Comprehensive NCLEX-RN Practice Exam

#2 latest edition 2024

1. Question

Category: Reduction of Risk Potential

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?

• A. Blood sugar check

• B. CT scan

• C. Blood cultures

• 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.
• 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.
• 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.
 • 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.
2. Question

Category: Health Promotion and Maintenance

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?

• A. The age of the child

• B. The child's ability to understand instruction

• C. The overall mental and physical abilities of the child

• 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.
• Option A: Readiness for toilet training varies with every age of the
child.
• Option B: A child who can follow simple instructions may start toilet
training. However, it is not considered the most important factor.
• Option D: Positive reinforcement is a great tool for toilet training,
yet, it may not be the most important one
3. Question

Category: Safety and Infection Control

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?

• A. This too shall pass

• B. Take the child immediately to the ER

• C. Contact the Poison Control Center quickly

• 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.
• Option A: Ingestion of a chemical is an emergency and should not
be delayed.
• Option B: Taking the client to the ER may be correct, however, they
will still have to contact the Poison Control Center.
• 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.
4. Question

Category: Pharmacological and Parenteral Therapies

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?

• A. Gluteus maximus

• B. Gluteus minimus

• C. Vastus lateralis

• 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.
• 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.
• Option B: Never give an IM injection in the gluteal muscles to avoid
the risk of sciatica nerve damage.
• Option D: The vastus medialis muscle is a part of the quadriceps
muscle group, located on the front of the thigh.
5. Question

Category: Safety and Infection Control

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?

• A. Contact the provider

• B. Ask the child to write their name on paper

• C. Ask a coworker about the identification of the child

• 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.
• 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.
• 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.
• Option C: Asking a coworker would be inappropriate and against
the patient’s confidentiality.
6. Question

Category: Reduction of Risk Potential

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?

• A. Elevated serum calcium

• B. Low serum parathyroid hormone (PTH)

• C. Elevated serum vitamin D

• 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.
• 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.
• 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.
• 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.
7. Question

Category: Basic Care and Comfort

A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which
of the following diet modifications is not recommended?

• A. A diet high in grains

• B. A diet with adequate caloric intake

• C. A high protein diet

• 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.
• 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.
• 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.
• Option C: Healthy fats and high-quality proteins slow the blood
sugar rollercoaster and promote stable blood sugar levels
throughout the day.
8. Question

Category: Physiological Adaptation

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?

• A. Anesthesia reaction

• B. Hyperglycemia

• C. Hypoglycemia

• 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.
• 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.
• 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.
• Option D: Symptoms of hyperglycemia associated with diabetic
ketoacidosis may include thirst, polyuria, polydipsia, and nocturia.
9. Question

Category: Reduction of Risk Potential

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?

• A. Bowel perforation

• B. Viral Gastroenteritis

• C. Colon cancer

• 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.
• 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.
• 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.
• Option D: Diverticulitis may cause pain, fever, and chills, but is far
less serious than perforation and peritonitis.
10. Question

Category: Reduction of Risk Potential

A patient is admitted to the same-day surgery unit for a liver biopsy. Which of the
following laboratory tests assesses coagulation? Select all that apply.

• A. Partial thromboplastin time

• B. Prothrombin time

• C. Platelet count

• D. Hemoglobin
Correct Answer: A, B, & C
Prothrombin time, partial thromboplastin time, and platelet count are all included
in coagulation studies.
• Option A: The partial thromboplastin time (PTT; also known as
activated partial thromboplastin time (aPTT)) is a screening test that
helps evaluate a person’s ability to appropriately form blood clots. It
measures the number of seconds it takes for a clot to form in a
sample of blood after substances (reagents) are added.
• Option B: Prothrombin time (PT) is a blood test that measures how
long it takes blood to clot. A prothrombin time test can be used to
check for bleeding problems. PT is also used to check whether
medicine to prevent blood clots is working.
• Option C: Platelets, also called thrombocytes, are tiny fragments of
cells that are essential for normal blood clotting. They are formed
from very large cells called megakaryocytes in the bone marrow and
 are released into the blood to circulate. The platelet count is a test
that determines the number of platelets in a sample of blood.
• Option D: The hemoglobin level, though important information
prior to an invasive procedure such as liver biopsy, does not assess
coagulation
11. Question

Category: Safety and Infection Control

A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the
following is the most likely route of transmission?

• A. Sexual contact with an infected partner

• B. Contaminated food

• C. Blood transfusion

• 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)
• 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.
• 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.
• 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
Category: Safety and Infection Control
A leukemia patient has a relative who wants to donate blood for transfusion.
Which of the following donor medical conditions would prevent this?

• A. A history of hepatitis C five years previously

• B. Cholecystitis requiring cholecystectomy one year previously

• C. Asymptomatic diverticulosis

• 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.
• Option B: Cholecystitis is the inflammation of the gallbladder. This
condition does not transmit through bodily fluids.
• 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.
• 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

Category: Pharmacological and Parenteral Therapies

A physician has diagnosed acute gastritis in a clinic patient. Which of the
following medications would be contraindicated for this patient?

• A. Naproxen sodium (Naprosyn)

• B. Calcium carbonate

• C. Clarithromycin (Biaxin)

• 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.
• 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.
• 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.
• 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

Category: Health Promotion and Maintenance

The nurse is conducting nutrition counseling for a patient with cholecystitis.
Which of the following information is important to communicate?
 • A. The patient must maintain a low-calorie diet.

• B. The patient must maintain a high protein/low carbohydrate diet.

• C. The patient should limit sweets and sugary drinks.

• 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.
• 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.
• 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.
• Option C: Replacing sugary drinks with drinks high in fiber would
reduce the risk of gallbladder stones by 15%.
15. Question

Category: Physiological Adaptation

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?

• A. Slow, deep respirations

• B. Stridor

• C. Bradycardia

• 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).
• 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.
• 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.
• 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

Category: Reduction of Risk Potential

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?

• A. A patient admitted for myocardial infarction without cardiac muscle

damage.

• B. A postoperative coronary bypass patient, recovering on schedule.

• C. A patient with a history of ventricular tachycardia and syncopal

episodes.

• 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.
• Option A: A patient with myocardial infarction that resolved with no
permanent cardiac damage would not be a candidate.
• Option B: A patient recovering well from coronary bypass would not
need the device.
• Option D: Atrial tachycardia is less serious and is treated
conservatively with medication and cardioversion as a last resort.
17. Question

Category: Reduction of Risk Potential

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?

• A. The patient is allergic to shellfish.

• B. The patient has a pacemaker.

• C. The patient suffers from claustrophobia.

• 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.
• 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.
• 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.
• 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

Category: Physiological Adaptation

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?

• A. The patient is somnolent with decreased response to the family.

• B. The patient suddenly complains of chest pain and shortness of

breath.

• C. The patient has developed a wet cough and the nurse hears crackles
on auscultation of the lungs.

• 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.
• Option A: The patient may present atypical symptoms based on risk
factors, such as delirium or a decreasing level of consciousness.
 • 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.
• 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

Category: Reduction of Risk Potential

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?

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

and medication.

• B. The patient will be admitted to the day surgery unit for

sclerotherapy.

• C. The patient will be admitted to the surgical unit and resection will be
scheduled.

• 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.
• 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.
• 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.
 • 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

Category: Reduction of Risk Potential

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?

• A. Monitor for fever every 4 hours.

• B. Require visitors to wear respiratory masks and protective clothing.

• C. Consider transfusion of packed red blood cells.

• 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.
• 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%).
• 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.
• 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

Category: Physiological Adaptation

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?

• A. Bulging anterior fontanel

• B. Repeated vomiting

• C. Signs of sleepiness at 10 PM

• 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.
• 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.
• 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.
• 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

Category: Health Promotion and Maintenance

A nonimmunized child appears at the clinic with a visible rash. Which of the
following observations indicates the child may have rubeola (measles)?

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

• B. The rash begins on the trunk and spreads outward.

• C. There is low-grade fever.

• 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.
• 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.
• 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”).
• 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

Category: Physiological Adaptation

A child is seen in the emergency department for scarlet fever. Which of the
following descriptions of scarlet fever is not correct?

• A. Scarlet fever is caused by infection with group A Streptococcus

bacteria.

• B. "Strawberry tongue" is a characteristic sign.

• C. Petechiae occur on the soft palate.

• 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.
• 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.
• 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.
• 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

Category: Pharmacological and Parenteral Therapies

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?

• A. It is the correct dose

• B. The dose is too low

• C. The dose is too high

• 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.
• 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.
• 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.
• 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

Category: Health Promotion and Maintenance

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?

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

• B. The infant will likely require surgical intervention.

• C. The infant probably has only one testis.

• 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.
• 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.
• 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.
• 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

Category: Physiological Adaptation

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?

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

 • B. The tumor did not extend beyond the kidney and was completely
resected.

• C. The tumor extended beyond the kidney but was completely

resected.

• 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.
• Option A: The mass is solid at presentation and usually >10 cm.
• Option B: This option describes stage 1, wherein the tumor is limited
to the kidney and completely resected.
• Option D: In stage IV, hematogenous metastasis has occurred with
spread beyond the abdomen.
27. Question

Category: Reduction of Risk Potential

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.

• A. Urine specific gravity of 1.040

• B. Urine output of 350 ml in 24 hours

• C. Brown ("tea-colored") urine

• 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.
• 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.
• 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.
• 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

Category: Physiological Adaptation

Which of the following conditions most commonly causes acute
glomerulonephritis?

• A. A congenital condition leading to renal dysfunction.

• B. Prior infection with group A Streptococcus within the past 10-14

days.

• C. Viral infection of the glomeruli.

• 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.
 • 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.
• 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.
• 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

Category: Health Promotion and Maintenance

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?

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

• B. Referral to a surgeon for repair.

• C. No treatment is necessary; the fluid is reabsorbing normally.

• 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.
 • 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.
• 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.
• 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

Category: Physiological Adaptation

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?

• A. Inadequate tissue perfusion leading to nerve damage.

• B. Fluid overload leading to compression of nerve tissue.

• C. Sensation distortion due to psychiatric disturbance.

• 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.
• 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.
• Option C: There is nothing to indicate a psychiatric disturbance in
the patient.
• 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.