
can damage delicate brain tissue and may become life-
threatening. Repeated vomiting can be an early sign of pressure
as the vomiting center within the medulla is stimulated.
o Option A: The anterior fontanel is closed in a 4-year-
old child. The average closure time of the anterior
fontanelle ranges from 13 to 24 months. Infants of
African descent statically have larger fontanelles that
range from 1.4 to 4.7 cm, and in terms of sex, the
fontanelles of male infants will closer sooner
compared to female infants.
 o Option C: Evidence of sleepiness at 10 PM is normal
for a four-year-old. Young toddlers have a sleep
schedule supplemented by two naps a day. Toddler
sleep problems are compounded by separation anxiety
and a fear of missing out, which translates to stalling
techniques and stubbornness at bedtime.
o Option D: The average 4-year-old child cannot read
yet, so this too is normal. At 4, many children just
aren’t ready to sit still and focus on a book for long.
Others may learn the mechanics of reading but aren’t
cognitively ready to comprehend the words.
 22. Question
A nonimmunized child appears at the clinic with a visible rash.
Which of the following observations indicates the child may have
rubeola (measles)?

o A. Small blue-white spots are visible on the oral

mucosa.
o B. The rash begins on the trunk and spreads outward.
o C. There is low-grade fever.
o D. The lesions have a "teardrop-on-a-rose-petal"
appearance.

Correct Answer: A. Small blue-white spots are visible on

the oral mucosa.
Koplik’s spots are small blue-white spots visible on the oral
mucosa and are characteristic of measles infection. Near the end
of the prodrome, Koplik spots (ie, bluish-gray specks or “grains of
sand” on a red base) appear on the buccal mucosa opposite the
second molars. The Koplik spots generally are first seen 1-2 days
before the appearance of the rash and last until 2 days after the
rash appears. This enanthem begins to slough as the rash
appears. Although this is the pathognomonic enanthem of
measles, its absence does not exclude the diagnosis.
o Option B: The body rash typically begins on the face
and travels downward. Blanching, erythematous
macules and papules begin on the face at the hairline,
on the sides of the neck, and behind the ears (see the
 images below). Within 48 hours, they coalesce into
patches and plaques that spread cephalocaudally to
the trunk and extremities, including the palms and
soles, while beginning to regress cephalocaudally,
starting from the head and neck. Lesion density is
greatest above the shoulders, where macular lesions
may coalesce. The eruption may also be petechial or
ecchymotic in nature.
o Option C: High fever (may spike to more than 104°F)
is often present. The first sign of measles is usually a
high fever (often >104o F [40o C]) that typically lasts
4-7 days. This prodromal phase is marked by malaise,
fever, anorexia, and the classic triad of conjunctivitis
(see the image below), cough, and coryza (the “3 Cs”).
o Option D: “Teardrop on a rose petal” refers to the
lesions found in varicella (chickenpox). The
characteristic chickenpox vesicle, surrounded by an
erythematous halo, is described as a dewdrop on a
rose petal
 23. Question
A child is seen in the emergency department for scarlet fever.
Which of the following descriptions of scarlet fever is not correct?

o A. Scarlet fever is caused by infection with group A

Streptococcus bacteria.
o B. "Strawberry tongue" is a characteristic sign.
o C. Petechiae occur on the soft palate.
o D. The pharynx is red and swollen.

Correct Answer: C. Petechiae occur on the soft palate.

Petechiae on the soft palate is characteristic of rubella infection.
o Option A: Bacteria called group A Streptococcus or
group A strep cause scarlet fever. The bacteria
sometimes make a poison (toxin), which causes a
rash- the “scarlet” of scarlet fever. As the name
“scarlet fever” implies, an erythematous eruption is
associated with a febrile illness. The circulating toxin,
produced by GABHS and often referred to as
 erythemogenic or erythrogenic toxin, causes the
pathognomonic rash as a consequence of local
production of inflammatory mediators and alteration
of the cutaneous cytokine milieu. This results in a
sparse inflammatory response and dilatation of blood
vessels, leading to the characteristic scarlet color of
the rash.
o Option B: The tongue may have a “strawberry”-like
(red and bumpy) appearance, which is a characteristic
sign of scarlet fever. On day 1 or 2, the tongue is
heavily coated with a white membrane through which
edematous red papillae protrude (classic appearance
of white strawberry tongue). By day 4 or 5, the white
membrane sloughs off, revealing a shiny red tongue
with prominent papillae (red strawberry tongue). Red,
edematous, exudative tonsils are typically observed if
the infection originates in this area.
o Option D: The throat and tonsils may be very red and
sore with scarlet fever, and swallowing may be painful.
The mucous membranes usually are bright red and
scattered petechiae and small red papular lesions on
the soft palate are often present.
 24. Question
A child weighing 30 kg arrives at the clinic with diffuse itching as
the result of an allergic reaction to an insect bite.
Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed.
The correct pediatric dose is 5 mg/kg/day. Which of the
following best describes the prescribed drug dose?

o A. It is the correct dose

o B. The dose is too low
o C. The dose is too high
o D. The dose should be increased or decreased,
depending on the symptoms

Correct Answer: B. The dose is too low

This child weighs 30 kg, and the pediatric dose of
diphenhydramine is 5 mg/kg/day (5 X 30 = 150/day). Therefore,
the correct dose is 150 mg/day. Divided into 3 doses per day, the
child should receive 50 mg 3 times a day rather than 25 mg 3
times a day. Dosage should not be titrated based on symptoms
without consulting a physician.
o Option A: Diphenhydramine is used to relieve red,
irritated, itchy, watery eyes; sneezing; and runny nose
caused by hay fever, allergies, or the common cold.
Diphenhydramine is also used to relieve coughs
caused by minor throat or airway irritation.
o Option C: Diphenhydramine comes as a tablet, a
rapidly disintegrating (dissolving) tablet, a capsule, a
liquid-filled capsule, a dissolving strip, powder, and a
liquid to take by mouth. When diphenhydramine is
used for the relief of allergies, cold, and cough
symptoms, it is usually taken every 4 to 6 hours.
o Option D: Before you give a diphenhydramine
product to a child, check the package label to find out
how much medication the child should receive. Give
the dose that matches the child’s age on the chart.
Ask the child’s doctor if you don’t know how much
medication to give the child.
 25. Question
The mother of a 2-month-old infant brings the child to the clinic
for a well-baby check. She is concerned because she feels only
one testis in the scrotal sac. Which of the following statements
about the undescended testis is the most accurate?

o A. Normally, the testes are descended by birth.

o B. The infant will likely require surgical intervention.
o C. The infant probably has only one testis.
o D. Normally, the testes descend by one year of
age.

Correct Answer: D. Normally, the testes descend by one

year of age.
Normally, the testes descend by one year of age. In young
infants, it is common for the testes to retract into the inguinal
canal when the environment is cold or the cremasteric reflex is
stimulated. The exam should be done in a warm room with warm
hands. It is most likely that both testes are present and will
descend by a year. If not, a full assessment will determine the
appropriate treatment.
o Option A: The testes usually descend by one year of
age. Most of the time, a boy’s testicles descend by the
time he is 9 months old. Undescended testicles are
common in infants who are born early. The problem
occurs less in full-term infants.
o Option B: Surgical intervention is unnecessary; the
testes descend by one year of age. The testicles will
descend normally at puberty and surgery is not
needed. Testicles that do not naturally descend into
the scrotum are considered abnormal. An
undescended testicle is more likely to develop cancer,
even if it is brought into the scrotum with surgery.
Cancer is also more likely in the other testicle.
o Option C: In young infants, it is common for the
testes to retract into the inguinal canal when the
environment is cold or the cremasteric reflex is
stimulated.
 26. Question
A child is admitted to the hospital with a diagnosis of Wilms
tumor, stage II. Which of the following
statements most accurately describes this stage?

o A. The tumor is less than 3 cm. in size and requires no

chemotherapy.
o B. The tumor did not extend beyond the kidney and was
completely resected.
o C. The tumor extended beyond the kidney but was
completely resected.
o D. The tumor has spread into the abdominal cavity and
cannot be resected.

Correct Answer: C. The tumor extended beyond the kidney

but was completely resected.
The staging of Wilms tumor is confirmed at surgery as follows:
Stage I, the tumor is limited to the kidney and completely
resected; stage II, the tumor extends beyond the kidney but is
completely resected; stage III, the residual non-hematogenous
tumor is confined to the abdomen; stage IV, hematogenous
metastasis has occurred with spread beyond the abdomen; and
stage V, bilateral renal involvement is present at diagnosis.
o Option A: The mass is solid at presentation and
usually >10 cm.
o Option B: This option describes stage 1, wherein the
tumor is limited to the kidney and completely
resected.
o Option D: In stage IV, hematogenous metastasis has
occurred with spread beyond the abdomen.
 27. Question
A teen patient is admitted to the hospital by his physician who
suspects a diagnosis of acute glomerulonephritis. Which of the
following findings is consistent with this diagnosis? Select all
that apply.

o A. Urine specific gravity of 1.040

o B. Urine output of 350 ml in 24 hours
o C. Brown ("tea-colored") urine
o D. Generalized edema

Correct Answer: A, B, & C

Acute glomerulonephritis is characterized by high urine specific
gravity related to oliguria as well as dark “tea-colored” urine
caused by large amounts of red blood cells.
Option A: The urine is dark. Its specific gravity is greater than
1.020. RBCs and RBC casts are present.
o Option B: Functional changes include proteinuria,
hematuria, reduction in GFR (ie, oliguria or anuria),
and active urine sediment with RBCs and RBC casts.
The decreased GFR and avid distal nephron salt and
water retention result in the expansion of intravascular
volume, edema, and, frequently, systemic
hypertension.
 o Option C: This is a universal finding, even if it is
microscopic. Gross hematuria is reported in 30% of
pediatric patients, often manifesting as smoky-,
coffee-, or cola-colored urine.
o Option D: There is periorbital edema, but generalized
edema is seen in nephrotic syndrome, not acute
glomerulonephritis. Most often, the patient is a boy,
aged 2-14 years, who suddenly develop puffiness of
the eyelids and facial edema in the setting of a post-
streptococcal infection.
 28. Question
Which of the following conditions most commonly causes acute
glomerulonephritis?

o A. A congenital condition leading to renal dysfunction.

o B. Prior infection with group A Streptococcus
within the past 10-14 days.
o C. Viral infection of the glomeruli.
o D. Nephrotic syndrome.

Correct Answer: B. Prior infection with group A

Streptococcus within the past 10-14 days.
Acute glomerulonephritis is most commonly caused by the
immune response to a prior upper respiratory infection with
group A Streptococcus. Glomerular inflammation occurs about
10-14 days after the infection, resulting in scant, dark urine, and
retention of body fluid. Periorbital edema and hypertension are
common signs at diagnosis.
o Option A: No congenital condition predisposes to
glomerulonephritis. Noninfectious causes of acute GN
may be divided into primary renal diseases, systemic
diseases, and miscellaneous conditions or agents.
o Option C: Viruses may cause acute
glomerulonephritis but rarely. Cytomegalovirus (CMV),
coxsackievirus, Epstein-Barr virus (EBV), hepatitis B
virus (HBV), rubella, rickettsiae (as in scrub typhus),
parvovirus B19, and mumps virus are accepted as
viral causes only if it can be documented that a recent
 group A beta-hemolytic streptococcal infection did not
occur. Acute GN has been documented as a rare
complication of hepatitis A.
o Option D: Nephrotic syndrome does not cause acute
glomerulonephritis. PSGN usually develops 1-3 weeks
after acute infection with specific nephritogenic strains
of group A beta-hemolytic streptococcus. The
incidence of GN is approximately 5-10% in persons
with pharyngitis and 25% in those with skin infections.
 29. Question
An infant with hydrocele is seen in the clinic for a follow-up visit
at 1 month of age. The scrotum is smaller than it was at birth, but
the fluid is still visible on illumination. Which of the following
actions is the physician likely to recommend?

o A. Massaging the groin area twice a day until the fluid is

gone.
o B. Referral to a surgeon for repair.
o C. No treatment is necessary; the fluid is
reabsorbing normally.
o D. Keeping the infant in a flat, supine position until the
fluid is gone.

Correct Answer: C. No treatment is necessary; the fluid is

reabsorbing normally.
A hydrocele is a collection of fluid in the scrotum that results from
a patent tunica vaginalis. Illumination of the scrotum with a
pocket light demonstrates the clear fluid. In most cases, the fluid
reabsorbs within the first few months of life and no treatment is
necessary.
o Option A: A hydrocele can develop before birth.
Normally, the testicles descend from the developing
baby’s abdominal cavity into the scrotum. A sac
accompanies each testicle, allowing fluid to surround
the testicles. Usually, each sac closes and the fluid is
absorbed. Sometimes, the fluid remains after the sac
closes (noncommunicating hydrocele). The fluid is
usually absorbed gradually within the first year of life.
 But occasionally, the sac remains open
(communicating hydrocele). The sac can change size
or if the scrotal sac is compressed, fluid can flow back
into the abdomen. Communicating hydroceles are
often associated with inguinal hernia.
o Option B: A hydrocele that doesn’t disappear on its
own might need to be surgically removed, typically as
an outpatient procedure. The surgery to remove a
hydrocele (hydrocelectomy) can be done under
general or regional anesthesia. An incision is made in
the scrotum or lower abdomen to remove the
hydrocele. If a hydrocele is found during surgery to
repair an inguinal hernia, the surgeon might remove
the hydrocele even if it’s causing no discomfort.
o Option D: A baby’s hydrocele typically disappears on
its own. But if the baby’s hydrocele doesn’t disappear
after a year or if it enlarges, ask the child’s doctor to
examine the hydrocele again.
 30. Question
A nurse is caring for a patient with peripheral vascular disease
(PVD). The patient complains of burning and tingling of the hands
and feet and cannot tolerate touch of any kind. Which of the
following is the most likely explanation for these symptoms?

o A. Inadequate tissue perfusion leading to nerve

damage.
o B. Fluid overload leading to compression of nerve tissue.
o C. Sensation distortion due to psychiatric disturbance.
o D. Inflammation of the skin on the hands and feet.

Correct Answer: A. Inadequate tissue perfusion leading to

nerve damage.
Patients with peripheral vascular disease often sustain nerve
damage as a result of inadequate tissue perfusion. Ischemic rest
pain is more worrisome; it refers to pain in the extremity that is
due to a combination of PVD and inadequate perfusion. Ischemic
rest pain often is exacerbated by poor cardiac output. The
condition is often partially or fully relieved by placing the
extremity in a dependent position, so that perfusion is enhanced
by the effects of gravity.
o Option B: Fluid overload is not characteristic of PVD.
Assess the heart for murmurs or other abnormalities.
Investigate all peripheral vessels, including carotid,
abdominal, and femoral, for pulse quality and bruit.
Note that the dorsalis pedis artery is absent in 5-8% of
normal subjects, but the posterior tibial artery usually
is present. Both pulses are absent in only about 0.5%
of patients. Exercise may cause the obliteration of
these pulses.
o Option C: There is nothing to indicate a psychiatric
disturbance in the patient.
o Option D: Skin changes in PVD are secondary to
decreased tissue perfusion rather than primary
inflammation. The skin may have an atrophic, shiny
appearance and may demonstrate trophic changes,
including alopecia; dry, scaly, or erythematous skin;
chronic pigmentation changes; and brittle nails.
 31. Question
A patient in the cardiac unit is concerned about the risk factors
associated with atherosclerosis. Which of the following are
hereditary risk factors for developing atherosclerosis?

o A. Family history of heart disease

o B. Overweight
o C. Smoking
o D. Age

Correct Answer: A. Family history of heart disease.

A family history of heart disease is an inherited risk factor that is
not subject to a lifestyle change. Having a first-degree relative
with heart disease has been shown to significantly increase risk.
o Option B: Overweight is a risk factor that is subject to
lifestyle change and can reduce risk significantly. The
terms “overweight” and “obesity” refer to body weight
that’s greater than what is considered healthy for a
certain height.
 o Option C: Smoking can damage and tighten blood
vessels, raise cholesterol levels, and raise blood
pressure. Smoking also doesn’t allow enough oxygen
to reach the body’s tissues.
o Option D: Advancing age increases the risk of
atherosclerosis but is not a hereditary factor. As one
gets older, the risk for atherosclerosis increases.
Genetic or lifestyle factors cause plaque to build up in
the arteries as one ages. By the time one is middle-
aged or older, enough plaque has built up to cause
signs or symptoms. In men, the risk increases after
age 45. In women, the risk increases after age 55.
 32. Question
Claudication is a well-known effect of peripheral vascular disease.
Which of the following facts about claudication is correct? Select
all that apply:

o A. It results when oxygen demand is greater than

oxygen supply.
o B. It is characterized by pain that often occurs during
rest.
o C. It is a result of tissue hypoxia.
o D. It is characterized by cramping and weakness.
o E. It always affects the upper extremities.

Correct Answer: A, C, & D.

Claudication describes the pain experienced by a patient with a
peripheral vascular disease when oxygen demand in the leg
muscles exceeds the oxygen supply. The tissue becomes hypoxic,
causing cramping, weakness, and discomfort.
o Option A: Claudication refers to muscle pain due to
lack of oxygen that’s triggered by activity and relieved
by rest.
o Option B: This most often occurs during activity when
demand increases in muscle tissue.
o Option C: The condition is also called intermittent
claudication because the pain usually isn’t constant. It
 begins during exercise and ends with rest. As
claudication worsens, however, the pain may occur
during rest.
o Option D: Claudication is pain caused by too little
blood flow to muscles during exercise. Most often this
pain occurs in the legs after walking at a certain pace
and for a certain amount of time — depending on the
severity of the condition.
Option E: Pain in the shoulders, biceps, and forearms
may occur, but less often.
 33. Question
A nurse is providing discharge information to a patient with
peripheral vascular disease. Which of the following information
should be included in the instructions?

o A. Walk barefoot whenever possible.

o B. Use a heating pad to keep feet warm.
o C. Avoid crossing the legs.
o D. Use antibacterial ointment to treat skin lesions at risk
of infection.

Correct Answer: C. Avoid crossing the legs.

Patients with peripheral vascular disease should avoid crossing
the legs because this can impede blood flow. PVD, also known as
arteriosclerosis obliterans, is primarily the result of
atherosclerosis. The atheroma consists of a core of cholesterol
joined to proteins with a fibrous intravascular covering. The
atherosclerotic process may gradually progress to complete
occlusion of medium-sized and large arteries. The disease
typically is segmental, with significant variation from patient to
patient.
o Option A: Walking barefoot is not advised, as foot
protection is important to avoid the trauma that may
lead to serious infection.
o Option B: Heating pads can cause injury, which can
also increase the risk of infection.
o Option D: Skin lesions at risk for infection should be
examined and treated by a physician.
  34. Question
A patient who has been diagnosed with the vasospastic disorder
(Raynaud’s disease) complains of cold and stiffness in the fingers.
Which of the following descriptions is most likely to fit the
patient?

o A. An adolescent male
o B. An elderly woman
o C. A young woman
o D. An elderly man

Correct Answer: C. young woman.

Raynaud’s disease is most common in young women and is
frequently associated with rheumatologic disorders, such as lupus
and rheumatoid arthritis. Vasospasm of the arteries reduces
blood flow to the fingers and toes. In people who have Raynaud’s,
the disorder usually affects the fingers. In about 40 percent of
people who have Raynaud’s, it affects the toes. Rarely, the
disorder affects the nose, ears, nipples, and lips.
o Option A: Primary Raynaud’s usually develops before
the age of 30. In primary Raynaud’s (also called
Raynaud’s disease), the cause isn’t known. Primary
Raynaud’s are more common and tend to be less
severe than secondary Raynaud’s.
o Option B: Secondary Raynaud’s usually develops
after the age of 30. Secondary Raynaud’s is caused by
an underlying disease, condition, or other factors. This
type of Raynaud’s is often called Raynaud’s
phenomenon.
o Option D: Although anyone can develop the
condition, Raynaud’s disease often begins between
the ages 15 to 30, but it mostly affects women. If one
has primary or secondary Raynaud’s, cold
temperatures or stress can trigger “Raynaud’s
attacks.” During an attack, little or no blood flows to
affected body parts.
  35. Question
A 23-year-old patient in the 27th week of pregnancy has been
hospitalized on complete bed rest for 6 days. She experiences
sudden shortness of breath, accompanied by chest pain. Which of
the following conditions is the most likely cause of her
symptoms?

o A. Myocardial infarction due to a history of

atherosclerosis.
o B. Pulmonary embolism due to deep vein
thrombosis (DVT).
o C. Anxiety attacks due to worries about her baby's
health.
o D. Congestive heart failure due to fluid overload.

Correct Answer: B. Pulmonary embolism due to deep vein

thrombosis (DVT).
In a hospitalized patient on prolonged bed rest, the most likely
cause of sudden onset shortness of breath and chest pain is
pulmonary embolism. Pregnancy and prolonged inactivity both
increase the risk of clot formation in the deep veins of the legs.
These clots can then break loose and travel to the lungs.
o Option A: Atherosclerosis is the disease primarily
responsible for most acute coronary syndrome (ACS)
cases. Approximately 90% of myocardial infarctions
(MIs) result from an acute thrombus that obstructs an
atherosclerotic coronary artery. Plaque rupture and
erosion are considered to be the major triggers for
coronary thrombosis. Following plaque erosion or
rupture, platelet activation and aggregation,
coagulation pathway activation, and endothelial
vasoconstriction occur, leading to coronary thrombosis
and occlusion.
o Option C: There is no reason to suspect an anxiety
disorder in this patient. Though anxiety is a possible
cause of her symptoms, the seriousness of pulmonary
embolism demands that it be considered first.
 o Option D: According to 2017 American Heart
Association (AHA) data, heart failure affects an
estimated 6.5 million Americans aged 20 years and
older. [31] With improved survival of patients with
acute myocardial infarction and with a population that
continues to age, heart failure will continue to increase
in prominence as a major health problem in the United
States.
 36. Question
Thrombolytic therapy is frequently used in the treatment of
suspected stroke. Which of the following is a significant
complication associated with thrombolytic therapy?

o A. Air embolus.
o B. Cerebral hemorrhage.
o C. Expansion of the clot.
o D. Resolution of the clot.

Correct Answer: B. Cerebral hemorrhage.

Cerebral hemorrhage is a significant risk when treating a stroke
victim with thrombolytic therapy intended to dissolve a suspected
clot. The success of the treatment demands that it be instituted
as soon as possible, often before the cause of stroke has been
determined.
o Option A: Air embolism is not a concern. Thrombosis
is an important part of the normal hemostatic
response that limits hemorrhage caused by
microscopic or macroscopic vascular injury. Physiologic
thrombosis is counterbalanced by intrinsic
antithrombotic properties and fibrinolysis. Under
normal conditions, a thrombus is confined to the
immediate area of injury and does not obstruct flow to
critical areas, unless the blood vessel lumen is already
diminished, as it is in atherosclerosis.
o Option C: Both hemostasis and thrombosis depend on
the coagulation cascade, vascular wall integrity, and
platelet response. Several cellular factors are
responsible for thrombus formation. When a vascular
 insult occurs, an immediate local cellular response
takes place. Platelets migrate to the area of injury,
where they secrete several cellular factors and
mediators. These mediators promote clot formation.
o Option D: Thrombolytic therapy does not lead to the
expansion of the clot, but to resolution, which is the
intended effect.
 37. Question
An infant is brought to the clinic by his mother, who has noticed
that he holds his head in an unusual position and always faces to
one side. Which of the following is the most likely explanation?

o A. Torticollis, with shortening of the

sternocleidomastoid muscle.
o B. Craniosynostosis, with premature closure of the
cranial sutures.
o C. Plagiocephaly, with flattening of one side of the head.
o D. Hydrocephalus, with increased head size.

Correct Answer: A. Torticollis, with shortening of the

sternocleidomastoid muscle.
In torticollis, the sternocleidomastoid muscle is contracted,
limiting the range of motion of the neck and causing the chin to
point to the opposing side.
o Option B: In craniosynostosis one of the cranial
sutures, often the sagittal, closes prematurely, causing
the head to grow in an abnormal shape.
o Option C: Plagiocephaly refers to the flattening of one
side of the head, caused by the infant being placed
supine in the same position over time.
o Option D: Hydrocephalus is caused by a build-up of
cerebrospinal fluid in the brain resulting in large head
size.
 38. Question
An adolescent brings a physician’s note to school stating that he
is not to participate in sports due to a diagnosis of Osgood-
Schlatter disease. Which of the following statements about the
disease is correct?

o A. The condition was caused by the student's

competitive swimming schedule.
o B. The student will most likely require surgical
intervention.
o C. The student experiences pain in the inferior
aspect of the knee.
o D. The student is trying to avoid participation in physical
education.

Correct Answer: C. The student experiences pain in the

inferior aspect of the knee.
Osgood-Schlatter disease occurs in adolescents in the rapid
growth phase when the infrapatellar ligament of the quadriceps
muscle pulls on the tibial tubercle, causing pain and swelling in
the inferior aspect of the knee. Osgood-Schlatter disease is
commonly caused by activities that require repeated use of the
quadriceps, including track and soccer.
o Option A: Swimming is not a likely cause. OSD is a
traction phenomenon resulting from repetitive
quadriceps contraction through the patellar tendon at
its insertion upon the skeletally immature tibial
tubercle. This occurs in preadolescence during a time
when the tibial tubercle is susceptible to strain. The
pain associated will be localized to the tibial tubercle
and occasionally the patellar tendon itself.
o Option B: The condition is usually self-limited,
responding to ice, rest, and analgesics. OSD is a self-
limiting condition. In a study by Krause et al, 90% of
patients treated with conservative care were relieved
of all of their symptoms approximately 1 year after the
onset of symptoms. [3] After skeletal maturity,
patients may continue to have problems kneeling. This
typically is due to tenderness over an unfused tibial
tubercle ossicle or a bursa that may require resection.
o Option D: Continued participation will worsen the
condition and the symptoms. The onset of OSD is
 usually gradual, with patients commonly complaining
of pain in the tibial tubercle and/or patellar tendon
region after repetitive activities. Typically, running or
jumping activities that significantly stress the patellar
tendon insertion upon the tibial tubercle aggravate the
patient’s symptoms.
 39. Question
The clinic nurse asks a 13-year-old female to bend forward at the
waist with arms hanging freely. Which of the following
assessments is the nurse most likely conducting?

o A. Spinal flexibility
o B. Leg length disparity
o C. Hypostatic blood pressure
o D. Scoliosis

Correct Answer: D. Scoliosis.

A check for scoliosis, a lateral deviation of the spine, is an
important part of the routine adolescent exam. It is assessed by
having the teen bend at the waist with arms dangling, while
observing for lateral curvature and uneven rib level. Scoliosis is
more common in female adolescents.
o Options A: The ability to move the spine through its
full range of motion, both forward and backward, is
called spinal flexibility. However, it is not included in
routine adolescent exams.
o Options B: Leg length discrepancy or disparity is a
condition in which the paired lower extremity limbs
have a noticeably unequal length.
o Option C: Hypostatic or orthostatic blood pressure is
a form of low blood pressure that happens when one is
sitting or stands up suddenly.
 40. Question
A clinic nurse interviews a parent who is suspected of abusing her
child. Which of the following characteristics is the
nurse least likely to find in an abusing parent?
 o A. Low self-esteem
o B. Unemployment
o C. Self-blame for the injury to the child
o D. Single status

Correct Answer: C. Self-blame for the injury to the child.

The profile of a parent at risk of abusive behavior includes a
tendency to blame the child or others for the injury sustained.
Abusers typically blame others, especially their partners, for the
mistakes in their lives. This is related to hypersensitivity, but they
are not necessarily alike. This occurs because most abusive
people don’t hold themselves as being accountable for the
actions they commit. Instead, they’ll try to shift the blame to the
person that they have abused and somehow say they “deserved
it” or that they were forced into a corner.
o Option A: Basically, domestic violence offenders
always feel the need to be in control of their victims.
The less in control an offender feels, the more they
want to hurt others.
o Option B: One study suggests that unemployment
can cause an increase in child neglect because
parents have more limited access to the resources
required to provide for a child’s basic needs, such as
clothing, food, and medical care.
o Option D: A “favorite” of abusers is to isolate their
partners from family or friends. This type of isolation is
often very common and often represents the first step
in an abusive relationship. The abusive partner will
attempt to set up an “us versus them” attitude and
will begin isolating family members. This can work
through the abuser’s use of jealousy, controlling
behavior, or veiled concern.
 41. Question
A nurse is assigned to the pediatric rheumatology clinic and is
assessing a child who has just been diagnosed with juvenile
idiopathic arthritis. Which of the following statements about the
disease is most accurate?
 o A. The child has a poor chance of recovery without joint
deformity.
o B. Most children progress to adult rheumatoid arthritis.
o C. Nonsteroidal anti-inflammatory drugs are the
first choice in treatment.
o D. Physical activity should be minimized.

Correct Answer: C. Nonsteroidal anti-inflammatory drugs

are the first choice in treatment.
Nonsteroidal anti-inflammatory drugs are an important first-line
treatment for juvenile idiopathic arthritis (formerly known as
juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the
therapeutic anti-inflammatory effects to be realized.
o Options A: Advances in treatment over the last 20
years—especially the introduction of early use of intra-
articular steroids, methotrexate, and biologic
medications—have dramatically improved the
prognosis for children with arthritis. Almost all children
with JIA lead productive lives. However, many patients,
particularly those with a polyarticular disease, may
have problems with the active disease throughout
adulthood, with sustained remission attained in a
minority of patients.
o Option B: Children with the systemic-onset disease
tend to either respond completely to medical therapy
or develop a severe polyarticular course that tends to
be refractory to medical treatment, with disease
persisting into adulthood.
o Option D: Physical activity is an integral part of
therapy. Encourage patients to be as active as
possible. Bed rest is not a part of the treatment. In
fact, the more active the patient, the better the long-
term prognosis. Children may experience increased
pain during routine physical activities. As a result,
these children must be allowed to self-limit their
activities, particularly during physical education
classes. A consistent physical therapy program, with
attention to stretching exercises, pain modalities, joint
 protection, and home exercises, can help ensure that
patients are as active as possible.
 42. Question
A child is admitted to the hospital several days after stepping on
a sharp object that punctured her athletic shoe and entered the
flesh of her foot. The physician is concerned about osteomyelitis
and has ordered parenteral antibiotics. Which of the following
actions is done immediately before the antibiotic is started?

o A. The admission orders are written.

o B. A blood culture is drawn.
o C. A complete blood count with differential is drawn.
o D. The parents arrive.

Correct Answer: B. A blood culture is drawn.

Antibiotics must be started after the blood culture is drawn, as
they may interfere with the identification of the causative
organism.
o Option A: Making sure that the physician’s orders for
antibiotics are written, instead of admitting orders,
should be done.
o Option C: The blood count will reveal the presence of
infection but does not help identify an organism or
guide antibiotic treatment.
o Option D: Parental presence is important for the
adjustment of the child but not for the administration
of medication.
 43. Question
A two-year-old child has sustained an injury to the leg and refuses
to walk. The nurse in the emergency department documents
swelling of the lower affected leg. Which of the following does the
nurse suspect is the cause of the child’s symptoms?

o A. Possible fracture of the tibia.

o B. Bruising of the gastrocnemius muscle.
 o C. Possible fracture of the radius.
o D. No anatomic injury, the child wants his mother to
carry him.

Correct Answer: A. Possible fracture of the tibia.

The child’s refusal to walk, combined with swelling of the limb is
suspicious for fracture.
o Option B: Toddlers will often continue to walk on a
muscle that is bruised or strained.
o Option C: The radius is found in the lower arm and is
not relevant to this question.
o Option D: Toddlers rarely feign injury to be carried,
and swelling indicates a physical injury.
 44. Question
A toddler has recently been diagnosed with cerebral palsy. Which
of the following information should the nurse provide to the
parents? Select all that apply.

o A. Regular developmental screening is important

to avoid secondary developmental delays.
o B. Cerebral palsy is caused by injury to the upper
motor neurons and results in motor dysfunction, as
well as possible ocular and speech difficulties.
o C. Developmental milestones may be slightly delayed
but usually will require no additional intervention.
o D. Parent support groups are helpful for sharing
strategies and managing health care issues.
o E. Therapies and surgical interventions can cure cerebral
palsy.

Correct Answer: A, B, and D.

Delayed developmental milestones are characteristic of cerebral
palsy, so regular screening and intervention is essential. Because
of injury to upper motor neurons, children may have ocular and
speech difficulties. Parent support groups help families to share
and cope. Physical therapy and other interventions can minimize
the extent of the delay in developmental milestones.
o Option A: During a developmental screening, a short
test is given to see if the child has specific
developmental delays, such as motor or movement
delays. If the results of the screening test are cause
for concern, then the doctor will make referrals for
developmental and medical evaluations.
o Option B: Cerebral palsy (CP) is a group of disorders
that affect a person’s ability to move and maintain
balance and posture. CP is the most common motor
disability in childhood. Cerebral means having to do
with the brain. Palsy means weakness or problems
with using the muscles. CP is caused by abnormal
brain development or damage to the developing brain
that affects a person’s ability to control his or her
muscles.
o Option C: Delayed developmental milestones
definitely need interventions and constant follow ups.
Developmental monitoring (also called surveillance)
means tracking a child’s growth and development over
time. If any concerns about the child’s development
are raised during monitoring, then a developmental
screening test should be given as soon as possible.
o Option D: Both early intervention and school-aged
services are available through a special education law
—the Individuals with Disabilities Education Act (IDEA).
Part C of IDEA deals with early intervention services
(birth through 36 months of age), while Part B applies
to services for school-aged children (3 through 21
years of age). Even if the child has not been diagnosed
with CP, he or she may be eligible for IDEA services.
o Option E: Cerebral palsy has no cure, but treatment
can improve the lives of those who have the condition.
After a CP diagnosis is made, a team of health
professionals works with the child and family to
develop a plan to help the child reach his or her full
potential. Common treatments include medicines;
surgery; braces; and physical, occupational, and
speech therapy. No single treatment is the best one for
all children with CP. Before deciding on a treatment
 plan, it is important to talk with the child’s doctor to
understand all the risks and benefits.
 45. Question
A child has recently been diagnosed with Duchenne muscular
dystrophy (DMD). The parents are receiving genetic counseling
prior to planning another pregnancy. Which of the following
statements includes the most accurate information?

o A. Duchenne's is an X-linked recessive disorder, so

daughters have a 50% chance of being carriers and
sons a 50% chance of developing the disease.
o B. Duchenne's is an X-linked recessive disorder, so both
daughters and sons have a 50% chance of developing the
disease.
o C. Each child has a 1 in 4 (25%) chance of developing
the disorder.
o D. Sons only have a 1 in 4 (25%) chance of developing
the disorder.

Correct Answer: A. Duchenne’s is an X-linked recessive

disorder, so daughters have a 50% chance of being
carriers and sons a 50% chance of developing the disease.
The recessive Duchenne gene is located on one of the two X
chromosomes of a female carrier. If her son receives the X
bearing the gene he will be affected. Thus, there is a 50% chance
of a son being affected. Daughters are not affected, but 50% are
carriers because they inherit one copy of the defective gene from
the mother. The other X chromosome comes from the father, who
cannot be a carrier.
o Option B: DMD carriers are females who have a
normal dystrophin gene on one X chromosome and an
abnormal dystrophin gene on the other X
chromosome. Most carriers of DMD do not themselves
have signs and symptoms of the disease, but a
minority do.
o Option C: Advances in molecular biology techniques
illuminate the genetic basis underlying all MD: defects
in the genetic code for dystrophin, a 427-kd skeletal
 muscle protein (Dp427). These defects result in the
various manifestations commonly associated with MD,
such as weakness and pseudohypertrophy.
o Option D: Minor variations notwithstanding, all types
of MD have in common progressive muscle weakness
that tends to occur in a proximal-to-distal direction,
though there are some rare distal myopathies that
cause predominantly distal weakness. The decreasing
muscle strength in those who are affected may
compromise the patient’s ambulation potential and,
eventually, cardiopulmonary function.
 46. Question
A client is scheduled for a percutaneous transluminal coronary
angioplasty (PTCA). The nurse knows that a PTCA is the

o A. Surgical repair of a diseased coronary artery.

o B. Placement of an automatic internal cardiac
defibrillator.
o C. Procedure that compresses plaque against the
wall of the diseased coronary artery to improve blood
flow.
o D. Non-invasive radiographic examination of the heart.

Correct Answer: C. Procedure that compresses plaque

against the wall of the diseased coronary artery to
improve blood flow
PTCA 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.
o Option A: Coronary artery bypass grafting is the
surgical repair of a diseased coronary artery.
o Option B: Angioplasty does not involve the placement
of an internal cardiac defibrillator. An internal cardiac
defibrillator is needed if the client has ventricular
tachycardia or ventricular fibrillation because they
detect and stop abnormal heartbeats or arrhythmias.
 o Option D: PTCA is not a radiographic examination of
the heart.
 47. Question
A newborn has been diagnosed with hypothyroidism. In
discussing the condition and treatment with the family, the nurse
should emphasize:

o A. They can expect the child will be mentally retarded.

o B. Administration of thyroid hormone will prevent
problems.
o C. This rare problem is always hereditary.
o D. Physical growth/development will be delayed.

Correct Answer: B. Administration of thyroid hormone will

prevent problems.
Early identification and continued treatment with hormone
replacement correct this condition.
o Option A: Mental retardation can be prevented with
early detection and treatment. Neurologic sequelae,
characterized by spasticity, tremor, and hyperactive
deep tendon reflexes, are found frequently in severe
cretinism, but not in mild cretinism or acquired
hypothyroidism. The severity of neurologic sequelae
parallels mental retardation. Early therapy apparently
prevents, in part, these sequelae.
o Option C: Congenital hypothyroidism is caused by
iodine deficiency and is occasionally exacerbated by
naturally occurring goitrogens. In the majority of
patients, CH is caused by abnormal development of
the thyroid gland (thyroid dysgenesis) which is a
sporadic disorder and accounts for 85% of cases, and
the remaining 15% of cases are caused by
dyshormonogenesis. The clinical features of congenital
hypothyroidism are so subtle that many newborn
infants remain undiagnosed at birth and delayed
diagnosis leads to the most severe outcome of CH,
mental retardation, emphasizing the importance of
neonatal screening.
 o Option D: The growth and development of an infant
with congenital hypothyroidism can be normal if it is
detected and treated early. In overt hypothyroidism,
the severe impairment of linear growth leads to
dwarfism, which is characterized by limbs that are
disproportionately short compared with the
 48. Question
A priority goal of involuntary hospitalization of the severely
mentally ill client is

o A. Re-orientation to reality
o B. Elimination of symptoms
o C. Protection from harm to self or others
o D. Return to independent functioning

Correct Answer: C. Protection from self-harm and harm to

others.
Involuntary hospitalization may be required for persons
considered dangerous to self or others or for individuals who are
considered gravely disabled.
o Option A: Mentally ill clients should be kept safe first
before reorienting them back to reality. In keeping with
emergent mental health public policy and nursing
professional ethics, the articulated aims of
deinstitutionalization included returning individuals to
home communities to restore freedom and autonomy
and reducing or eliminating nursing practices
grounded in punishment that was being societally
reconceptualized as harmful.
o Option B: Gradual elimination of the symptoms is not
the primary goal in the hospitalization of a mentally ill
client. There are two important concepts of
psychological treatment. First, although it is called
“psychological” treatment, the ultimate effect of these
treatments is to bring some changes in the very
delicate change in the structure and function of
neurons by changing the way a person habitually
thinks and behaves. They also promote the healing of
 the brain by reducing the stress experienced by the
patients in daily life. In psychological treatment, all
treatment effects come from the effort to take new
behavior and adopt new ways of thinking.
o Option D: The client should be kept safe from himself
and others first before he can return to independent
functioning. The measurement of functional capacity
in mental illness is an important recent development.
Determination of functional capacity may serve as a
surrogate marker for real-world functioning, thereby
aiding clinicians in making important treatment
determinations.
 49. Question
A 19-year-old client is paralyzed in a car accident. Which
statement used by the client would indicate to the nurse that the
client was using the mechanism of “suppression”?

o A. “I don’t remember anything about what

happened to me.”
o B. “I’d rather not talk about it right now.”
o C. “It’s the other entire guy’s fault! He was going too
fast.”
o D. “My mother is heartbroken about this.”

Correct Answer: A. “I don’t remember anything about

what happened to me.”
Suppression is willfully putting an unacceptable thought or feeling
out of one’s mind. A deliberate exclusion “voluntary forgetting” is
generally used to protect one’s own self-esteem.
o Option B: Denial is a defense mechanism proposed
by Anna Freud which involves a refusal to accept
reality, thus blocking external events from awareness.
If a situation is just too much to handle, the person
may respond by refusing to perceive it or by denying
that it exists.
o Option C: This statement refers to projection, which is
when an individual attributes her negative self-concept
onto others.
 o Option D: This statement refers to the identification,
which is when the client identifies herself with an
image that she sees is ideal to our ego.
 50. Question
The nurse is caring for a woman 2 hours after a vaginal delivery.
Documentation indicates that the membranes were ruptured for
36 hours prior to delivery. What are the priority nursing diagnoses
at this time?

o Altered tissue perfusion

o Risk for fluid volume deficit
o High risk for hemorrhage
o Risk for infection

Correct Answer: D. Risk for infection

Membranes ruptured over 24 hours prior to birth greatly
increases the risk of infection to both mother and the newborn.
Rupture of membranes results from a variety of factors that
ultimately lead to accelerated membrane weakening. This is
caused by an increase in local cytokines, an imbalance in the
interaction between matrix metalloproteinases and tissue
inhibitors of matrix metalloproteinases, increased collagenase
and protease activity, and other factors that can cause increased
intrauterine pressure.
o Option A: There should be little or no alteration in
perfusion after premature rupture of the membranes.
Decreased tissue perfusion can be temporary, with
few or minimal consequences to the health of the
patient, or it can be more acute or protracted, with
potentially destructive effects on the patient. When
diminished tissue perfusion becomes chronic, it can
result in tissue or organ damage or death.
o Option B: There may be a risk for deficient fluid
volume, but it is not a priority. Fluid volume deficit
(FVD) or hypovolemia is a state or condition where the
fluid output exceeds the fluid intake. It occurs when
the body loses both water and electrolytes from the
ECF in similar proportions. Common sources of fluid
 loss are the gastrointestinal tract, polyuria, and
increased perspiration.
o Option C: Hemorrhage is not a great risk in
premature rupture of membranes. One of the
complications of PROM is intraventricular hemorrhage.
This is because blood vessels in the brain of premature
infants are not fully developed, and are therefore
weaker than that of term babies. Research shows that
intraventricular hemorrhages (IVH) or brain bleeds are
significantly reduced by steroid treatment, without an
increase in either maternal or neonatal infection.
 51. Question
A 3-year-old had a hip spica cast applied 2 hours ago. In order to
facilitate drying, the nurse should:

o A. Expose the cast to air and turn the child

frequently.
o B. Use a heat lamp to reduce the drying time.
o C. Handle the cast with the abductor bar.
o D. Turn the child as little as possible.

Correct Answer: A. Expose the cast to air and turn the

child frequently
The child should be turned every 2 hours, with the surface
exposed to the air. Casts and splints hold the bones in place while
they heal. They also reduce pain, swelling, and muscle spasm.
o Option B: Heat lamps may cause burns in the skin
inside the cast. Inspect the skin around the cast. If the
skin becomes red or raw around the cast, contact a
doctor.
o Option C: Do not handle the cast until it is dry
because it might still break. It takes about one hour for
fiberglass, and two to three days for plaster to become
hard enough to walk on. Some physicians will give a
“cast shoe” to wear over a walking cast. The cast shoe
will help protect the bottom of the cast.
o Option D: Turning the child would ensure equal drying
of the cast at all sides. Keep the cast dry. If the cast
 becomes wet, it can hurt the child’s skin. Do not try to
dry cast with something warm (i.e., a blow dryer) this
may cause burns.
 52. Question
A client is scheduled for an Intravenous Pyelogram (IVP). In order
to prepare the client for this test, the nurse would:

o A. Instruct the client to maintain a regular diet the day

prior to the examination.
o B. Restrict the client’s fluid intake 4 hours prior to the
examination.
o C. Administer a laxative to the client the evening
before the examination.
o D. Inform the client that only 1 x-ray of his abdomen is
necessary.

Correct Answer: C. 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. Intravenous pyelogram (IVP) is an x-
ray exam that uses an injection of contrast material to evaluate
the kidneys, ureters, and bladder and help diagnose blood in the
urine or pain in the side or lower back. An IVP may provide
enough information to allow the doctor to treat with medication
and avoid surgery.
o Option A: Eating and drinking the night before the
exam should be avoided.
o Option B: Restriction of fluids on the night before the
exam should be emphasized.
o Option D: An intravenous pyelogram is an x-ray of
the kidneys, ureters, and urinary bladder that uses
iodinated contrast material injected into veins.
 53. Question
Following a diagnosis of acute glomerulonephritis (AGN) in their
6-year-old child, the parent’s remark: “We just don’t know how he
caught the disease!” The nurse’s response is based on an
understanding that:
 o A. AGN is a streptococcal infection that involves the
kidney tubules.
o B. The disease is easily transmissible in schools and
camps.
o C. The illness is usually associated with chronic
respiratory infections.
o D. It is not “caught” but is a response to a
previous B-hemolytic strep infection.

Correct Answer: D. It is not “caught” but is a response to

a previous B-hemolytic strep infection.
AGN 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.
o Option A: Acute glomerulonephritis comprises a
specific set of renal diseases in which an immunologic
mechanism triggers inflammation and proliferation of
glomerular tissue that can result in damage to the
basement membrane, mesangium, or capillary
endothelium.
o Option B: The disease is most commonly caused by
Streptococcus species. Glomerulonephritis may
develop a week or two after recovery from a strep
throat infection or, rarely, a skin infection (impetigo).
To fight the infection, the body produces extra
antibodies that can eventually settle in the glomeruli,
causing inflammation.
o Option C: Acute glomerulonephritis is usually
associated with staphylococcal infection. Infections
with other types of bacteria, such as staphylococcus
and pneumococcus, viral infections, such as
chickenpox, and parasitic infections, such as malaria,
can also result in acute glomerulonephritis. Acute
glomerulonephritis that results from any of these
infections is called postinfectious glomerulonephritis.
 54. Question
The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day
history of diarrhea, occasional vomiting and fever. Peripheral
intravenous therapy has been initiated, with 5% dextrose in
0.33% normal saline with 20 mEq of potassium per liter infusing
at 35 ml/hr. Which finding should be reported to the healthcare
provider immediately?

o A. 3 episodes of vomiting in 1 hour.

o B. Periodic crying and irritability.
o C. Vigorous sucking on a pacifier.
o D. No measurable voiding in 4 hours.

Correct Answer: D. 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. Successful
management of acute hyperkalemia involves protecting the heart
from arrhythmias with the administration of calcium, shifting
potassium (K+) into the cells, and enhancing the elimination of
K+ from the body.
o Option A: Episodes of vomiting should be reported,
but it is not the priority and is currently being
managed with intravenous infusions. Once clinically
significant dehydration is present, effective and safe
strategies for rehydration are required. Additionally,
following rehydration there may be a risk of recurrence
of dehydration and appropriate fluid management may
reduce the likelihood of that event.
o Option B: Crying and irritability is a normal reaction
of an infant who is unwell.
o Option C: Vigorous sucking is a good sign in an infant
who has episodes of vomiting.
 55. Question
While caring for the client during the first hour after delivery, the
nurse determines that the uterus is boggy and there is vaginal
bleeding. What should be the nurse’s first action?

o A. Check vital signs.

 o B. Massage the fundus.
o C. Offer a bedpan.
o D. Check for perineal lacerations.

Correct Answer: B. Massage the fundus

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. Approximately 3% to 5% of obstetric patients
will experience postpartum hemorrhage. Annually, these
preventable events are the cause of one-fourth of maternal
deaths worldwide and 12% of maternal deaths in the United
States.
o Option A: Vital signs should be checked after vaginal
delivery, but in this situation, the nurse should
prioritize prevention of bleeding. 20% of postpartum
hemorrhage occurs in women with no risk factors, so
physicians must be prepared to manage this condition
at every delivery
o Option C: The client’s fundus should be massaged
first to prevent uterine atony and hemorrhage. Uterine
atony is the most common cause of postpartum
hemorrhage. Brisk blood flow after delivery of the
placenta unresponsive to transabdominal massage
should prompt immediate action including bimanual
compression of the uterus and use of uterotonic
medications. Massage is performed by placing one
hand in the vagina and pushing against the body of
the uterus while the other hand compresses the
fundus from above through the abdominal wall
o Option D: Perineal lacerations may be present but it
is not a primary concern during uterine atony.
Lacerations and hematomas due to birth trauma can
cause significant blood loss that can be lessened by
hemostasis and timely repair. Episiotomy increases the
risk of blood loss and anal sphincter tears; this
procedure should be avoided unless urgent delivery is
necessary and the perineum is thought to be a limiting
factor.
  56. Question
The nurse is assessing an infant with developmental dysplasia of
the hip. Which finding would the nurse anticipate?

o A. Unequal leg length

o B. Limited adduction
o C. Diminished femoral pulses
o D. Symmetrical gluteal folds

Correct Answer: A. Unequal leg length

Shortening of a leg is a sign of developmental dysplasia of the
hip. The hip is a “ball-and-socket” joint. In a normal hip, the ball
at the upper end of the thigh bone (femur) fits firmly into the
socket, which is part of the large pelvis bone. In babies and
children with developmental dysplasia (dislocation) of the hip
(DDH), the hip joint has not formed normally. The ball is loose in
the socket and may be easy to dislocate.
o Option B: Limited adduction is not a sign of
developmental dysplasia. In all cases of DDH, the
socket (acetabulum) is shallow, meaning that the ball
of the thighbone (femur) cannot firmly fit into the
socket. Sometimes, the ligaments that help to hold the
joint in place are stretched. The degree of hip
looseness, or instability, varies among children with
DDH.
o Option C: Femoral pulses in a client with
developmental dysplasia of the hip are normal.
o Option D: Asymmetric gluteal folds with uneven
gluteal creases are associated with developmental hip
dysplasia.
 57. Question
To prevent a Valsalva maneuver in a client recovering from an
acute myocardial infarction, the nurse would:

o A. Assist the client to use the bedside commode.

 o B. Administer stool softeners every day as
ordered.
o C. Administer antidysrhythmics prn as ordered.
o D. Maintain the client on strict bed rest.

Correct Answer: B. Administer stool softeners every day

as ordered.
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.
o Option A: A bedside commode for a client with acute
MI should be provided, but it does not prevent Valsalva
maneuver alone.
o Option C: Antidysrhythmics do not prevent Valsalva
maneuver. Antidysrhythmic agents, which are also
known as antiarrhythmic agents, are a broad category
of medications that help ameliorate the spectrum of
cardiac arrhythmias to maintain normal rhythm and
conduction in the heart.
o Option D: A client with acute MI can be given
bathroom privileges with assistance.
 58. Question
On admission to the psychiatric unit, the client is trembling and
appears fearful. The nurse’s initial response should be to:

o A. Give the client orientation materials and review the

unit rules and regulations.
o B. Introduce him/her and accompany the client to
the client’s room.
o C. Take the client to the day room and introduce her to
the other clients.
o D. Ask the nursing assistant to get the client’s vital signs
and complete the admission search.
Correct Answer: B. Introduce him/herself and accompany
the client to the client’s room.
Anxiety is triggered by change that threatens the individual’s
sense of security. In response to anxiety in clients, the nurse
should remain calm, minimize stimuli, and move the client to a
calmer, more secure/safe setting.
o Option A: The client is still confused and fearful.
Orientation should be postponed until he is calm. They
can deliver effective, safe care by assessing risk and
building a rapport with the patient during the
admission process; utilizing crisis prevention
strategies, including appropriate medication
administration, environmental, psychobiological,
counseling, and health teaching interventions; and
employing conflict resolution techniques.
o Option C: The client should be taken to a calm
environment with less stimuli so he could feel safe and
become calmer.
o Option D: Taking the client’s vital signs while he is
still fearful would further aggravate his feelings of
insecurity and fear. Utilizing the nursing process, the
nurse can provide effective therapeutic interventions
to promote safety for both the patient and the nurse.
 59. Question
During the admission assessment on a client with chronic
bilateral glaucoma, which statement by the client would the
nurse anticipate since it is associated with this problem?

o A. “I have constant blurred vision.”

o B. “I can’t see on my left side.”
o C. “I have to turn my head to see my room.”
o D. “I have specks floating in my eyes.”

Correct Answer: C. “I have to turn my head to see my

room.”
Intraocular pressure becomes elevated which slowly produces a
progressive loss of the peripheral visual field in the affected eye
along with rainbow halos around lights. Intraocular pressure
becomes elevated from the microscopic obstruction of the
trabecular meshwork. If left untreated or undetected blindness
results in the affected eye.
o Option A: Central vision is one of the most common
signs of glaucoma. The fluid inside the eye, called
aqueous humor, usually flows out of the eye through a
mesh-like channel. If this channel gets blocked, the
liquid builds up. Sometimes, experts don’t know what
causes this blockage. But it can be inherited, meaning
it’s passed from parents to children.
o Option B: The peripheral field of vision is most often
lost in a client with glaucoma. The increased pressure
in the eye, called intraocular pressure, can damage
the optic nerve, which sends images to the brain. If
the damage worsens, glaucoma can cause permanent
vision loss or even total blindness within a few years.
o Option D: Patchy blind spots in the peripheral or
central vision of both eyes is a symptom of open-angle
glaucoma. It is caused by the drainage channels in the
eye becoming gradually clogged over time.
 60. Question
A client with asthma has low pitched wheezes present in the final
half of exhalation. One hour later the client has high pitched
wheezes extending throughout exhalation. This change in
assessment indicates to the nurse that the client:

o A. Has increased airway obstruction.

o B. Has improved airway obstruction.
o C. Needs to be suctioned.
o D. Exhibits hyperventilation.

Correct Answer: A. Has increased airway obstruction.

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.
 o Option B: Improvement in airway obstruction should
decrease the presence of wheezes. Wheezing most
often is caused by an obstruction (blockage) or
narrowing of the small bronchial tubes in the chest. It
can also be caused by an obstruction in the larger
airways or vocal cords. The tone of the wheeze can
vary depending on which part of the respiratory
system is blocked or narrowed.
o Option C: There is no indication for suctioning.
Suctioning is used to obtain mucus and other fluids
(secretions) and cells from the windpipe (trachea) and
large airways (bronchi) and is typically used in people
who are on mechanical ventilation or have problems
with nerves or muscles that make coughing less
effective for bringing up secretions.
o Option D: Hyperventilation does not produce high
pitched wheezes that extend throughout exhalation.
The lowered carbon dioxide levels in the blood can
cause squeezing of the airways, which then results in
wheezing. Hyperventilation syndrome may cause the
following chest symptoms like chest pains or
tenderness, shortness of breath, and wheezing.
 61. Question
Which behavioral characteristic describes the domestic abuser?

o A. Alcoholic
o B. Overconfident
o C. High tolerance for frustrations
o D. Low self-esteem

Correct Answer: D. Low self-esteem

Batterers are usually physically or psychologically abused as
children or have had experiences of parental violence. Batterers
are also manipulative, have low self-esteem, and have a great
need to exercise control or power-over partners.
o Option A: Being an alcoholic predisposes an
individual to be a domestic abuser. To be perfectly
clear, alcohol and alcoholism are never a sole trigger
 for, or cause of, domestic abuse. Rather, they are
compounding factors that could eventually trigger
intimate partner abuse in a violent individual.
o Option B: Most domestic abusers have low self-
confidence or self-esteem. Basically, domestic violence
offenders always feel the need to be in control of their
victims. The less in control an offender feels, the more
they want to hurt others.
o Option C: Domestic abusers often vent out their
frustrations on their partners or children. Domestic
abuse, often referred to as domestic violence or
intimate partner violence (IPV), is a pattern of
behavior or behaviors used by one partner to maintain
power and control over another partner that they are
in a relationship with. Anyone, regardless of race,
gender, sexual orientation, religion, or age, can be a
victim or perpetrator of domestic abuse. Abuse can be
physical, sexual, emotional, mental, social, and
financial.
 62. Question
The nurse is caring for a client with a long leg cast. During
discharge teaching about appropriate exercises for the affected
extremity, the nurse should recommend:

o A. Isometric
o B. Range of motion
o C. Aerobic
o D. Isotonic

Correct Answer: A. Isometric

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.
o Option B: Active range of motion exercises should
accompany isometric exercises for every joint that is
not immobilized at regular and frequent intervals.
 o Option C: Aerobic exercise is any type of
cardiovascular conditioning and is inappropriate for a
client who has a leg cast.
o Option D: Isotonic exercise is one method of
muscular exercise and it is not recommended for a
client who has leg cast.
 63. Question
A client is in her third month of her first pregnancy. During the
interview, she tells the nurse that she has several sex partners
and is unsure of the identity of the baby’s father. Which of the
following nursing interventions is a priority?A. Counsel the woman
to consent to HIV screening.

o A. Counsel the woman to consent to HIV

screening.
o B. Perform tests for sexually transmitted diseases.
o C. Discuss her high risk for cervical cancer.
o D. Refer the client to a family planning clinic.

Correct Answer: A. Counsel the woman to consent to HIV

screening
The client”s behavior places her at high risk for HIV. Testing is the
first step. If the woman is HIV positive, the earlier treatment
begins, the better the outcome.
o Option B: Before performing the tests, the client
should be informed first and she must give her
consent. Separate written consent for HIV testing is
not recommended. General informed consent for
medical care that notifies the patient that an HIV test
will be performed unless the patient declines (opt-out
screening) should be considered sufficient to
encompass informed consent for HIV testing.
o Option C: Discussion about the risks can come after
determining if the client is HIV positive or not.
Increased HIV vulnerability is often associated with
legal and social factors, which increases exposure to
risk situations and creates barriers to accessing
 effective, quality and affordable HIV prevention,
testing and treatment services.
o Option D: Family planning could come after the HIV
screening has results. For women with HIV who want
to become pregnant, use of antiretroviral prophylaxis
during pregnancy can reduce mother-to-child
transmission of HIV. Afterwards, family planning
services that promote healthy timing and spacing of
pregnancies are important to reduce the risk of
adverse pregnancy outcomes such as low birth weight,
preterm birth, and infant mortality.
 64. Question
A 16-month-old child has just been admitted to the hospital. As
the nurse assigned to this child enters the hospital room for the
first time, the toddler runs to the mother, clings to her, and
begins to cry. What would be the initial action by the nurse?

o A. Arrange to change client care assignments.

o B. Explain that this behavior is expected.
o C. Discuss the appropriate use of “time-out”.
o D. Explain that the child needs extra attention.

Correct Answer: B. Explain that this behavior is expected.

During normal development, fear of strangers becomes
prominent beginning around age 6-8 months. Such behaviors
include clinging to parents, crying, and turning away from the
stranger. These fears/behaviors extend into the toddler period
and may persist into preschool.
o Option A: Changing client assignments is
unnecessary. The nurse may wait for the child to calm
down.
o Option C: Time outs are usually not appropriate for a
toddler, especially if she is in a new environment.
o Option D: The behavior shown by the toddler is
normal and she does not need any additional
attention.
  65. Question
While planning care for a 2-year-old hospitalized child, which
situation would the nurse expect to most likely affect the
behavior?

o A. Strange bed and surroundings.

o B. Separation from parents.
o C. Presence of other toddlers.
o D. Unfamiliar toys and games.

Correct Answer: B. Separation from parents

Separation anxiety is most evident from 6 months to 30 months
of age. It is the greatest stress imposed on a toddler by
hospitalization. If separation is avoided, young children have a
tremendous capacity to withstand other stress.
o Option A: Most children, even school-aged children,
are fearful of a strange bed and new surroundings.
o Option C: The presence of other toddlers might help
the client calm down and adjust with the environment.
o Option D: Unfamiliar toys and games would least
likely affect the toddler’s behavior.
 66. Question
While explaining an illness to a 10-year-old, what should the
nurse keep in mind about the cognitive development at this age?

o A. They are able to make simple associations of ideas.

o B. They are able to think logically in organizing
facts.
o C. Interpretation of events originates from their own
perspective.
o D. Conclusions are based on previous experiences.

Correct Answer: B. They are able to think logically in

organizing facts.
The child in the concrete operational stage, according to Piaget,
is capable of mature thought when allowed to manipulate and
organize objects.
o Option A: Option A describes the preoperational
stage. During this stage, young children can think
about things symbolically. The preoperational stage is
the second stage in Piaget’s theory of cognitive
development. This stage begins around age 2, as
children start to talk, and lasts until approximately age
7. 1 During this stage, children begin to engage in
symbolic play and learn to manipulate symbols.
o Option C: In the formal operational stage, people
develop the ability to think about abstract concepts,
and logically test hypotheses.
o Option D: Option D describes the formal operational
stage. The formal operational stage begins at
approximately age twelve and lasts into adulthood. As
adolescents enter this stage, they gain the ability to
think in an abstract manner by manipulating ideas in
their head, without any dependence on concrete
manipulation.
 67. Question
The nurse has just admitted a client with severe depression. From
which focus should the nurse identify a priority nursing diagnosis?

o A. Nutrition
o B. Elimination
o C. Activity
o D. Safety

Correct Answer: D. Safety

Safety is a priority of care for the depressed client. Precautions to
prevent suicide must be a part of the plan. Depression can be
effectively treated in primary care settings using an evidence-
based collaborative approach in which primary care providers are
systematically supported by mental health providers in caring for
a caseload of patients.
 o Option A: The client’s nutritional plan can be
discussed after his safety has been ensured.
Researchers found that a healthy diet (the
Mediterranean diet as an example) was associated
with a significantly lower risk of developing depressive
symptoms.
o Option B: Elimination should also be part of the
nursing care plan, but this is not the priority. Any
psychosocial disturbances can impact on nervous
system neuroplasticity and this, in turn, will adversely
affect downstream systems including the GIT.
o Option C: Activities for a depressed client should be
structured and introduced gradually. Teach
visualization as a tool to “bring them back down to
their bodies” and out of the constant cycle of negative
thoughts. Clients learn methods such as the “tree
meditation,” in which they imagine themselves as a
tree that is growing from the ground and sprouting
branches.
 68. Question
Which playroom activities should the nurse organize for a small
group of 7-year-old hospitalized children?

o A. Sports and games with rules

o B. Finger paints and water play.
o C. “Dress-up” clothes and props.
o D. Chess and television programs

Correct Answer: A. Sports and games with rules

The purpose of play for the 7-year-old is cooperation. Rules are
very important. Logical reasoning and social skills are developed
through play.
o Option B: Finger paints and water play are
appropriate play for toddlers. Most toddlers do parallel
play. When a child plays alongside or near others but
does not play with them this stage is referred to as
parallel play.
 o Option C: Dress-up and props are recommended for
preschool. When a child plays together with others
and has interest in both the activity and other children
involved in playing they are participating in
cooperative play.
o Option D: Chess is recommended for school-age to
adolescent stage. During the school-age years, you’ll
see a change in your child. He or she will move from
playing alone to having multiple friends and social
groups.
 69. Question
A client is discharged following hospitalization for congestive
heart failure. The nurse teaching the family suggests they
encourage the client to rest frequently in which of the following
positions?

o A. High Fowler’s
o B. Supine
o C. Left lateral
o D. Low Fowler’s

Correct Answer: A. High Fowler’s

Sitting in a chair or resting in a bed in a high Fowler”s position
decreases the cardiac workload and facilitates breathing.
o Option B: Lying flat or in a supine position would be
difficult for the client and may induce increased
cardiac workload.
o Option C: Left lateral position may increase the
client’s cardiac workload.
o Option D: Low Fowler’s may not be sufficient enough
to support the client’s cardiac workload.
 70. Question
The nurse is caring for a 10-year-old on admission to the burn
unit. One assessment parameter that will indicate that the child
has adequate fluid replacement is:
 o A. Urinary output of 30 ml per hour
o B. No complaints of thirst
o C. Increased hematocrit
o D. Good skin turgor around burn

Correct Answer: A. Urinary output of 30 ml per hour

For a child of this age, this is adequate output, yet does not
suggest overload. Disruption of sodium-ATPase activity
presumably causes an intracellular sodium shift which contributes
to hypovolemia and cellular edema. Heat injury also initiates the
release of inflammatory and vasoactive mediators. These
mediators are responsible for local vasoconstriction, systemic
vasodilation, and increased transcapillary permeability. Increase
in transcapillary permeability results in a rapid transfer of water,
inorganic solutes, and plasma proteins between the intravascular
and interstitial spaces.
o Option B: Relying on the client’s thirst would not
create accurate results. The steady intravascular fluid
loss due to these sequences of events requires
sustained replacement of intravascular volume in
order to prevent end-organ hypoperfusion and
ischemia.
o Option C: An increase in hematocrit suggests
vascular space fluid losses. Reduced cardiac output is
a hallmark in this early post-injury phase. The
reduction in cardiac output is the combined result of
decreased plasma volume, increased afterload and
decreased cardiac contractility, induced by circulating
mediators.
o Option D: A good skin turgor is not an accurate
indicator of adequate fluid replacement. The goal of
fluid management in major burn injuries is to maintain
the tissue perfusion in the early phase of burn shock,
in which hypovolemia finally occurs due to steady fluid
extravasation from the intravascular compartment.
 71. Question
What is the priority nursing diagnosis for a patient experiencing
a migraine headache?
 o A. Acute pain related to biologic and chemical
factors
o B. Anxiety related to change in or threat to health status
o C. Hopelessness related to deteriorating physiological
condition
o D. Risk for Side effects related to medical therapy

Correct Answer: A. Acute pain related to biologic and

chemical factors
The priority for interdisciplinary care for the patient experiencing
a migraine headache is pain management.
o Option B: Anxiety is a correct diagnosis, but it is not
the priority. Tension headaches are common for people
that struggle with severe anxiety or anxiety disorders.
Tension headaches can be described as a heavy head,
migraine, head pressure, or feeling like there is a tight
band wrapped around their head. These headaches
are due to a tightening of the neck and scalp muscles.
o Option C: Hopelessness should be addressed as part
of the nursing care plan, but it does not require
urgency. Hopelessness can result when someone is
going through difficult times or unpleasant
experiences. A person may feel overwhelmed,
trapped, or insecure, or may have a lot of self-doubts
due to multiple stresses and losses. He or she might
think that challenges are unconquerable or that there
are no solutions to the problems and may not be able
to mobilize the energy needed to act on his or her own
behalf.
o Option D: The risk for side effects is accurate, but it is
not as urgent as the issue of pain, which is often
incapacitating. Focus: Prioritization
 72. Question
You are creating a teaching plan for a patient with newly
diagnosed migraine headaches. Which key items should be
included in the teaching plan? Select all that apply.
 o A. Avoid foods that contain tyramine, such as
alcohol and aged cheese.
o B. Avoid drugs such as Tagamet, nitroglycerin and
Nifedipine.
o C. Abortive therapy is aimed at eliminating the
pain during the aura.
o D. A potential side effect of medications is
rebound headache.
o E. Complementary therapies such as relaxation
may be helpful.
o F. Continue taking estrogen as prescribed by your
physician.

Correct Answer: A, B, C, D, & E.

The client should be counseled on the food and drugs that are
allowed. He should also be educated about the side effects of the
medications given. Methods of distraction from pain should also
be included in the teaching plan.
o Option A: One explanation is that it causes nerve
cells in the brain to release the chemical
norepinephrine. Having higher levels of tyramine in
the system — along with an unusual level of brain
chemicals — can cause changes in the brain that lead
to headaches.
o Option B: Oral contraceptives and vasodilators, such
as nitroglycerin, can aggravate migraines. Dilation of
cerebral arteries causes the commonly reported side
effect of migraine-type headache.
o Option C: Abortive therapy should be used as early as
possible in the course of a migraine. Combination
analgesics containing aspirin, caffeine, and
acetaminophen are an effective first-line abortive
treatment for migraines. Ibuprofen at standard doses
is effective for acute migraine treatment.
o Option D: Medication overuse headaches or rebound
headaches are caused by regular, long-term use of
medication to treat headaches, such as migraines.
Pain relievers offer relief for occasional headaches. But
 if one takes them more than a couple of days a week,
they may trigger medication overuse headaches.
o Option E: Complementary therapies are add-on
therapies meant to be used along with traditional
treatment, according to the National Center for
Complementary and Integrative Health (NCCIH).
Massage, spinal manipulation, and acupuncture are
examples of complementary therapies that may be
beneficial for people with migraines.
o Option F: Medications such as estrogen supplements
may actually trigger a migraine headache attack.
Fluctuations in estrogen, such as before or during
menstrual periods, pregnancy, and menopause, seem
to trigger headaches in many women.
 73. Question
The patient with migraine headaches has a seizure. After the
seizure, which action can you delegate to the nursing assistant?

o A. Document the seizure

o B. Perform neurologic checks
o C. Take the patient’s vital signs
o D. Restrain the patient for protection

Correct Answer: C. Take the patient’s vital signs.

Taking vital signs is within the education and scope of practice for
a nursing assistant.
o Option A: Documentation is one of the nursing
responsibilities.
o Option B: The nurse should perform neurologic
checks.
o Option D: Patients with seizures should not be
restrained; however, the nurse may guide the
patient’s movements as necessary. Focus:
Delegation/supervision
 74. Question
You are preparing to admit a patient with a seizure disorder.
Which of the following actions can you delegate to LPN/LVN?
 o A. Complete admission assessment
o B. Set up oxygen and suction equipment
o C. Place a padded tongue blade at the bedside
o D. Pad the side rails before the patient arrives

Correct Answer: B. Set up oxygen and suction equipment

The LPN/LVN can set up the equipment for oxygen and suction.
o Option A: The RN should perform the complete initial
assessment.
o Option C: Tongue blades should not be at the bedside
and should never be inserted into the patient’s mouth
after a seizure begins.
o Option D: Padded side rails are controversial in terms
of whether they actually provide safety and may
embarrass the patient and family.
 75. Question
A nursing student is teaching a patient and family about epilepsy
prior to the patient’s discharge. For which statement should you
intervene?

o A. “You should avoid consumption of all forms of

alcohol.”
o B. “Wear your medical alert bracelet at all times.”
o C. “Protect your loved one’s airway during a seizure.”
o D. “It’s OK to take over-the-counter medications.”

Correct Answer: D. “It’s OK to take over-the-counter

medications.”
A patient with a seizure disorder should not take over-the-counter
medications without consulting with the physician first.
o Option A: Alcohol is not allowed for patients with
seizures because it increases the risk of another
episode.
o Option B: A medical alert bracelet bears the message
that the wearer has an important medical condition
that might require immediate attention.
o Option C: One of the priorities during a seizure is to
prevent obstruction of the airway by turning the client
into a side-lying position to allow drainage to flow.