Fundamentals of Nursing NCLEX Practice
Irregularly
Exam: Part 4
1. All of the following can cause tachycardia except:
A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation
Parasympathetic nervous system stimulation of the
heart decreases the heart rate as well as the force of
contraction, rate of impulse conduction and blood flow
through the coronary vessels. Fever, exercise, and
sympathetic stimulation all increase the heart rate. The
parasympathetic nervous system (PNS) releases the
hormone acetylcholine to slow the heart rate. Such
factors as stress, caffeine, and excitement may
temporarily accelerate your heart rate, while meditating
or taking slow, deep breaths may help to slow your heart
rate.
Option A: Tachypnea and tachycardia develop, and the
patient becomes dehydrated because of sweating and
vapor losses from the increased respiratory rate. Many
manifestations of fever are related to the increased
metabolic rate, increased need for oxygen, and use of
body proteins as an energy source.
Option B: Often, ventricular tachycardia will occur
during the recovery period post exercise due to
increased levels of adrenaline. In a study conducted in
1991, it was found that 70% of patients tested
experienced idiopathic ventricular tachycardia as a
result of exercise. Exercising for any duration will
increase your heart rate and will remain elevated for as
long as the exercise is continued. At the beginning of
exercise, your body removes the parasympathetic
stimulation, which enables the heart rate to gradually
increase. As you exercise more strenuously, the
sympathetic system “kicks in” to accelerate your heart
rate even more.
Option C: Heart rate is controlled by the two branches
of the autonomic (involuntary) nervous system. The
sympathetic nervous system (SNS) and the
parasympathetic nervous system (PNS). The
sympathetic nervous system (SNS) releases the
hormones (catecholamines – epinephrine and
norepinephrine) to accelerate the heart rate.
2. Palpating the midclavicular line is the correct
technique for assessing:
A. Baseline vital signs
B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse
The apical pulse (the pulse at the apex of the heart) is
located on the midclavicular line at the fourth, fifth, or
sixth intercostal space. Assessing whether the rhythm of
the pulse is regular or irregular is essential. The pulse
could be regular, irregular, or irregularly irregular.
Changes in the rate of the pulse, along with changes in
respiration is called sinus arrhythmia. In sinus
arrhythmia, the pulse rate becomes faster during
inspiration and slows down during expiration.
irregular pattern is more commonly indicative of
processes like atrial flutter or atrial fibrillation.
Option A: Baseline vital signs include pulse rate,
temperature, respiratory rate, and blood pressure. Vital
signs are an objective measurement for the essential
physiological functions of a living organism. They have
the name “vital” as their measurement and assessment
is the critical first step for any clinic evaluation. The first
set of clinical examinations is an evaluation of the vital
signs of the patient.
Option B: Blood pressure is typically assessed at the
antecubital fossa. The arm should be supported at the
heart level. Unsupported arm leads to 10 mmHg to the
pressure readings. The patient’s blood pressure should
get checked in each arm, and in younger patients, it
should be tested in an upper and lower extremity to rule
out the coarctation of the aorta.
Option C: Respiratory rate is assessed best by
observing chest movement with each inspiration and
expiration. The respiratory rate is the number of breaths
per minute. The normal breathing rate is about 12 to 20
beats per minute in an average adult. In the pediatric
age group, it is defined by the particular age group.
Parameters important here again include its rate, depth
of breathing, and its pattern rate of breathing is a crucial
parameter.
3. The absence of which pulse may not be a significant
finding when a patient is admitted to the hospital?
A. Apical
B. Radial
C. Pedal
D. Femoral
Because the pedal pulse cannot be detected in 10% to
20% of the population, its absence is not necessarily a
significant finding. However, the presence or absence of
the pedal pulse should be documented upon admission
so that changes can be identified during the hospital
stay. Absent peripheral pulses may be indicative of
peripheral vascular disease (PVD). PVD may be caused
by atherosclerosis, which can be complicated by an
occluding thrombus or embolus. This may be life-
threatening and may cause the loss of a limb.
Option A: Apical pulse rate is indicated during some
assessments, such as when conducting a
cardiovascular assessment and when a client is taking
certain cardiac medications (e.g., digoxin). Sometimes
the apical pulse is auscultated pre and post medication
administration. It is also a best practice to assess apical
pulse in infants and children up to five years of age
because radial pulses are difficult to palpate and count
in this population.
Option B: Examiners frequently evaluate the radial
artery during a routine examination of adults, due to the
unobtrusive position required to palpate it and it’s easy
accessibility in various types of clothing. Like other distal
peripheral pulses (such as those in the feet) it also may
be quicker to show signs of pathology. Palpation is at
the anterior wrist just proximal to the base of the thumb.
Option D: The femoral pulse may be the most sensitive
in assessing for septic shock and is routinely checked
during resuscitation. It is palpated distally to the inguinal
ligament at a point less than halfway from the pubis to
the anterior superior iliac spine.
4. Which of the following patients is at greatest risk for
developing pressure ulcers?
A. An alert, chronic arthritic patient treated with steroids
and aspirin.
B. An 88-year old incontinent patient with gastric
cancer who is confined to his bed at home.
C. An apathetic 63-year old COPD patient receiving
nasal oxygen via cannula.
D. A confused 78-year old patient with congestive heart
failure (CHF) who requires assistance to get out of bed.
Pressure ulcers are most likely to develop in patients
with impaired mental status, mobility, activity level,
nutrition, circulation and bladder or bowel control. Age is
also a factor. Thus, the 88-year old incontinent patient
who has impaired nutrition (from gastric cancer) and is
confined to bed is at greater risk. Pressure injuries are
defined as localized damage to the skin as well as
underlying soft tissue, usually occurring over a bony
prominence or related to medical devices. They are the
result of prolonged or severe pressure with contributions
from shear and friction forces.
Option A: Risk factors for developing pressure injuries,
in general, include immobility, reduced perfusion,
malnutrition, and sensory loss. Other patients at
increased risk for pressure injury development include
those with cerebrovascular or cardiovascular disease,
recent fracture of a lower extremity, diabetes, and
incontinence. Older patients are also at increased risk
for the formation of pressure injuries due to skin
changes associated with aging, including thinning of the
dermis and epidermis, resulting in decreased resistance
to shear forces.
Option C: The pressure of an individual’s body weight
or pressure from a medical device above a certain
threshold for a prolonged period is thought to be the
cause of pressure injuries. In patients with sensory
deficits, an absent pressure feedback response may
result in sustained pressure for a prolonged period,
leading to tissue injury. Many factors are identified in
contributing to pressure ulcer and injury formation, such
as increased arteriole pressure, shearing forces, friction,
moisture, and nutrition status.
Option D: Pressure injuries of the skin and soft tissues
affect an estimated 1 to 3 million people in the United
States each year. The incidence differs based on the
clinical setting. For example, the prevalence of pressure
injuries among hospitalized patients is 5% to 15%, with
the percentage considerably higher in some long-term
care environments and intensive care units.
5. The physician orders the administration of high-
humidity oxygen by face mask and placement of the
patient in a high Fowler’s position. After assessing Mrs.
Paul, the nurse writes the following nursing diagnosis:
Impaired gas exchange related to increased secretions.
Which of the following nursing interventions has the
greatest potential for improving this situation?
A. Encourage the patient to increase her fluid intake
to 200 ml every 2 hours.
B. Place a humidifier in the patient’s room.
C. Continue administering oxygen by a high humidity
face mask.
D. Perform chest physiotherapy on a regular schedule.
Adequate hydration thins and loosens pulmonary
secretions and also helps to replace fluids lost from
elevated temperature, diaphoresis, dehydration, and
dyspnea. Encourage patients to increase fluid intake to
3 liters per day within the limits of cardiac reserve and
renal function. Fluids help minimize mucosal drying and
maximize ciliary action to move secretions.
Option B: Consider the need for humidifiers in-home
care settings. This facilitates the liquefaction of
secretions. Teach the patient the proper ways of
coughing and breathing. (e.g., take a deep breath, hold
for 2 seconds, and cough two or three times in
succession). The most convenient way to remove most
secretions is coughing. So it is necessary to assist the
patient during this activity. Deep breathing, on the other
hand, promotes oxygenation before controlled coughing.
Option C: Maintain humidified oxygen as prescribed.
Increasing humidity of inspired air will reduce the
thickness of secretions and aid their removal. Provide
supplemental oxygen if the patient experiences
bradycardia, an increase in ventricular ectopy, and/or
significant desaturation. Oxygen therapy is
recommended to improve oxygen saturation and reduce
possible complications.
Option D: Coordinate with a respiratory therapist for
chest physiotherapy and nebulizer management as
indicated. Chest physiotherapy includes the techniques
of postural drainage and chest percussion to mobilize
secretions from smaller airways that cannot be
eliminated by means of coughing or suctioning.
6. The most common deficiency seen in alcoholics is:
A. Thiamine
B. Riboflavin
C. Pyridoxine
D. Pantothenic acid
Chronic alcoholism commonly results in thiamine
deficiency and other symptoms of malnutrition. Chronic
alcohol consumption can cause thiamine deficiency and
thus reduced enzyme activity through several
mechanisms, including inadequate dietary intake,
malabsorption of thiamine from the gastrointestinal tract,
and impaired utilization of thiamine in the cells.
Option B: Riboflavin, vitamin B2, is a water-soluble and
heat-stable vitamin that the body uses to metabolize
fats, protein, and carbohydrates into glucose for energy.
In addition to boosting energy, riboflavin functions as an
antioxidant for the proper function of the immune
system, healthy skin, and hair. Riboflavin deficiency can
result from inadequate dietary intake or by endocrine
abnormalities. Riboflavin deficiency also correlates with
other vitamin B complexes.
Option C: Vitamin B6 deficiency is usually caused by
pyridoxine-inactivating drugs (eg, isoniazid), protein-
energy undernutrition, malabsorption, alcoholism, or
excessive loss. Deficiency can cause peripheral
neuropathy, seborrheic dermatitis, glossitis, and
cheilosis, and, in adults, depression, confusion, and
seizures.
Option D: Pantothenic acid deficiency is very rare in the
United States. Severe deficiency can cause numbness
and burning of the hands and feet, headache, extreme
tiredness, irritability, restlessness, sleeping problems,
stomach pain, heartburn, diarrhea, nausea, vomiting,
and loss of appetite.
7. Which of the following statements is incorrect about a
patient with dysphagia?
A. The patient will find pureed or soft foods, such as
custards, easier to swallow than water.
B. Fowler’s or semi Fowler’s position reduces the risk of
aspiration during swallowing.
C. The patient should always feed himself.
D. The nurse should perform oral hygiene before
assisting with feeding.
A patient with dysphagia (difficulty swallowing) requires
assistance with feeding. Feeding himself is a long-range
expected outcome. Dysphagia is defined as objective
impairment or difficulty in swallowing, resulting in an
abnormal delay in the transit of a liquid or solid bolus.
The delay may be during the oropharyngeal or
esophageal phase of swallowing.
Option A: The Academy of Nutrition and Dietetics has
created a diet plan for people with dysphagia. The plan
is called the National Dysphagia Diet. The dysphagia
diet has 4 levels of foods. Level 1 foods are foods that
are pureed or smooth, like pudding. They need no
chewing. This includes foods such as yogurt, mashed
potatoes with gravy to moisten it, smooth soups, and
pureed vegetables and meats.
Option B: While eating or drinking, it may help to sit
upright, with the back straight. The client may need
support pillows to get into the best position. It may also
help to have few distractions while eating or drinking.
Changing between solid food and liquids may also help
the swallowing. Stay upright for at least 30 minutes after
eating. This can help reduce the risk for aspiration.
Option D: After meals, it’s important to do proper oral
care. The SLP (speech-language pathologist) can give
the client instructions for the teeth or dentures. Make
sure to not swallow any water during the oral care
routine. While on a dysphagia diet, the client may have
trouble taking in enough fluid. This can cause
dehydration, which can lead to serious health problems.
Talk with the healthcare team about how it can be
prevented. In some cases drinking thicker liquids may
make some of the medicines work less well. Because of
this, the client may need some of the medicines
changed for a while.
8. To assess the kidney function of a patient with an
indwelling urinary (Foley) catheter, the nurse measures
his hourly urine output. She should notify the physician if
the urine output is:
A. Less than 30 ml/hour
B. 64 ml in 2 hours
C. 90 ml in 3 hours
D. 125 ml in 4 hours
A urine output of less than 30ml/hour indicates
hypovolemia or oliguria, which is related to kidney
function and inadequate fluid intake. Urine output is a
noninvasive method to measure fluid balance once
intravascular volume has been restored. Normal urine
output is defined as 1.5 to 2 mL/kg per hour
Option B: Micturition process entails contraction of the
detrusor muscle and relaxation of the internal and
external urethral sphincter. The process is slightly
different based on age. Children younger than three
years old have the micturition process coordinated by
the spinal reflex.
Option C: It starts with urine accumulation in the
bladder that stretches the detrusor muscle causing
activation of stretch receptors. The stretch sensation is
carried by the visceral afferent to the sacral region of the
spinal cord where it synapses with the interneuron that
excites the parasympathetic neurons and inhibits the
sympathetic neurons. The visceral afferent impulse
concurrently decreases the firing of the somatic efferent
that normally keeps the external urethral sphincter
closed allowing reflexive urine output.
Option D: Low bladder volume activates the pontine
storage center which activates the sympathetic nervous
system and inhibits the parasympathetic nervous system
cumulatively allowing the accumulation of urine in the
bladder. High bladder volume activates the pontine
micturition center which activates the parasympathetic
nervous system and inhibits the sympathetic nervous
system as well as triggers awareness of a full bladder;
consequently leading to relaxation of the internal
sphincter and a choice to relax the external urethral
sphincter once ready to void.
9. Certain substances increase the amount of urine
produced. These include:
A. Caffeine-containing drinks, such as coffee and
cola
B. Beets
C. Urinary analgesics
D. Kaolin with pectin (Kaopectate)
Fluids containing caffeine have a diuretic effect. Drinking
caffeine-containing beverages as part of a normal
lifestyle doesn’t cause fluid loss in excess of the volume
ingested. While caffeinated drinks may have a mild
diuretic effect — meaning that they may cause the need
to urinate — they don’t appear to increase the risk of
dehydration.
Option B: In some people, eating beets turn urine pink
or red—which can be alarming because it looks like
blood in the urine. These odor and color changes are
harmless. But if urine smells sweet, that’s a cause for
concern because it could mean diabetes.
Option C: Pyridium will most likely darken the color of
urine to an orange or red color. This is a normal effect
and is not cause for alarm unless there are other
symptoms such as pale or yellowed skin, fever, stomach
pain, nausea, and vomiting.
Option D: Kaopectate is an antidiarrheal medication.
This medication is used to treat occasional upset
stomach, heartburn, and nausea. It is also used to treat
diarrhea and help prevent travelers’ diarrhea. It works by
helping to slow the growth of bacteria that might be
causing diarrhea. This product should not be used to
self-treat diarrhea if there is also fever or blood/mucus in
the stools. These could be signs of a serious health
condition.
10. A male patient who had surgery 2 days ago for head
and neck cancer is about to make his first attempt to
ambulate outside his room. The nurse notes that he is
steady on his feet and that his vision was unaffected by
the surgery. Which of the following nursing interventions
would be appropriate?
A. Encourage the patient to walk in the hall alone.
B. Discourage the patient from walking in the hall for a
few more days.
C. Accompany the patient for his walk.
D. Consult a physical therapist before allowing the
patient to ambulate.
Accompanying him will offer moral support, enabling him
to face the rest of the world. Ambulation stimulates
circulation which can help stop the development of
stroke-causing blood clots. Walking improves blood flow
which aids in quicker wound healing. The
gastrointestinal, genitourinary, pulmonary and urinary
tract functions are all improved by walking.
Option A: A hospitalized surgical patient leaving his
room for the first time fears rejection and others staring
at him, so he should not walk alone. Refusal to ambulate
correlated with those that eventually developed a
complication. Those that eventually developed a
postoperative complication were more likely to be in the
higher refusal group. Thorn et al. suggested that patient
compliance may be a marker of underlying
complications. If patients are not engaged in their
recovery, there may be a physiologic reason for refusal
(i.e., a developing abscess).
Option B: Patients should begin ambulation as soon as
possible after surgery to decrease complications and to
regain strength and confidence. The multiple
physiological benefits of patient ambulation have been
documented including the prevention of muscular and
cardiovascular deconditioning, reducing the risk of
pulmonary and thromboembolic events, and stimulating
gastrointestinal recovery through prokinetic effects
Option D: Waiting to consult a physical therapist is
unnecessary. Daily ambulation requires collaboration
between hospital resources, patient education and
available personnel. Second, aggressive non-opioid pain
medication regimens are critical to maintain a low
mLOS. The increasing use of narcotics especially with a
PCA prolonged the LOS. Third, refusal of ambulation
often predicted the development of a postoperative
complication.
11. A patient has exacerbation of chronic obstructive
pulmonary disease (COPD) manifested by shortness of
breath; orthopnea: thick, tenacious secretions; and a dry
hacking cough. An appropriate nursing diagnosis would
be:
A. Ineffective airway clearance related to thick,
tenacious secretions
B. Ineffective airway clearance related to dry, hacking
cough
C. Ineffective individual coping to COPD
D. Pain related to immobilization of affected leg
Thick, tenacious secretions, a dry, hacking cough,
orthopnea, and shortness of breath are signs of
ineffective airway clearance. Chronic obstructive
pulmonary disease (COPD) is a common and treatable
disease characterized by progressive airflow limitation
and tissue destruction. It is associated with structural
lung changes due to chronic inflammation from
prolonged exposure to noxious particles or gases most
commonly cigarette smoke. Chronic inflammation
causes airway narrowing and decreased lung recoil. The
disease often presents with symptoms of cough,
dyspnea, and sputum production.
Option B: Ineffective airway clearance related to dry,
hacking cough is incorrect because the cough is not the
reason for the ineffective airway clearance. COPD is an
inflammatory condition involving the airways, lung
parenchyma, and pulmonary vasculature. The process
is thought to involve oxidative stress and protease-
antiprotease imbalances. Emphysema describes one of
the structural changes seen in COPD where there is the
destruction of the alveolar air sacs (gas-exchanging
surfaces of the lungs) leading to obstructive physiology.
Option C: Ineffective individual coping related to COPD
is wrong because the etiology for a nursing diagnosis
should not be a medical diagnosis (COPD) and because
no data indicate that the patient is coping ineffectively. In
emphysema, an irritant (e.g., smoking) causes an
inflammatory response. Neutrophils and macrophages
are recruited and release multiple inflammatory
mediators. Oxidants and excess proteases leading to
the destruction of the air sacs. The protease-mediated
destruction of elastin leads to a loss of elastic recoil and
results in airway collapse during exhalation.
Option D: Pain related to immobilization of affected legs
would be an appropriate nursing diagnosis for a patient
with a leg fracture. COPD will typically present in
adulthood and often during the winter months. Patients
usually present with complaints of chronic and
progressive dyspnea, cough, and sputum production.
Patients may also have wheezing and chest tightness.
While a smoking history is present in most cases, there
are many without such history.
12. Mrs. Lim begins to cry as the nurse discusses hair
loss. The best response would be:
A. “Don’t worry. It’s only temporary”
B. “Why are you crying? I didn’t get to the bad news
yet”
C. “Your hair is really pretty”
D. “I know this will be difficult for you, but your hair
will grow back after the completion of
chemotherapy”
“I know this will be difficult” acknowledges the problem
and suggests a resolution to it. The term alopecia
means hair loss regardless of the cause. It is not
exclusive to the scalp; it can be anywhere on the body.
As an individual grows older, they will lose hair. The
difference between male hair loss and female hair loss
is the pattern. Men generally lose hair in the front and
the temporal region, while women tend to lose hair from
the central area of the scalp. Also, female hair loss will
not end up with complete baldness, whereas male hair
loss can end up with complete baldness.
Option A: “Don’t worry..” offers some relief but doesn’t
recognize the patient’s feelings. The epidemiology is
variable depending on the cause of alopecia and the
type. In alopecia areata, the prevalence is 0.2% with no
racial or sexual predilection, and it may affect any age
group. Androgenetic alopecia is a common disorder
affecting 50% of men and 15% of women, especially
postmenopausal women.
Option B: “..I didn’t get to the bad news yet” would be
inappropriate at any time. Pathophysiology is dependent
on the type of alopecia. In alopecia areata, it is
unknown, but the most common hypothesis involves
autoimmunity in the form of a T-cell–mediated pathway.
In androgenetic alopecia, both genetic and hormonal
androgens play a role in pathogenesis. In telogen
effluvium, the shedding of hair is under the influence of
hormone or stress, but sometimes the trigger is not very
clear.
Option C: “Your hair is really pretty” offers no
consolation or alternatives to the patient. During the
physical examination, it is essential to notice the pattern
of hair loss. In a patient with androgenetic alopecia,
patients tend to lose hair from the frontal and temporal
area (male type) and the central scalp area (female
type). In alopecia areata, the patient may lose hair from
a single area (alopecia areata classical type), the whole
scalp and eyebrows (alopecia totalis), or from the entire
body (alopecia universalis). In tinea capitis, the classic
presentation is black dots associated with broken hair,
while the inflammatory type (favus) correlates with the
scarring type of alopecia.
13. An additional Vitamin C is required during all of the
following periods except:
A. Infancy
B. Young adulthood
C. Childhood
D. Pregnancy
Additional Vitamin C is needed in growth periods, such
as infancy and childhood, and during pregnancy to
supply demands for fetal growth and maternal tissues.
Other conditions requiring extra vitamin C include wound
healing, fever, infection and stress. Vitamin C is a water-
soluble vitamin, antioxidant, and essential cofactor for
collagen biosynthesis, carnitine and catecholamine
metabolism, and dietary iron absorption. Humans are
unable to synthesize vitamin C, so they can only obtain
it through dietary intake of fruits and vegetables.
Option A: An infant requires Vitamin C. Although most
vitamin C is completely absorbed in the small intestine,
the percentage of absorbed vitamin C decreases as
intraluminal concentrations increase. Proline residues on
procollagen require vitamin C for the hydroxylation,
making it necessary for the triple-helix formation of
mature collagen. The lack of a stable triple-helical
structure compromises the integrity of the skin, mucous
membranes, blood vessels, and bone.
Option C: Children need lots of Vitamin C. Usual dietary
doses of up to 100 mg/day are almost completely
absorbed. The highest concentrations of ascorbic acid
are in the pituitary gland, the adrenal gland, the brain,
leukocytes, and eyes. Ascorbic acid functions as a
cofactor, enzyme complement, co-substrate, and a
powerful antioxidant in a variety of reactions and
metabolic processes. It also stabilizes vitamin E and
folic acid and enhances iron absorption. It neutralizes
free radicals and toxins as well as attenuates
inflammatory response, including sepsis syndrome.
Option D: A pregnant woman requires an abundant
amount of Vitamin C. The average protective adult dose
of vitamin C is 70 to 150 mg daily. Increase the dose to
300 mg to 1 g daily when scurvy is present. Daily need
increases in patients with conditions like gingivitis,
asthma, glaucoma, collagen disorders, heatstroke,
arthritis, infections (pneumonia, sinusitis, rheumatic
fever), and chronic illnesses. Hemovascular disorders,
burns, and delayed wound healing are causes for an
increase in daily intake.
14. A prescribed amount of oxygen is needed for a
patient with COPD to prevent:
A. Cardiac arrest related to increased partial pressure
of carbon dioxide in arterial blood (PaCO2).
B. Circulatory overload due to hypervolemia.
C. Respiratory excitement.
D. Inhibition of the respiratory hypoxic stimulus.
Delivery of more than 2 liters of oxygen per minute to a
patient with chronic obstructive pulmonary disease
(COPD), who is usually in a state of compensated
respiratory acidosis (retaining carbon dioxide (CO2)),
can inhibit the hypoxic stimulus for respiration. Long-
term oxygen therapy is used for COPD if the client has
low levels of oxygen in the blood (hypoxia). It is used
mostly to slow or prevent right-sided heart failure. It can
help the client live longer.
Option A: An increased partial pressure of carbon
dioxide in arterial blood (PACO2) would not initially
result in cardiac arrest. Long-term oxygen therapy
should be used for at least 15 hours a day with as few
interruptions as possible. Regular use can reduce the
risk of death from low oxygen levels.. To get the most
benefit from oxygen, the client should use it 24 hours a
day. Supplemental oxygen is a well-established therapy
with clear evidence for benefit in patients with COPD
and severe resting hypoxemia, which is defined as a
room air Pao2 ? 55 mm Hg or ? 59 mm Hg with signs of
right-sided heart strain or polycythemia.
Option B: Long-term use of supplemental oxygen
improves survival in patients with COPD and severe
resting hypoxemia. However, the role of oxygen in
symptomatic patients with COPD and more moderate
hypoxemia at rest and desaturation with activity is
unclear. The few long-term reports of supplemental
oxygen in this group have been of small size and
insufficient to demonstrate a survival benefit.
Option C: Circulatory overload and respiratory
excitement have no relevance to the question. Short-
term trials have suggested beneficial effects other than
survival in patients with COPD and moderate hypoxemia
at rest. In addition, supplemental oxygen appeared to
improve exercise performance in small short-term
investigations of patients with COPD and moderate
hypoxemia at rest and desaturation with exercise, but
long-term trials evaluating patient-reported outcomes
are lacking.
15. After 1 week of hospitalization, Mr. Gray develops
hypokalemia. Which of the following is the most
significant symptom of his disorder?
A. Lethargy
B. Increased pulse rate and blood pressure
C. Muscle weakness
D. Muscle irritability
Presenting symptoms of hypokalemia ( a serum
potassium level below 3.5 mEq/liter) include muscle
weakness, chronic fatigue, and cardiac dysrhythmias.
The combined effects of inadequate food intake and
prolonged diarrhea can deplete the potassium stores of
a patient with GI problems. Significant muscle weakness
occurs at serum potassium levels below 2.5 mmol/L but
can occur at higher levels if the onset is acute. Similar to
the weakness associated with hyperkalemia, the pattern
is ascending in nature affecting the lower extremities,
progressing to involve the trunk and upper extremities,
and potentially advancing to paralysis.
Option A: Periodic paralysis is a rare neuromuscular
disorder, which is inherited or acquired, that is caused
by an acute transcellular shift of potassium into the cells.
It is characterized by potentially fatal episodes of muscle
weakness or paralysis that can affect the respiratory
muscles. Clinical manifestations mainly involve the
musculoskeletal and cardiovascular systems. Hence,
the physical exam should focus on identifying neurologic
manifestations and cardiac dysrhythmias.
Option B: Clinical symptoms of hypokalemia do not
become evident until the serum potassium level is less
than 3 mmol/L unless there is a precipitous fall or the
patient has a process that is potentiated by
hypokalemia. The severity of symptoms also tends to be
proportional to the degree and duration of hypokalemia.
Symptoms resolve with correction of the hypokalemia.
Option D: Affected muscles can include the muscles of
respiration which can lead to respiratory failure and
death. Involvement of GI muscles can cause an ileus
with associated symptoms of nausea, vomiting, and
abdominal distension. Severe hypokalemia can also
lead to muscle cramps, rhabdomyolysis, and resultant
myoglobinuria.
16. Which of the following nursing interventions
promotes patient safety?
A. Assess the patient’s ability to ambulate and transfer
from a bed to a chair.
B. Demonstrate the signal system to the patient.
C. Check to see that the patient is wearing his
identification band.
D. All of the above.
Patient Safety is a healthcare discipline that emerged
with the evolving complexity in health care systems and
the resulting rise of patient harm in health care facilities.
It aims to prevent and reduce risks, errors, and harm
that occur to patients during the provision of health care.
A cornerstone of the discipline is a continuous
improvement based on learning from errors and adverse
events.
Option A: Assisting a patient with ambulation and
transfer from a bed to a chair allows the nurse to
evaluate the patient’s ability to carry out these functions
safely. Patient safety is fundamental to delivering quality
essential health services. Indeed, there is a clear
consensus that quality health services across the world
should be effective, safe, and people-centered. In
addition, to realize the benefits of quality health care,
health services must be timely, equitable, integrated,
and efficient.
Option B: Demonstrating the signal system and
providing an opportunity for a return demonstration
ensures that the patient knows how to operate the
equipment and encourages him to call for assistance
when needed. To ensure successful implementation of
patient safety strategies; clear policies, leadership
capacity, data to drive safety improvements, skilled
health care professionals, and effective involvement of
patients in their care, are all needed.
Option C: Checking the patient’s identification band
verifies the patient’s identity and prevents identification
mistakes in drug administration. Safety of patients
during the provision of health services that are safe and
of high quality is a prerequisite for strengthening health
care systems and making progress towards effective
universal health coverage (UHC) under Sustainable
Development Goal 3 (Ensure healthy lives and promote
health and well-being for all at all ages).
17. Studies have shown that about 40% of patients fall
out of bed despite the use of side rails; this has led to
which of the following conclusions?
A. Side rails are ineffective.
B. Side rails should not be used.
C. Side rails are a deterrent that prevent a patient from
falling out of bed.
D. Side rails are a reminder to a patient not to get
out of bed.
Since about 40% of patients fall out of bed despite the
use of side rails, side rails cannot be said to prevent
falls; however, they do serve as a reminder that the
patient should not get out of bed. A process that
requires ongoing patient evaluation and monitoring will
result in optimizing bed safety. Many patients go through
a period of adjustment to become comfortable with new
options. Patients and their families should talk to their
health care planning team to find out which options are
best for them.
Option A: Patients who have problems with memory,
sleeping, incontinence, pain, uncontrolled body
movement, or who get out of bed and walk unsafely
without assistance, must be carefully assessed for the
best ways to keep them from harm, such as falling.
Assessment by the patient’s health care team will help
to determine how best to keep the patient safe.
Option B: Historically, physical restraints (such as
vests, ankle or wrist restraints) were used to try to keep
patients safe in health care facilities. In recent years, the
health care community has recognized that physically
restraining patients can be dangerous. Although not
indicated for this use, bed rails are sometimes used as
restraints. Regulatory agencies, health care
organizations, product manufacturers, and advocacy
groups encourage hospitals, nursing homes, and home
care providers to assess patients’ needs and to provide
safe care without restraints.
Option C: Anticipate the reasons patients get out of bed
such as hunger, thirst, going to the bathroom,
restlessness, and pain; meet these needs by offering
food and fluids, scheduling ample toileting, and
providing calming interventions and pain relief. When
bed rails are used, perform an on-going assessment of
the patient’s physical and mental status; closely monitor
high-risk patients.
18. Examples of patients suffering from impaired
awareness include all of the following except:
A. A semiconscious or over fatigued patient.
B. A disoriented or confused patient.
C. A patient who cannot care for himself at home.
D. A patient demonstrating symptoms of drugs or
alcohol withdrawal.
Incorrect
A patient who cannot care for himself at home does not
necessarily have impaired awareness; he may simply
have some degree of immobility.
Option A: Fatigue is the feeling of tiredness and
decreased energy that results from inadequate sleep
time or poor quality of sleep. Fatigue can also result
from increased work intensity or long work hours. Sleep
deprivation has long been known to impair various
cognitive functions, including mood, motivation,
response time, and initiative. In a classic review of sleep
deprivation and decision-making, investigators argued
that effective performance in health care environments
requires naturalistic decision-making and situation
awareness.
Option B: Impaired self-awareness of deficits is a
common finding in patients who have suffered a
traumatic brain injury. Impaired awareness can limit
motivation for treatment and contribute to a poor
outcomes. Consequently, it is important for brain injury
rehabilitation professionals to understand this
phenomenon and utilize treatment approaches that may
improve patient awareness.
Option D: Most alcoholics exhibit mild-to-moderate
deficiencies in intellectual functioning, along with
diminished brain size and regional changes in brain-cell
activity. The most prevalent alcohol-associated brain
impairments affect visuospatial abilities and higher
cognitive functioning. Visuospatial abilities include
perceiving and remembering the relative locations of
objects in 2- and 3-dimensional space. Examples
include driving a car or assembling a piece of furniture
based on instructions contained in a line drawing. Higher
cognitive functioning includes the abstract-thinking
capabilities needed to organize a plan, set it in motion,
and change it as needed.
19. The most common injury among elderly persons is:
A. Atherosclerotic changes in the blood vessels
B. Increased incidence of gallbladder disease
C. Urinary Tract Infection
D. Hip fracture
Hip fracture, the most common injury among elderly
persons, usually results from osteoporosis. Hip fractures
from falls are one of the leading causes of injuries for
seniors and result in the largest number of
hospitalizations. Family members and hourly caregivers
can take steps to prevent falls, such as removing area
rugs, improving lighting throughout the home, and
offering mobility support when needed.
Option A: Some changes in the heart and blood vessels
normally occur with age. However, many other changes
that are common with aging are due to modifiable
factors. If not treated, these can lead to heart disease.
Arteriosclerosis (hardening of the arteries) is very
common. Fatty plaque deposits inside the blood vessels
cause them to narrow and totally block blood vessels.
The capillary walls thicken slightly. This may cause a
slightly slower rate of exchange of nutrients and wastes.
Option B: Increasing age is a major risk factor for their
formation, with the prevalence of gallstones being
greatest at advanced age. While the majority of
gallstones remain asymptomatic, seniors have a high
risk for acute cholecystitis with atypical presentation,
even when gangrene or perforation has occurred.
Option C: The main cause of UTIs, at any age, is
usually bacteria. Escherichia coli is the primary cause,
but other organisms can also cause a UTI. In older
adults who use catheters or live in a nursing home or
other full-time care facility, bacteria such as Enterococci
and Staphylococci are more common causes.
20. The most common psychogenic disorder among
elderly person is:
A. Depression
B. Sleep disturbances (such as bizarre dreams)
C. Inability to concentrate
D. Decreased appetite
Depression typically begins before the onset of old age
and usually is caused by psychosocial, genetic, or
biochemical factors. Depression is a common problem
among older adults, but it is NOT a normal part of aging.
In fact, studies show that most older adults feel satisfied
with their lives, despite having more illnesses or physical
problems. However, important life changes that happen
as we get older may cause feelings of uneasiness,
stress, and sadness. Sometimes older people who are
depressed appear to feel tired, have trouble sleeping, or
seem grumpy and irritable. Confusion or attention
problems caused by depression can sometimes look like
Alzheimer’s disease or other brain disorders.
Option B: Primary sleep disorders are more common in
the elderly than in younger persons. Restless legs
syndrome and periodic limb movement disorder can
disrupt sleep and may respond to low doses of
antiparkinsonian agents as well as other drugs. Sleep
apnea can lead to excessive daytime sleepiness.
Option C: A study finds that seniors’ attention shortfall
is associated with the locus coeruleus, a tiny region of
the brainstem that connects to many other parts of the
brain. The locus coeruleus helps focus brain activity
during periods of stress or excitement. Increased
distractibility is a sign of cognitive aging.
Option D: Sleep disturbances, inability to concentrate,
and decreased appetite are symptoms of depression,
the most common psychogenic disorder among elderly
persons. Other symptoms include diminished memory,
apathy, disinterest in appearance, withdrawal, and
irritability.
21. Which of the following vascular system changes
results from aging?
A. Increased peripheral resistance of the blood vessels
B. Decreased blood flow
C. Increased workload of the left ventricle
D. All of the above
Aging decreases the elasticity of the blood vessels,
which leads to increased peripheral resistance and
decreased blood flow. These changes, in turn, increase
the workload of the left ventricle. Some changes in the
heart and blood vessels normally occur with age.
However, many other changes that are common with
aging are due to modifiable factors. If not treated, these
can lead to heart disease.
Option A: Receptors called baroreceptors monitor the
blood pressure and make changes to help maintain a
fairly constant blood pressure when a person changes
positions or is doing other activities. The baroreceptors
become less sensitive with aging. This may explain why
many older people have orthostatic hypotension, a
condition in which the blood pressure falls when a
person goes from lying or sitting to standing. This
causes dizziness because there is less blood flow to the
brain.
Option B: The main artery from the heart (aorta)
becomes thicker, stiffer, and less flexible. This is
probably related to changes in the connective tissue of
the blood vessel wall. This makes the blood pressure
higher and makes the heart work harder, which may
lead to thickening of the heart muscle (hypertrophy). The
other arteries also thicken and stiffen. In general, most
older people have a moderate increase in blood
pressure.
Option C: The heart has a natural pacemaker system
that controls the heartbeat. Some of the pathways of this
system may develop fibrous tissue and fat deposits. The
natural pacemaker (the SA node) loses some of its cells.
These changes may result in a slightly slower heart rate.
A slight increase in the size of the heart, especially the
left ventricle occurs in some people. The heart wall
thickens, so the amount of blood that the chamber can
hold may actually decrease despite the increased
overall heart size. The heart may fill more slowly.
22. Which of the following is the most common cause of
dementia among elderly persons?
A. Parkinson’s disease
B. Multiple sclerosis
C. Amyotrophic lateral sclerosis (Lou Gehrig’s disease)
D. Alzheimer’s disease
Alzheimer’s disease, sometimes known as senile
dementia of the Alzheimer’s type or primary
degenerative dementia, is an insidious; progressive,
irreversible, and degenerative disease of the brain
whose etiology is still unknown. Alzheimer’s is the most
common cause of dementia among older adults.
Dementia is the loss of cognitive functioning—thinking,
remembering, and reasoning—and behavioral abilities to
such an extent that it interferes with a person’s daily life
and activities.
Option A: Parkinson’s disease is a neurologic disorder
caused by lesions in the extrapyramidal system and
manifested by tremors, muscle rigidity, hypokinesia,
dysphagia, and dysphonia. Parkinson’s disease is a
neurodegenerative disorder that mostly presents in later
life with generalized slowing of movements
(bradykinesia) and at least one other symptom of resting
tremor or rigidity. Other associated features are a loss of
smell, sleep dysfunction, mood disorders, excess
salivation, constipation, and excessive periodic limb
movements in sleep (REM behavior disorder).
Option B: Multiple sclerosis, a progressive,
degenerative disease involving demyelination of the
nerve fibers, usually begins in young adulthood and is
marked by periods of remission and exacerbation.
Multiple sclerosis (MS) is a chronic autoimmune disease
of the central nervous system (CNS) characterized by
inflammation, demyelination, gliosis, and neuronal loss.
Pathologically, perivascular lymphocytic infiltrates, and
macrophages produce degradation of myelin sheaths
that surround neurons.
Option C: Amyotrophic lateral sclerosis, a disease
marked by progressive degeneration of the neurons,
eventually results in atrophy of all the muscles; including
those necessary for respiration. Amyotrophic lateral
sclerosis (ALS), also known as “Lou Gehrig’s disease,”
is a neurodegenerative disease of the motor neurons.
No single etiology has been proven; rather, multiple
pathways (both heritable and sporadic) have been
shown to result in unmistakably similar disease entities.
ALS necessarily affects both upper and lower motor
neurons with variable patterns of onset, most commonly
beginning with signs of lower motor neuron
degeneration within proximal limbs.
23. The nurse’s most important legal responsibility after
a patient’s death in a hospital is:
A. Obtaining a consent of an autopsy.
B. Notifying the coroner or medical examiner.
C. Labeling the corpse appropriately.
D. Ensuring that the attending physician issues the
death certification.
The nurse is legally responsible for labeling the corpse
when death occurs in the hospital. After a person dies it
is important to give the family the time that they need
with the body. Some family members might like to lie in
bed with their loved one who has died, while others
might like to be involved with washing the body. Others
may not want to be there at all. Washing the body is
particularly important in paediatric palliative care, as
often parents feel it is a special ritual to have washed
their baby after they are born, and it is the same after
they die. It is important to discuss rigor mortis with
families as people are often unaware of this.
Option A: She may be involved in obtaining consent for
an autopsy. There are considerations regarding care
and preparation of the body after someone dies.
Traditionally this task was performed by families, but
nowadays much of the preparation of a body is done by
nursing staff or undertakers. The required procedures
are often included in an organizations’ procedures
manual or there may be local requirements regarding
the preparation of a body.
Option B: The nurse may be responsible for notifying
the coroner or medical examiner of a patient’s death;
however, she is not legally responsible for performing
these functions. Depending on the location of the death,
the nurse would contact the medical examiner to notify
them of the death, as well as the physician and other
clinicians who were involved with the patient. The nurse
can also contact the funeral home for the family as
requested.
Option D: The attending physician may need
information from the nurse to complete the death
certificate, but he is responsible for issuing it. A doctor
must certify the death. This involves completing a
medical certificate of the cause of death and stating
what the cause of death was. This should happen as
soon as possible. If there are any unexpected or
suspicious circumstances, or if the cause of death is not
known, the doctor may not be able to issue a death
certificate without talking to the coroner (England,
Wales, and Northern Ireland) or procurator fiscal
(Scotland). The doctor completing the certificate may
wish to talk to you as part of their standard checks.
24. Before rigor mortis occurs, the nurse is responsible
for:
A. Providing a complete bath and dressing change.
B. Placing one pillow under the body’s head and
shoulders.
C. Removing the body’s clothing and wrapping the body
in a shroud.
D. Allowing the body to relax normally.
The nurse must place a pillow under the deceased
person’s head and shoulders to prevent blood from
settling in the face and discoloring it. A body undergoes
complex and intricate changes after death. These post
mortem changes depend on a diverse range of
variables. Factors such as the ambient temperature,
season, and geographical location at which the body is
found, the fat content of the body, sepsis/injuries,
intoxication, presence of clothes/insulation over the
body, etc. determine the rate at which post-mortem
changes occur in a cadaver.
Option A: She is required to bathe only soiled areas of
the body since the mortician will wash the entire body.
Changes that occur to a body after death are a result of
complex physicochemical and environmental processes.
They are affected by factors within the cadaver and
outside it. These factors affect the onset and either
increase the rate of post-mortem changes or retard it.
Factors that hasten the rate of post mortem changes
include hot and humid climate, presence of body fat,
open injuries on the body, sepsis or infection, and the
location of the cadaver in the open.
Option C: Before wrapping the body in a shroud, the
nurse places a clean gown on the body and closes the
eyes and mouth. Rigor Mortis appears in 1 to 2 hours
after death, is completely formed 12 hours after death, is
sustained for the next 12 hours, and vanishes over the
next 12 hours, sometimes referred to as the ‘march of
rigor.’
Option D: Rigor mortis appears rapidly in children and
old aged individuals, in cases of persons dying of
diseases or conditions involving great exhaustion such
as cholera, or due to convulsions as in cases of
strychnine poisoning. In such cases, the rigor
disappears early as well. The effect of rigor on individual
muscles can be of additional significance. The rigor of
erector pilae muscles may cause elevation of hair
leading to the pimpled appearance of the skin.
25. When a patient in the terminal stages of lung cancer
begins to exhibit loss of consciousness, a major nursing
priority is to:
A. Protect the patient from injury.
B. Insert an airway.
C. Elevate the head of the bed.
D. Withdraw all pain medications.
Ensuring the patient’s safety is the most essential action
at this time. This phase is different for each patient, and
the needs may differ for each patient and family, but it is
vital for healthcare providers to provide care and support
in a way that respects the patient’s dignity and
autonomous wishes.
Option B: The vast majority of patients who experience
a natural death, meaning no medical, life-saving
interventions to counter the process, follow a
stereotypical pattern of signs and symptoms in the time
leading up to death. This time frame is often referred to
as “actively dying” or “imminent death.” It is important for
healthcare providers to be familiar with this process, not
only so they know what to expect when providing direct
care to patients during this time, but also so they can
guide the family in understanding what to expect during
this process and providing support as needed.
Option C: The self-determination of the patient with
capacity must be respected. When the patient can make
their own choices, their autonomy must be upheld. It is
not the role of the provider to impart their values and
beliefs onto patients. Patients’ families may experience
anticipatory grief and have a hard time fully handling the
current situation, and they may want to push their
personal choices for the situation instead of respecting
their loved one’s wishes and choices.
Option D: The primary goal in treatment for patients is
alleviating suffering. Hospice care and palliative care are
often confused. Hospice care is the term given to the
care provided when a patient is given a prognosis of
death within 6 months, and they do not pursue curative
treatments. They focus on improving the quality of life
which can mean many things. Palliative care can be
incorporated into the plan of care at any time for any
patient who is experiencing suffering and wants to ease
that suffering without directly treating the cause of that
suffering.
26. Which element in the circular chain of infection can
be eliminated by preserving skin integrity?
A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry
In the circular chain of infection, pathogens must be able
to leave their reservoir and be transmitted to a
susceptible host through a portal of entry, such as
broken skin. The portal of entry refers to the manner in
which a pathogen enters a susceptible host. The portal
of entry must provide access to tissues in which the
pathogen can multiply or a toxin can act. Often,
infectious agents use the same portal to enter a new
host that they used to exit the source host.
Option A: The final link in the chain of infection is a
susceptible host. Susceptibility of a host depends on
genetic or constitutional factors, specific immunity, and
nonspecific factors that affect an individual’s ability to
resist infection or to limit pathogenicity. An individual’s
genetic makeup may either increase or decrease
susceptibility.
Option B: The reservoir of an infectious agent is the
habitat in which the agent normally lives, grows, and
multiplies. Reservoirs include humans, animals, and the
environment. The reservoir may or may not be the
source from which an agent is transferred to a host.
Option C: An infectious agent may be transmitted from
its natural reservoir to a susceptible host in different
ways. There are different classifications for modes of
transmission. In direct transmission, an infectious agent
is transferred from a reservoir to a susceptible host by
direct contact or droplet spread. Indirect transmission
refers to the transfer of an infectious agent from a
reservoir to a host by suspended air particles, inanimate
objects (vehicles), or animate intermediaries (vectors).
27. Which of the following will probably result in a break
in sterile technique for respiratory isolation?
A. Opening the patient’s window to the outside
environment.
B. Turning on the patient’s room ventilator.
C. Opening the door of the patient’s room leading
into the hospital corridor.
D. Failing to wear gloves when administering a bed
bath.
Respiratory isolation, like strict isolation, requires that
the door to the door patient’s room remain closed.
Appropriate patient placement is a significant
component of isolation precautions. A private room is
important to prevent direct- or indirect-contact
transmission when the source patient has poor hygienic
habits, contaminates the environment, or cannot be
expected to assist in maintaining infection control
precautions to limit transmission of microorganisms (ie,
infants, children, and patients with altered mental
status).
Option A: Opening the patient’s window is acceptable
because the room needs to be well-ventilated. A private
room with appropriate air handling and ventilation is
particularly important for reducing the risk of
transmission of microorganisms from a source patient to
susceptible patients and other persons in hospitals when
the microorganism is spread by airborne transmission.
Some hospitals use an isolation room with an anteroom
as an extra measure of precaution to prevent airborne
transmission.
Option B: The patient’s room should be well ventilated,
so turning on the ventilator is desirable.
Option D: The nurse does not need to wear gloves for
respiratory isolation, but good handwashing is important
for all types of isolation. Wearing gloves does not
replace the need for handwashing, because gloves may
have small, apparent defects or may be torn during use,
and hands can become contaminated during removal of
gloves. Failure to change gloves between patient
contacts is an infection control hazard.
28. Which of the following patients is at greater risk for
contracting an infection?
A. A postoperative patient who has undergone
orthopedic surgery.
B. A patient receiving broad-spectrum antibiotics.
C. A patient with leukopenia.
D. A newly diagnosed diabetic patient.
Leukopenia is a decreased number of leukocytes (white
blood cells), which are important in resisting infection.
Leukopenia is a condition where a person has a reduced
number of white blood cells. This increases their risk of
infections. A person’s blood is made up of many
different types of blood cells. White blood cells, also
known as leukocytes, help to fight off infection.
Leukocytes are a vital part of the immune system.
Option A: Surgical site infections (SSI) following total
hip arthroplasty (THA) have a significantly adverse
impact on patient outcomes and pose a great challenge
to the treating surgeon. Therefore, timely recognition of
those patients at risk for this complication is very
important, as it allows for adopting measures to reduce
this risk.
Option B: Antibiotic-mediated cell death, however, is a
complex process that begins with the physical
interaction between a drug molecule and its bacterial-
specific target, and involves alterations to the affected
bacterium at the biochemical, molecular and
ultrastructural levels. Antibiotic-induced cell death has
been associated with the formation of double-stranded
DNA breaks following treatment with DNA gyrase
inhibitors, with the arrest of DNA-dependent RNA
synthesis following treatment with rifamycins, with cell
envelope damage and loss of structural integrity
following treatment with cell-wall synthesis inhibitors,
and with cellular energetics, ribosome binding and
protein mistranslation following treatment with protein
synthesis inhibitors.
Option D: People who have had diabetes for a long
time may have peripheral nerve damage and reduced
blood flow to their extremities, which increases the
chance for infection. The high sugar levels in your blood
and tissues allow bacteria to grow and allow infections
to develop more quickly.
29. Effective handwashing requires the use of:
A. Soap or detergent to promote emulsification.
B. Hot water to destroy bacteria.
C. A disinfectant to increase surface tension.
D. All of the above.
Soaps and detergents are used to help remove bacteria
because of their ability to lower the surface tension of
water and act as emulsifying agents. Handwashing is
the act of washing hands with soap, either antimicrobial
or non antimicrobial, and water for at least 15 to 20
seconds with a vigorous motion to cause friction making
sure to include all surfaces of the hands and fingers.
Option B: Hot water may lead to skin irritation or burns.
Warm water would be enough for handwashing.
Healthcare professionals caring for high-risk patients
that are immunocompromised must take great care in
performing proper hand hygiene as this patient
population is at high risk for opportunistic infections
Option C: Handwashing with soap and water will
remove nearly all transient gram-negative bacilli in 10
seconds while chlorhexidine may be more appropriate
than soap and water for the removal of transient gram-
positive bacteria. According to the CDC, established
guidelines recommend that agents used for surgical
hand scrubs should reduce microorganisms on intact
skin in a substantial manner, contain a nonirritating
antimicrobial preparation, have broad-spectrum activity,
and be fast-acting and persistent.
Option D: Hand hygiene practices are paramount in
reducing cross-transmission of microorganisms,
hospital-acquired infections and the risk of occupational
exposure to infectious diseases. According to the CDC,
understanding the importance of hand hygiene and its
impact on the pathogenic spread of microorganisms is
best understood when one understands the anatomy of
the skin. The skin serves as a protective barrier against
water loss, heat loss, microorganisms, and other
environmental hazards.
30. After routine patient contact, handwashing should
last at least:
A. 30 seconds
B. 1 minute
C. 2 minutes
D. 3 minutes
Depending on the degree of exposure to pathogens,
hand washing may last from 10 seconds to 4 minutes.
After routine patient contact, hand washing for 30
seconds effectively minimizes the risk of pathogen
transmission. According to the Centers for Disease
Control and Prevention (CDC), hand hygiene is the
single most important practice in the reduction of the
transmission of infection in the healthcare setting.
Option B: According to the CDC, hand hygiene
encompasses the cleansing of your hands with soap
and water, antiseptic hand washes, antiseptic hand rubs
such as alcohol-based hand sanitizers, foams or gels, or
surgical hand antisepsis. Indications for handwashing
include when hands are visibly soiled, contaminated with
blood or other bodily fluids, before eating, and after
restroom use.
Option C: Handwashing is the act of washing hands
with soap, either antimicrobial or non-antimicrobial, and
water for at least 15 to 20 seconds with a vigorous
motion to cause friction making sure to include all
surfaces of the hands and fingers. Hand rubbing with an
alcohol-based rub should not be performed when the
hands are visibly soiled. In this case, the CDC and WHO
guidelines recommend that handwashing with soap and
water
Option D: Alcohol-based hand sanitizers are the
recommended product for hand hygiene when hands
are not visibly soiled. Apply alcohol-based products per
manufacturer guidelines on dispensing of the product.
Typically, 3 mL to 5 mL in the palm, rubbing vigorously,
ensuring all surfaces on both hands get covered, about
20 seconds is required for all surfaces to dry completely.
31. Which of the following procedures always requires
surgical asepsis?
A. Vaginal instillation of conjugated estrogen
B. Urinary catheterization
C. Nasogastric tube insertion
D. Colostomy irrigation
The urinary system is normally free of microorganisms
except at the urinary meatus. Any procedure that
involves entering this system must use surgically aseptic
measures to maintain a bacteria-free state. Guidelines
from The Centers for Disease Control and Prevention
(CDC) and The European Association of Urology Nurses
(EAUN) recommend ‘sterile technique’ when inserting
an indwelling urinary catheter. Insertion of indwelling
urinary catheters should be performed in a way that
minimizes the risk of introducing bacteria to the urinary
bladder.
Option A: Conjugated estrogens is a medicine that
contains a mixture of estrogen hormones. Conjugated
estrogen vaginal cream is used to treat changes in and
around the vagina (such as vaginal dryness, itching, and
burning) caused by low estrogen levels or menopause. It
is also used to treat vaginal pain during sexual
intercourse. This medicine is to be used only in the
vagina. Use at bedtime unless your doctor tells
otherwise.
Option C: Nasogastric (NG) intubation is a procedure in
which a thin, plastic tube is inserted into the nostril,
toward the esophagus, and down into the stomach.
Once an NG tube is properly placed and secured,
healthcare providers such as the nurses can deliver food
and medicine directly to the stomach or obtain
substances from it. Clean, not sterile, technique is
necessary because the gastrointestinal (GI) tract is not
sterile.
Option D: Sterile supplies are used in acute care with a
fresh post-surgical urostomy. A patient in the community
may not use sterile supplies, but strict adherence to
proper hand hygiene is required to prevent infections of
the bladder, kidney, or urinary tract. Never place
anything inside the stoma.
32. Sterile technique is used whenever:
A. Strict isolation is required
B. Terminal disinfection is performed
C. Invasive procedures are performed
D. Protective isolation is necessary
All invasive procedures, including surgery, catheter
insertion, and administration of parenteral therapy,
require a sterile technique to maintain a sterile
environment. All equipment must be sterile, and the
nurse and the physician must wear sterile gloves and
maintain surgical asepsis. In the operating room, the
nurse and physician are required to wear sterile gowns,
gloves, masks, hair covers, and shoe covers for all
invasive procedures.
Option A: Strict isolation requires the use of clean
gloves, masks, gowns, and equipment to prevent the
transmission of highly communicable diseases by
contact or by airborne routes. Strict isolation is used for
diseases spread through the air and in some cases by
contact. Patients must be placed in isolation to prevent
the spread of infectious diseases. Those who are kept in
strict isolation are often kept in a special room at the
facility designed for that purpose.
Option B: Terminal disinfection is the disinfection of all
contaminated supplies and equipment after a patient
has been discharged to prepare them for reuse by
another patient. Terminal disinfection has the objective
of preparing complete rooms or areas for subsequent
patients or residents for them to be treated or cared for
without the risk of acquiring an infection. This
disinfection measure is applied in rooms and areas
where an infected or colonized patient/resident has been
cared for or treated. Depending on the existing disease
or type of pathogen all near-patient surfaces/objects or
all accessible surfaces (e.g. also floors or walls) are to
be disinfected.
Option D: The purpose of protective (reverse) isolation
is to prevent a person with seriously impaired resistance
from coming into contact with potentially pathogenic
organisms. Protective Isolation aims to protect an
immunocompromised patient who is at high risk of
acquiring micro-organisms from either the environment
or from other patients, staff, or visitors.
33. Which of the following constitutes a break in sterile
technique while preparing a sterile field for a dressing
change?
A. Using sterile forceps, rather than sterile gloves, to
handle a sterile item.
B. Touching the outside wrapper of sterilized material
without sterile gloves.
C. Placing a sterile object on the edge of the sterile
field.
D. Pouring out a small amount of solution (15 to 30 ml)
before pouring the solution into a sterile container.
The edges of a sterile field are considered
contaminated. When sterile items are allowed to come in
contact with the edges of the field, the sterile items also
become contaminated. The sterile field should be
prepared as close as possible to the time of use.2 The
sterility of supplies used during a surgical procedure can
be affected by the events taking place within the
operating room, and the length of time the items have
been exposed to the environment.
Option A: Under no circumstances should sterile and
nonsterile items/areas be mixed since one contaminates
the other.4 Sterilization provides the highest level of
assurance that all instruments, sutures, fluids, supplies,
and drapes are void of microorganisms.2 The sterility of
a package is determined by events, not by time. To
ensure sterility, all sterile items need to be inspected for
package integrity and sterilization process indicators,
such as indicator tape and internal chemical indicators,
prior to introduction onto the sterile field. If a package
has been compromised, it should be considered
contaminated and not be used.
Option B: When opening wrapped supplies, the
nonsterile person should open the top wrapper flap
away from them first, then open the flaps to each side.
The last wrapper flap is pulled toward the nonsterile
person opening the package. This technique of opening
a wrapped package ensures that the nonsterile person
does not reach over the sterile item inside. All wrapper
edges should be secured to prevent flipping the wrapper
and contaminating the contents of the sterile package or
field.
Option D: Only the top rim of the bottle top and bottle
contents are considered sterile once the cap has been
removed from the bottle. Therefore, when sterile fluids
are dispensed, the entire contents of the bottle must be
poured or the fluid remaining in the bottle discarded.
When solutions are poured onto the sterile field, they
should be poured slowly to prevent contamination and
fluid strikethrough from splashing.
34. A natural body defense that plays an active role in
preventing infection is:
A. Yawning
B. Body hair
C. Hiccupping
D. Rapid eye movements
Hair on or within body areas, such as the nose, traps
and holds particles that contain microorganisms. One of
the body’s most important physical barriers is the skin
barrier, which is composed of three layers of closely
packed cells. The thin upper layer is called the
epidermis. A second, thicker layer, called the dermis,
contains hair follicles, sweat glands, nerves, and blood
vessels. A layer of fatty tissue called the hypodermis lies
beneath the dermis and contains blood and lymph
vessels
Option A: Evidence suggests that drowsiness is the
most common stimulus of yawn. Boredom occurs when
the main source of stimulation in a person’s environment
is no longer able to sustain their attention. This induces
drowsiness by stimulating the sleep generating system.
At this moment, the mind has to make an effort to
maintain contact with the external environment.
Option C: Hiccupping does not prevent microorganisms
from entering or leaving the body. As they breathe out,
the diaphragm pushes up to expel the air. When a
person has hiccups, the diaphragm contracts and pulls
down, drawing in air between breaths. Immediately after
this, the windpipe closes for a moment to prevent more
air from entering the lungs. Hiccups often come after
eating or drinking too much or too quickly.
Option D: Rapid eye movement marks the stage of
sleep during which dreaming occurs. Rapid eye
movement (REM) is the stage of sleep characterized by
rapid saccadic movements of the eyes. During this
stage, the activity of the brain’s neurons is quite similar
to that during waking hours. Most of the vividly recalled
dreams occur during REM sleep.
35. All of the following statement are true about donning
sterile gloves except:
A. The first glove should be picked up by grasping the
inside of the cuff.
B. The second glove should be picked up by inserting
the gloved fingers under the cuff outside the glove.
C. The gloves should be adjusted by sliding the gloved
fingers under the sterile cuff and pulling the glove over
the wrist.
D. The inside of the glove is considered sterile.
The inside of the glove is always considered to be clean,
but not sterile. Sterile gloves are gloves that are free
from all microorganisms. They are required for any
invasive procedure and when contact with any sterile
site, tissue, or body cavity is expected (PIDAC, 2012).
Option A: Pick up the glove for the dominant hand by
touching the inside cuff of the glove. Do not touch the
outside of the glove. Pull the glove completely over the
dominant hand. Sterile gloves help prevent surgical site
infections and reduce the risk of exposure to blood and
body fluid pathogens for the health care worker. Studies
have shown that 18% to 35% of all sterile gloves have
tiny holes after surgery, and up to 80% of the tiny
puncture sites go unnoticed by the surgeon (Kennedy,
2013).
Option B: Insert gloved hand into the cuff of the
remaining glove. Pull the remaining glove on a non-
dominant hand and insert fingers. Adjust gloves if
necessary. Double gloving is known to reduce the risk of
exposure and has become common practice, but does
not reduce the risk of cross-contamination after surgery
(Kennedy, 2013).
Option C: Once gloves are on, interlock gloved hands
and keep at least six inches away from clothing, keeping
hands above waist level and below the shoulders. To
remove gloves, grasp the outside of the cuff or palm of
the glove and gently pull the glove off, turning it inside
out and placing it into a gloved hand.
36. When removing a contaminated gown, the nurse
should be careful that the first thing she touches is the:
A. Waist tie and necktie at the back of the gown
B. Waist tie in front of the gown
C. Cuffs of the gown
D. Inside of the gown
The back of the gown is considered clean, the front is
contaminated. So, after removing gloves and washing
hands, the nurse should untie the back of the gown;
slowly move backward away from the gown, holding the
inside of the gown and keeping the edges off the floor;
turn and fold the gown inside out; discard it in a
contaminated linen container; then wash her hands
again.
Option B: First, release the tie, then grasp the gown at
the hip area, and pull the gown down and away from the
sides of the body. Once the gown is off the shoulders,
pull one arm at a time from the sleeves of the gown so
that the gown arms are bunched at the wrists. Then, roll
the exposed side of the gown inward until it’s a tight ball.
Dispose of it.
Option C: Following the doffing protocol will minimize
the risk for disease transmission, so it’s very important
that you understand all the steps. A Trained Observer
will help you with the process. Gown front and sleeves
are contaminated!
Option D: Grasp the gown in the front and pull away
from your body so that the ties break, touching the
outside of the gown only with gloved hands. While
removing the gown, fold or roll the gown inside-out into a
bundle
37. Which of the following nursing interventions is
considered the most effective form for universal
precautions?
A. Cap all used needles before removing them from
their syringes.
B. Discard all used uncapped needles and syringes
in an impenetrable protective container.
C. Wear gloves when administering IM injections.
D. Follow enteric precautions.
According to the Centers for Disease Control (CDC),
blood-to-blood contact occurs most commonly when a
health care worker attempts to cap a used needle.
Universal precautions are a standard set of guidelines
aimed at preventing the transmission of bloodborne
pathogens from exposure to blood and other potentially
infectious materials (OPIM).
Option A: Therefore, used needles should never be
recapped; instead they should be inserted in a specially
designed puncture resistant, labeled container. In 1987,
the CDC introduced another set of guidelines termed
Body Substance Isolation. These guidelines advocated
the avoidance of direct physical contact with “all moist
and potentially infectious body substances,” even if
blood is not visible. A limitation of this guideline was that
it emphasized handwashing after removal of gloves only
if the hands were visibly soiled.
Option C: Wearing gloves is not always necessary
when administering an I.M. injection. Must be worn
when touching blood, body fluids, secretions, excretions,
mucous membranes, or non-intact skin. Change when
there is contact with potentially infected material in the
same patient to avoid cross-contamination. Remove
before touching surfaces and clean items. Wearing
gloves does not mitigate the need for proper hand
hygiene.
Option D: Enteric precautions prevent the transfer of
pathogens via feces. Universal precautions do not apply
to sputum, feces, sweat, vomit, tears, urine, or nasal
secretions unless they are visibly contaminated with
blood because their transmission of Hepatitis B or HIV is
extremely low or non-existent.
38. All of the following measures are recommended to
prevent pressure ulcers except:
A. Massaging the reddened area with lotion.
B. Using a water or air mattress.
C. Adhering to a schedule for positioning and turning.
D. Providing meticulous skin care.
Nurses and other healthcare professionals previously
believed that massaging a reddened area with lotion
would promote venous return and reduce edema to the
area. However, research has shown that massage only
increases the likelihood of cellular ischemia and
necrosis to the area.
Option B: In patients with a high risk of developing
pressure injuries, support surfaces to alleviate pressure
can be used. This can include higher-speciation foam
mattresses, medical-grade sheepskins, continuous low-
pressure supports, alternating-pressure devices, low air
loss therapy; however, the effectiveness of these
devices compared to other surfaces in the treatment of
existing pressure injuries has not been conclusively
established.
Option C: General care for pressure injuries can include
redistribution of pressure with the use of support
surfaces and changes in positioning. Redistribution of
pressure and appropriate patient positioning is required
to prevent the development and worsening of pressure
injuries, as these methods can reduce force from friction
and shear.
Option D: Wound care, including maintaining a clean
environment, debridement, application of dressings,
monitoring, and various adjunctive therapies, is
generally advised to facilitate the healing of pressure
injuries. Options for treatment can be guided by the
stage of the pressure injury. Stage 1 pressure injuries
can be covered with transparent film dressings as
needed.
39. Which of the following blood tests should be
performed before a blood transfusion?
A. Prothrombin and coagulation time
B. Blood typing and cross-matching
C. Bleeding and clotting time
D. Complete blood count (CBC) and electrolyte levels
Before a blood transfusion is performed, the blood of the
donor and recipient must be checked for compatibility.
This is done by blood typing (a test that determines a
person’s blood type) and cross-matching (a procedure
that determines the compatibility of the donor’s and
recipient’s blood after the blood types have been
matched). If the blood specimens are incompatible,
hemolysis and antigen-antibody reactions will occur. If
the donor is eligible to donate, the donated blood is
tested for blood type (ABO group) and Rh type (positive
or negative). This is to make sure that patients receive
blood that matches their blood type. Before transfusion,
the donor and blood unit are also tested for certain
proteins (antibodies) that may cause adverse reactions
in a person receiving a blood transfusion.
Option A: A prothrombin time (PT) is a test used to help
detect and diagnose a bleeding disorder or excessive
clotting disorder. A PT measures the number of seconds
it takes for a clot to form in your sample of blood after
substances (reagents) are added. The PT is often
performed along with a partial thromboplastin time (PTT)
and together they assess the amount and function of
proteins called coagulation factors that are an important
part of proper blood clot formation. The coagulation time
is a measurement of the intrinsic power of the blood to
convert fibrinogen to fibrin. It is an empirical test no
matter how performed, and therefore in order to be
reliable requires that the test be done on venous blood
under strictly controlled conditions.
Option C: Bleeding time is a laboratory test to assess
platelet function and the body’s ability to form a clot. The
test involves making a puncture wound in a superficial
area of the skin and monitoring the time needed for
bleeding to stop (ie, the bleeding site turns “glassy”).
The expected range for clotting time is 4-10 mins. This
test measures the time taken for blood vessel
constriction and platelet plug formation to occur. No clot
is allowed to form, so that the arrest of bleeding
depends exclusively on blood vessel constriction and
platelet action.
Option D: The complete blood count (CBC) is a group
of tests that evaluate the cells that circulate in the blood,
including red blood cells (RBCs), white blood cells
(WBCs), and platelets (PLTs). The CBC can evaluate
your overall health and detect a variety of diseases and
conditions, such as infections, anemia, and leukemia.
40. The primary purpose of a platelet count is to
evaluate the:
A. Potential for clot formation
B. Potential for bleeding
C. Presence of an antigen-antibody response
D. Presence of cardiac enzymes
Platelets are disk-shaped cells that are essential for
blood coagulation. A platelet count determines the
number of thrombocytes in blood available for promoting
hemostasis and assisting with blood coagulation after
injury. 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 your sample
of blood.
Option B: It also is used to evaluate the patient’s
potential for bleeding; however, this is not its primary
purpose. The normal count ranges from 150,000 to
350,000/mm3. A count of 100,000/mm3 or less indicates
a potential for bleeding; count of less than 20,000/mm3
is associated with spontaneous bleeding.
Option C: Platelets, the smallest of our blood cells, can
only be seen under a microscope. They’re literally
shaped like small plates in their inactive form. A blood
vessel will send out a signal when it becomes damaged.
When platelets receive that signal, they’ll respond by
traveling to the area and transforming into their “active”
formation. To make contact with the broken blood
vessel, platelets grow long tentacles and then resemble
a spider or an octopus.
Option D: If you have too many platelets, it can
increase your risk for clotting. But often your
cardiovascular risk has more to do with platelet function
than platelet number. For example, you could have a
healthy number of platelets, but if they’re sticking
together too much it can increase your chance of having
a heart attack or stroke.
41. Which of the following white blood cell (WBC) counts
clearly indicates leukocytosis?
A. 4,500/mm³
B. 7,000/mm³
C. 10,000/mm³
D. 25,000/mm³
Leukocytosis is any transient increase in the number of
white blood cells (leukocytes) in the blood. The normal
number of WBCs in the blood is 4,500 to 11,000 WBCs
per microliter (4.5 to 11.0 × 109/L). Normal value ranges
may vary slightly among different labs. Thus, a count of
25,000/mm3 indicates leukocytosis.
Option A: A WBC count is a blood test to measure the
number of white blood cells (WBCs) in the blood. WBCs
are also called leukocytes. They help fight infections. A
higher than normal WBC count is called leukocytosis.
Leukocytosis is the broad term for an elevated white
blood cell (WBC) count, typically above 11.0×10^9/L, on
a peripheral blood smear collection. The exact value of
WBC elevation can vary slightly between laboratories
depending on their ‘upper limits of normal’ as identified
by their reference ranges.
Option B: The WBC value represents the sum-total of
white blood cell subtypes, including neutrophils,
eosinophils, lymphocytes, monocytes, atypical
leukocytes that are not normally present on a peripheral
blood smear (e.g., lymphoblasts), or any combination of
these. The clinician should properly characterize the
leukocytosis and determine if further evaluation and
workup are indicated.
Option C: Leukocytosis can occur acutely and often
transiently or chronically, either in response to an
inflammatory stressor/cytokine cascade or as part of an
autonomous myeloproliferative neoplasm. Neutrophilia
is the most common presentation, but clinicians should
be aware of the other cell lines that can be involved in
acute and chronic presentations. A detailed history,
physical examination, medication reconciliation, full
evaluation of a CBC with differential, and comparison to
prior CBCs can help clinicians elucidate the underlying
cause of leukocytosis and guide appropriate treatment.
42. After 5 days of diuretic therapy with 20mg of
furosemide (Lasix) daily, a patient begins to exhibit
fatigue, muscle cramping, and muscle weakness. These
symptoms probably indicate that the patient is
experiencing:
A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia
Fatigue, muscle cramping, and muscle weaknesses are
symptoms of hypokalemia (an inadequate potassium
level), which is a potential side effect of diuretic therapy.
The physician usually orders supplemental potassium to
prevent hypokalemia in patients receiving diuretics.
Hypokalemia is more prevalent than hyperkalemia;
however, most cases are mild. Although there is a slight
variation, an acceptable lower limit for normal serum
potassium is 3.5 mmol/L. Severity is categorized as mild
when the serum potassium level is 3 to 3.4 mmol/L,
moderate when the serum potassium level is 2.5 to 3
mmol/L, and severe when the serum potassium level is
less than 2.5 mmol/L.
Option B: Hyperkalemia is defined as a serum or
plasma potassium level above the upper limits of
normal, usually greater than 5.0 mEq/L to 5.5 mEq/L.
While mild hyperkalemia is usually asymptomatic, high
levels of potassium may cause life-threatening cardiac
arrhythmias, muscle weakness or paralysis. Symptoms
usually develop at levels higher levels, 6.5 mEq/L to 7
mEq/L, but the rate of change is more important than the
numerical value.
Option C: Anorexia is another symptom of hypokalemia.
The most frequent electrolyte imbalances seen in
anorexia are hyponatremia (a low concentration of
sodium ions in the bloodstream) and hypokalemia (a low
concentration of potassium ions). A low potassium level
has many causes but usually results from vomiting,
diarrhea, adrenal gland disorders, or use of diuretics. A
low potassium level can make muscles feel weak,
cramp, twitch or even become paralyzed, and abnormal
heart rhythms may develop.
Option D: Dysphagia means difficulty swallowing.
Dysphagia is the medical term for swallowing difficulties.
Some people with dysphagia have problems swallowing
certain foods or liquids, while others can’t swallow at all.
Other signs of dysphagia include: coughing or choking
when eating or drinking. bringing food back up,
sometimes through the nose.
43. Which of the following statements about chest X-
rays is not true?
A. No contradictions exist for this test.
B. Before the procedure, the patient should remove all
jewelry, metallic objects, and buttons above the waist.
C. A signed consent is not required.
D. Eating, drinking, and medications are allowed before
this test.
Pregnancy or suspected pregnancy is the only
contraindication for a chest X-ray. However, if a chest X-
ray is necessary, the patient can wear a lead apron to
protect the pelvic region from radiation. X-rays during
pregnancy don’t increase the risk of miscarriage or
cause problems in the unborn baby, such as birth
defects and physical or mental development problems.
However, if a pregnant woman has an X-ray and is
exposed to radiation there is a very small increased risk
that the baby may go on to develop cancer in childhood.
This is why the dose of radiation used in an X-ray is
always as low as possible.
Option B: Jewelry, metallic objects, and buttons would
interfere with the X-ray and thus should not be worn
above the waist. Metal appears as a bright area on an
X-ray, blocking visibility of underlying structures. The
reason you’re asked to remove metal is to give the
radiologist an unobstructed view of the area of interest.
Basically, you remove metal because it blocks anatomy.
Option C: A signed consent is not required because a
chest X-ray is not an invasive examination. Consent is
ensuring the patient is aware of the purpose and nature
of any procedure to be carried out. The radiographer
must ensure that the patient is fully aware of his/her
options, including alternatives, the right to refuse and the
consequences of refusal.
Option D: Eating, drinking, and medications are allowed
because the X-ray is of the chest, not the abdominal
region. To create a radiograph, a patient is positioned so
that the part of the body being imaged is located
between an x-ray source and an x-ray detector. When
the machine is turned on, x-rays travel through the body
and are absorbed in different amounts by different
tissues, depending on the radiological density of the
tissues they pass through.
44. The most appropriate time for the nurse to obtain a
sputum specimen for culture is:
A. Early in the morning
B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy
Obtaining a sputum specimen early in this morning
ensures an adequate supply of bacteria for culturing and
decreases the risk of contamination from food or
medication. A sputum culture is a test to detect and
identify bacteria or fungi that infect the lungs or
breathing passages. Sputum is a thick fluid produced in
the lungs and in the adjacent airways. Normally, a fresh
morning sample is preferred for the bacteriological
examination of sputum.
Option B: A sputum culture is a test that checks for
bacteria or another type of organism that may be
causing an infection in your lungs or the airways leading
to the lungs. Sputum, also known as phlegm, is a thick
type of mucus made in your lungs. If you have an
infection or chronic illness affecting the lungs or airways,
it can make you cough up sputum.
Option C: Sputum is not the same as spit or saliva.
Sputum contains cells from the immune system that help
fight the bacteria, fungi, or other foreign substances in
your lungs or airways. The thickness of sputum helps
trap the foreign material. This allows cilia (tiny hairs) in
the airways to push it through the mouth and be
coughed out.
Option D: A sputum culture is often done with another
test called a Gram stain. A Gram stain is a test that
checks for bacteria at the site of a suspected infection or
in body fluids such as blood or urine. It can help identify
the specific type of infection you may have.
45. A patient with no known allergies is to receive
penicillin every 6 hours. When administering the
medication, the nurse observes a fine rash on the
patient’s skin. The most appropriate nursing action
would be to:
A. Withhold the moderation and notify the
physician.
B. Administer the medication and notify the physician.
C. Administer the medication with an antihistamine.
D. Apply cornstarch soaks to the rash.
Initial sensitivity to penicillin is commonly manifested by
a skin rash, even in individuals who have not been
allergic to it previously. Because of the danger of
anaphylactic shock, the nurse should withhold the drug
and notify the physician, who may choose to substitute
another drug.
Option B: To determine if a patient has an IgE mediated
penicillin allergy, the only validated test currently
available in the united states is penicillin skin testing. A
board-certified allergist should perform the test. It
involves a skin-prick with the application of the major
and minor determinants as well as a control. The area of
skin is examined 15 minutes later. If a wheel of at least 3
mm and concomitant erythema develop, the test is
positive. The test should not be performed if the reaction
to penicillin was a severe non-IgE mediated reaction.
Option C: Administering an antihistamine is a
dependent nursing intervention that requires a written
physician’s order. Treatment for acute IgE mediated
reaction to penicillin depends on severity. Patients
presenting in acute anaphylaxis need to have immediate
treatment with IM epinephrine (1 mg/ml) 0.3 mg to 0.5
mg every 5 to 15 minutes until resolution of symptoms.
Adjunctive therapies include H1 and H2 antihistamines
including diphenhydramine 25 mg to 50 mg
intravenously (IV) and ranitidine 50 mg IV, respectively.
Option D: Although applying cornstarch to the rash may
relieve discomfort, it is not the nurse’s top priority in
such a potentially life-threatening situation. Cutaneous
symptoms are often the first and most common finding
of an allergic reaction, however, are absent in 10% to
20% of patients experiencing an allergic reaction.
Common cutaneous symptoms are generalized urticaria,
flushing, pruritus, and angioedema.
46. All of the following nursing interventions are correct
when using the Z-track method of drug injection except:
A. Prepare the injection site with alcohol.
B. Use a needle that’s at least 1” long.
C. Aspirate for blood before injection.
D. Rub the site vigorously after the injection to
promote absorption.
The Z-track method is an I.M. injection technique in
which the patient’s skin is pulled in such a way that the
needle track is sealed off after the injection. This
procedure seals medication deep into the muscle,
thereby minimizing skin staining and irritation. Rubbing
the injection site is contraindicated because it may
cause the medication to extravasate into the skin.
Option A: Clean the injection site with an alcohol pad to
minimize the possibility of infection. Allow the area to air
dry for a few minutes. The Z-track method is not often
recommended but can be particularly useful with
medication that must be absorbed by muscles to work. It
also helps to prevent the medication from seeping into
the subcutaneous tissue and ensures a full dosage.
Option B: In an adult, the most commonly used needles
are one inch or one and a half inches long, and 22 to 25
gauge thick. Smaller needles are typically used when
injecting a child. Some medications are dark-colored
and can cause staining of the skin. If this is a side effect
of the medication you will be taking, the doctor may
recommend using this technique to prevent injection site
discoloration or lesions.
Option C: Use one hand to pull downward on your skin
and fatty tissue. Hold it firmly about an inch away (2.54
cm) from the muscle. On the other hand, hold the needle
at a 90-degree angle and insert it quickly and deeply
enough to penetrate your muscle. If there is no blood in
the syringe, push on the plunger to inject the medication
slowly into the muscle.
47. The correct method for determining the vastus
lateralis site for I.M. injection is to:
A. Locate the upper aspect of the upper outer quadrant
of the buttock about 5 to 8 cm below the iliac crest.
B. Palpate the lower edge of the acromion process and
the midpoint lateral aspect of the arm.
C. Palpate a 1” circular area anterior to the umbilicus.
D. Divide the area between the greater femoral
trochanter and the lateral femoral condyle into
thirds, and select the middle third on the anterior of
the thigh.
The vastus lateralis, a long, thick muscle that extends
the full length of the thigh, is viewed by many clinicians
as the site of choice for I.M. injections because it has
relatively few major nerves and blood vessels. The
middle third of the muscle is recommended as the
injection site. The patient can be in a supine or sitting
position for an injection into this site.
Option A: There are specific landmarks to be taken into
consideration while giving IM injections so as to avoid
any neurovascular complications. The heel of the
opposing hand is placed in the greater trochanter, the
index finger in the anterior superior iliac spine, and the
middle finger below the iliac crest. The drug is injected in
the triangle formed by the index, middle finger, and the
iliac crest
Option B: The deltoid area is 2.5 to 5 cm below the
acromion process. Intramuscular injection is the method
of installing medications into the depth of the bulk of
specifically selected muscles. The basis of this process
is that the bulky muscles have good vascularity, and
therefore the injected drug quickly reaches the systemic
circulation and thereafter into the specific region of
action, bypassing the first-pass metabolism.
Option C: The vastus lateralis is a common site for IM
injection. The middle third of the line joining the greater
trochanter of the femur and the lateral femoral condyle
of the knee. It is one of the most common medical
procedures to be performed on an annual basis.
However, there is still a lack of uniform guidelines and
an algorithm in giving IM among health professionals
across the world.
48. The mid-deltoid injection site is seldom used for I.M.
injections because it:
A. Can accommodate only 1 ml or less of
medication.
B. Bruises too easily.
C. Can be used only when the patient is lying down.
D. Does not readily absorb parenteral medication.
The mid-deltoid injection site can accommodate only 1
ml or less of medication because of its size and location
(on the deltoid muscle of the arm, close to the brachial
artery and radial nerve). It is becoming increasingly
important for clinicians to identify a safer intramuscular
(IM) injection site in the deltoid muscle because of
possible complications following the vaccine
administration of IM injections.
Option B: However, Cook reported that these 4
injection sites have the potential to cause injury to the
subdeltoid/subacromial bursa and/or anterior branch of
the axillary nerve with the arm in the anatomical
position. Additionally, we showed that the axillary nerve
often runs near the site 5 cm below the mid-acromion
lateral border, and concluded that this site is unsuitable
for IM injection in terms of the high risk for the
complications related to this nerve.
Option C: The deltoid muscle has been used in clinical
settings because it is easy for clinicians to administer
injections at this site and for patients to expose it, and it
is the most commonly used site for vaccines worldwide.
Four injection sites have been recommended as safer
and appropriate IM injection sites in the deltoid muscle:
the first site is 1 to 3 fingerbreadths (5 cm) below the
mid-acromion, the second is a triangular injection site,
the third is the middle third of the deltoid muscle, and the
fourth is a mid-deltoid site.
Option D: The following complications have been
reported after the administration of IM injections:
injection site reactions such as pain, erythema, and
swelling due to over-or under penetration by the needle,
axillary or radial nerve palsies, musculoskeletal injuries,
local sepsis, and vascular complications. Therefore, it is
becoming increasingly important to establish a safer site
for IM injections.
49. The appropriate needle size for insulin injection is:
A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½” long
D. 25G, 5/8” long
A 25G, 5/8” needle is the recommended size for insulin
injection because insulin is administered by the
subcutaneous route. The board recommends 4-, 5-, and
6-mm needles for all adult patients regardless of their
BMI. It is also recommended to insert 4-, 5-, and 6-mm
needles at a 90-degree angle and that, if needed, longer
needles should be injected with either a skinfold or a 45-
degree angle to avoid intramuscular injection of insulin.
Option A: An 18G, 1 ½” needle is usually used for I.M.
injections in children, typically in the vastus lateralis.
Ensuring the correct delivery of insulin is essential in the
treatment of diabetes. Both proper injection technique
and needle length are important considerations for
adequate insulin delivery. There have been several
studies demonstrating that BMI does not affect efficacy
or insulin leakage with shorter pen needles (e.g., 4 or 5
mm vs. 12.7 mm).
Option B: Additionally, the International Scientific
Advisory Board for the Third Injection Technique
Workshop released recommendations in 2010 on best
practices for injection technique for patients with
diabetes, which, with regard to needle length, concluded
that 4-mm pen needles were efficacious in all patients
regardless of BMI.
Option C: A 22G, 1 ½” needle is usually used for adult
I.M. injections, which are typically administered in the
vastus lateralis or ventrogluteal site. Needle lengths for
subcutaneous injections started out as long as 16 mm in
1985, and 12.7-mm needles were introduced in the early
1990s. Over time, with growing evidence of longer
needles increasing risks for intramuscular injections and
improved technology, shorter needles of 4, 5, 6, and 8
mm have been developed.
50. The appropriate needle gauge for intradermal
injection is:
A. 20G
B. 22G
C. 25G
D. 26G
Because an intradermal injection does not penetrate
deeply into the skin, a small-bore 26G-27G needle is
recommended. This type of injection is used primarily to
administer antigens to evaluate reactions for allergy or
sensitivity studies. Equipment used for ID injections is a
tuberculin syringe calibrated in tenths and hundredths of
a millilitre, and a 1/4 to 1/2 in., 26 or 27 gauge needle.
The dosage of an ID injection is usually under 0.5 ml.
The angle of administration for an ID injection is 5 to 15
degrees.
Option A: A 20G needle is usually used for I.M.
injections of oil-based medications. Intramuscular
injections are administered at a 90-degree angle to the
skin, preferably into the anterolateral aspect of the thigh
or the deltoid muscle of the upper arm, depending on
the age of the patient. The needle gauge for
intramuscular injection is 22-25 gauge.
Option B: A 22G-25G needle for I.M. injections. A
decision on needle length and site of injection must be
made for each person on the basis of the size of the
muscle, the thickness of adipose tissue at the injection
site, the volume of the material to be administered,
injection technique, and the depth below the muscle
surface into which the material is to be injected
Option C: A 25G needle, for subcutaneous insulin
injections. Choosing the right size needle and syringe is
necessary to get the correct dose of medicine, inject it
properly, and minimize pain. To make it easier, these
items are sold separately and designed to attach
securely. Subcutaneous injections go into the fatty
tissue just below the skin. Since these are relatively
shallow shots, the needle required is small and short—
typically one-half to five-eighths of an inch long with a
gauge of 25 to 30.
51. Parenteral penicillin can be administered as an:
A. IM injection or an IV solution
B. IV or an intradermal injection
C. Intradermal or subcutaneous injection
D. IM or a subcutaneous injection
Parenteral penicillin can be administered I.M. or added
to a solution and given I.V. It cannot be administered
subcutaneously or intradermally. Penicillin G
administration can be either intravenously or
intramuscularly. Penicillin G benzathine administration
ensures a continuous low dose of penicillin G over 2 to 4
weeks.
Option B: Intradermal injection, often abbreviated ID, is
a shallow or superficial injection of a substance into the
dermis, which is located between the epidermis and the
hypodermis. This route is relatively rare compared to
injections into the subcutaneous tissue or muscle.
Option C: A subcutaneous injection is a method of
administering medication. Subcutaneous means under
the skin. In this type of injection, a short needle is used
to inject a drug into the tissue layer between the skin
and the muscle. Medication given this way is usually
absorbed more slowly than if injected into a vein,
sometimes over a period of 24 hours.
Option D: An intramuscular injection is a technique
used to deliver a medication deep into the muscles. This
allows the medication to be absorbed into the
bloodstream quickly. Intramuscular injections are a
common practice in modern medicine. They’re used to
deliver drugs and vaccines. Several drugs and almost all
injectable vaccines are delivered this way.
52. The physician orders gr 10 of aspirin for a patient.
The equivalent dose in milligrams is:
A. 0.6 mg
B. 10 mg
C. 60 mg
D. 600 mg
gr 10 x 60 mg/gr 1 = 600 mg. There are 3 primary
methods for the calculation of medication dosages, as
referenced above. These include Desired Over Have
Method or Formula, Dimensional Analysis and Ratio and
Proportion (as cited in Boyer, 2002)[Lindow, 2004].
Option A: Desired over Have or Formula Method is a
formula or equation to solve for an unknown quantity (x)
much like ratio proportion. Drug calculations require the
use of conversion factors, such as when converting from
pounds to kilograms or liters to milliliters. Simplistic in
design, this method allows us to work with various units
of measurement, converting factors to find our answer.
Useful in checking the accuracy of the other methods of
calculation as above mentioned, thus acting as a double
or triple check.
Option B: Units of measurement must match, for
example, milliliters and milliliters, or one needs to
convert to like units of measurement. In the example
above, the ordered dose was in milligrams, and the have
dose was in milligrams, both of which cancel out leaving
milliliters (answer called for milliliters), so no further
conversion is required.
Option C: The Ratio and Proportion Method has been
around for years and is one of the oldest methods
utilized in drug calculations (as cited in Boyer,
2002)[Lindow, 2004]. Addition principals is a problem-
solving technique that has no bearing on this
relationship, only multiplication, and division are used to
navigate through a ratio and proportion problem, not
adding.
53. The physician orders an IV solution of dextrose 5%
in water at 100ml/hour. What would the flow rate be if
the drop factor is 15 gtt = 1 ml?
A. 5 gtt/minute
B. 13 gtt/minute
C. 25 gtt/minute
D. 50 gtt/minute
100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute. When the
nurse has an order for an IV infusion, it is her
responsibility to make sure the fluid will infuse at the
prescribed rate. IV fluids may be infused by gravity using
a manual roller clamp or dial-a-flow, or infused using an
infusion pump. Regardless of the method, it is important
to know how to calculate the correct IV flow rate.
Option A: When calculating the flow rate, determine
which IV tubing you will be using, microdrip or
macrodrip, so you can use the proper drop factor in your
calculations. The drop factor is the number of drops in
one mL of solution, and is printed on the IV tubing
package.
Option B: Macrodrip and microdrip refers to the
diameter of the needle where the drop enters the drip
chamber. Macrodrip tubing delivers 10 to 20 gtts/mL and
is used to infuse large volumes or to infuse fluids
quickly. Microdrip tubing delivers 60 gtts/mL and is used
for small or very precise amounts of fluid, as with
neonates or pediatric patients.
Option C: To calculate the drops per minute, the drop
factor is needed. The formula for calculating the IV flow
rate (drip rate).. total volume (in mL) divided by time (in
min), multiplied by the drop factor (in gtts/mL), which
equals the IV flow rate in gtts/min.
54. Which of the following is a sign or symptom of a
hemolytic reaction to blood transfusion?
A. Hemoglobinuria
B. Chest pain
C. Urticaria
D. Distended neck veins
Hemoglobinuria, the abnormal presence of hemoglobin
in the urine, indicates a hemolytic reaction
(incompatibility of the donor’s and recipient’s blood). In
this reaction, antibodies in the recipient’s plasma
combine rapidly with donor RBC’s; the cells are
hemolyzed in either circulatory or reticuloendothelial
systems. Hemolysis occurs more rapidly in ABO
incompatibilities than in Rh incompatibilities.
Option B: Flank pain is a common sign of hemolytic
reaction. Symptoms of a hemolytic transfusion reaction
most often appear during or right after the transfusion.
Sometimes, they may develop after several days
(delayed reaction).
Option C: Chest pain and urticaria may be symptoms of
impending anaphylaxis. A hemolytic transfusion reaction
is a serious complication that can occur after a blood
transfusion. The reaction occurs when the red blood
cells that were given during the transfusion are
destroyed by the person’s immune system. When red
blood cells are destroyed, the process is called
hemolysis.
Option D: Distended neck veins are an indication of
hypervolemia. Most of the time, a blood transfusion
between compatible groups (such as O+ to O+) does
not cause a problem. Blood transfusions between
incompatible groups (such as A+ to O-) cause an
immune response. This can lead to a serious transfusion
reaction. The immune system attacks the donated blood
cells, causing them to burst.
55. Which of the following conditions may require fluid
restriction?
A. Fever
B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
D. Dehydration
In renal failure, the kidney loses their ability to effectively
eliminate wastes and fluids. Because of this, limiting the
patient’s intake of oral and I.V. fluids may be necessary.
The term renal failure denotes the inability of the kidneys
to perform excretory function leading to retention of
nitrogenous waste products from the blood.
Option A: A fever draws moisture out of the body. Plus,
you lose fluid as your body makes mucus and it drains
away. And that over-the-counter cold medicine you’re
taking to dry up your head can dry the rest of you out,
too. So drink plenty of water, juice, or soup.
Option B: Chronic obstructive pulmonary disease
(COPD) is airflow limitation caused by an inflammatory
response to inhaled toxins, often cigarette smoke.
Alpha-1 antitrypsin deficiency and various occupational
exposures are less common causes in nonsmokers.
Option D: Dehydration must be treated by replenishing
the fluid level in the body. This can be done by
consuming clear fluids such as water, clear broths,
frozen water or ice pops, or sports drinks (such as
Gatorade). Some dehydration patients, however, will
require intravenous fluids in order to rehydrate.
56. All of the following are common signs and symptoms
of phlebitis except:
A. Pain or discomfort at the IV insertion site
B. Edema and warmth at the IV insertion site
C. A red streak exiting the IV insertion site
D. Frank bleeding at the insertion site
Phlebitis, the inflammation of a vein, can be caused by
chemical irritants (I.V. solutions or medications),
mechanical irritants (the needle or catheter used during
venipuncture or cannulation), or a localized allergic
reaction to the needle or catheter. It usually affects lower
limbs, particularly the great saphenous vein (60% to
80%) or the small/short saphenous vein (10% to 20%).
However, it can occur at other sites (10% to 20%) and
may occur bilaterally (5% to 10%).
Option A: When there is venous turbulence or stasis,
vessel wall injuries, abnormal coagulability, or vessel
wall injuries, microthrombi could propagate and then
form macroscopic thrombi. Vascular endothelial injury
reliably results in thrombus formation by triggering an
inflammatory response that results in immediate platelet
adhesion. Platelet aggregation is mediated by thrombin
and thromboxane A2.
Option B: Patients with superficial thrombophlebitis
typically present with a reddened, warm, inflamed,
tender area overlying the track of a superficial vein.
There is often a palpable cord. Some surrounding
edema or associated pruritus may occur. Significant
swelling of the limb is more commonly associated with
DVT and should only be attributed to SVT after DVT has
been excluded.
Option C: Signs and symptoms of phlebitis include pain
or discomfort, edema and heat at the I.V. insertion site,
and a red streak going up the arm or leg from the I.V.
insertion site. Patients should be educated on the
likelihood and significance of the propagation of disease
and recurrence based on their risk factors. They should
be advised of the need for further evaluation in the
presence of migratory thrombophlebitis or if they are
more than 40 years old at the time of their initial
presentation and are without other risk factors for
venous thromboembolic disease.
57. The best way of determining whether a patient has
learned to instill ear medication properly is for the nurse
to:
A. Ask the patient if he/she has used ear drops before.
B. Have the patient repeat the nurse’s instructions using
her own words.
C. Demonstrate the procedure to the patient and
encourage to ask questions.
D. Ask the patient to demonstrate the procedure.
Return demonstration provides the most certain
evidence for evaluating the effectiveness of patient
teaching. No matter what kind of ear drops you use or
why you use them, it’s important to administer them
correctly. Using ear drops properly allows the
medication to enter your ear canal and treat your ear
problem.
Option A: Merely asking the patient does not guarantee
that he knows the correct way of instilling the ear drops.
Position the head so that the ear faces upward. If you’re
giving the drops to yourself, it may be easiest to sit or
stand upright and tilt your head to the side. If you’re
giving the drops to someone else, it may be easiest if
the person tilts their head or lies down on their side.
Option B: It is better to repeat actions than only
repeating words. or adults, gently pull the upper ear up
and back. For children, gently pull the lower ear down
and back. Squeeze the correct number of drops into the
ear. Your doctor’s instructions or the bottle’s label will
tell you how many drops to use.
Option C: After demonstrating to the patient, allow him
to demonstrate the procedure too. You should also know
how long you can use the ear drops safely after opening
the bottle. For prescription ear drops, ask your
pharmacist or doctor about the expiration date. For over-
the-counter drops, check the expiration date on the
label. If the drops have expired, throw them away. Don’t
use expired ear drops.
58. Which of the following types of medications can be
administered via gastrostomy tube?
A. Any oral medications.
B. Capsules' whole contents are dissolved in water.
C. Enteric-coated tablets that are thoroughly dissolved
in water.
D. Most tablets designed for oral use, except for
extended-duration compounds.
Most tablets designed for oral use, except for extended-
duration compounds can be administered via
gastrostomy tube. Drug therapy can be complicated in
hospitalized patients requiring an enteral feeding tube
(EFT). Some medications may be given via an EFT
while others are unsuitable for this form of
administration.
Option A: Inappropriate drug selection for EFT
administration can cause potential toxicity, reduced
efficacy, and tube obstruction. Therefore, it is important
to know which drugs may be altered for EFT
administration as well as appropriate therapeutic
alternatives that can temporarily be substituted for those
that may not be given via that route.
Option B: It is preferable to utilize a liquid dosage form
whenever possible for EFT administration especially if
the patient has a small-bore feeding tube. If an
appropriate liquid preparation is not available, the
dilution of crushed tablets or the contents of capsules
may be necessary prior to EFT administration.
Option C: Capsules, enteric-coated tablets, and most
extended duration or sustained-release products should
not be dissolved for use in a gastrostomy tube. They are
pharmaceutically manufactured in these forms for valid
reasons, and altering them destroys their purpose. The
nurse should seek an alternate physician’s order when
an ordered medication is inappropriate for delivery by
tube.
59. A patient who develops hives after receiving an
antibiotic is exhibiting drug:
A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy
A drug-allergy is an adverse reaction resulting from an
immunologic response following previous sensitizing
exposure to the drug. The reaction can range from a
rash or hives to anaphylactic shock.
Option A: Tolerance to a drug means that the patient
experiences a decreasing physiologic response to
repeated administration of the drug in the same dosage.
Option B: Idiosyncrasy is an individual’s unique
hypersensitivity to a drug, food, or other substance; it
appears to be genetically determined.
Option C: Synergism, is a drug interaction in which the
sum of the drug’s combined effects is greater than that
of their separate effects.
60. A patient has returned to his room after femoral
arteriography. All of the following are appropriate
nursing interventions except:
A. Assess femoral, popliteal, and pedal pulses every 15
minutes for 2 hours.
B. Check the pressure dressing for sanguineous
drainage.
C. Assess vital signs every 15 minutes for 2 hours.
D. Order a hemoglobin and hematocrit count 1 hour
after the arteriography.
A hemoglobin and hematocrit count would be ordered by
the physician if bleeding were suspected. Arterial
puncture occurs at the start of angiography and
interventional radiology, and is a very important factor
determining the success or failure of successive
procedures. Recently, this procedure has been
performed by a range of approaches depending on the
type of surgery, e.g, through the radial artery.
Option A: The methods of hemostasis for the femoral
artery include manual compression, which is the
removal of the sheath and compression with the hands,
and methods that apply compression devices1). Of
these, manual compression requires absolute bed rest
for a few hours. On the other hand, the level of patient
discomfort is increased due to lengthy bed rest and the
restriction of walking.
Option B: Moreover, hematoma in the punctured area
of blood vessels, formation of a pseudoaneurysm, and
vascular occlusions develop in approximately 1–5% of
cases). A variety of hemostasis devices have been
developed to treat these complications that allow for
rapid recovery of patients from bed rest. These include
Angio-seal device (collagen sponge and copolymer
anchor) and percutaneous placement of a device
(Prostar) that utilizes two nonabsorbable sutures
(Perclose, Redwood City, CA, USA).
Option C: The other answers are appropriate nursing
interventions for a patient who has undergone femoral
arteriography. The Angio-seal device uses a method of
adsorption with a collagen sponge placed within the
blood vessels. The Prostar device uses a method in
which the blood vessels are sutured. These hemostasis
devices can reduce the discomfort and the time to
hemostasis (clotting time) in the puncture area when
used in patients, who cannot lie down in bed for a long
time or in patients with low platelet values who have
received anticoagulation treatments.
61. The nurse explains to a patient that a cough:
A. Is a protective response to clear the respiratory
tract of irritants.
B. Is primarily a voluntary action.
C. Is induced by the administration of an antitussive
drug.
D. Can be inhibited by “splinting” the abdomen.
Coughing, a protective response that clears the
respiratory tract of irritants, usually is involuntary. A
cough is an innate primitive reflex and acts as part of the
body’s immune system to protect against foreign
materials. This reflex is characterized with the closing of
the glottis apparatus with subsequent increases in the
intrathoracic pressure which often exceeds 300 mm Hg.
This is followed by the forceful expulsion of the airway
contents through the glottis into the pharyngeal space
and out of the body.
Option B: However, it can be voluntary as when a
patient is taught to perform coughing exercises.
Coughing is associated with a wide assortment of
clinical associations and etiologies. Furthermore, there
are no objective tools to measure or clinically quantify a
cough. As such, evaluation of a cough is initially a
subjective and highly variable assessment.
Option C: An antitussive drug inhibits coughing. Cough
suppressants may be used to lessen the cough by
blunting the cough reflex, and expectorants may be
used when excessive mucous secretions are
determined to be the primary issue to increase mucus
clearance. The most commonly used suppressant is
dextromethorphan, and the most common suppressant
is guaifenesin.
Option D: Splinting the abdomen supports the
abdominal muscles when a patient coughs. The reflex of
coughing is initiated with a chemical irritation at
peripheral nerve receptors within the trachea, main
carina, branching points of large airways, and more
distal smaller airways. They are also present in the
pharynx. Laryngeal and tracheobronchial receptors
respond to mechanical and chemical stimuli.
62. An infected patient has chills and begins shivering.
The best nursing intervention is to:
A. Apply iced alcohol sponges
B. Provide increased cool liquids
C. Provide additional bedclothes
D. Provide increased ventilation
In an infected patient, shivering results from the body’s
attempt to increase heat production and the production
of neutrophils and phagocytic action through increased
skeletal muscle tension and contractions. Initial
vasoconstriction may cause skin to feel cold to the
touch. Applying additional bed clothes helps to equalize
the body temperature and stop the chills. Attempts to
cool the body result in further shivering, increased
metabolism, and thus increased heat production.
Option A: This intervention would further increase
shivering. Therapeutic temperature modulation, which
incorporates mild hypothermia and maintenance of
normothermia, is being used to manage patients
resuscitated after cardiac arrest. During this therapy, the
shiver response is activated as a defense mechanism in
response to an altered set-point temperature and
causes metabolic and hemodynamic stress for patients.
Option B: Cool liquids may increase the shivering.
Recognition of shivering according to objective and
subjective assessments is vital for early detection of the
condition. Once shivering is detected, treatment is
imperative to avoid deleterious effects. The Bedside
Shivering Assessment Scale can be used to determine
the efficacy of interventions intended to blunt
thermoregulatory defenses and can provide continual
evaluation of patients’ responses to the interventions.
Option D: Increased ventilation may be done, but it
could still increase shivering. Nurses’ knowledge and
understanding of the harmful effects of shivering are
important to affect care and prevent injury associated
with uncontrolled shivering. Chills may also be a
symptom of a serious or life-threatening condition that
should be immediately evaluated in an emergency
setting, such as hypothermia, which is an abnormally
low body temperature.
63. A clinical nurse specialist is a nurse who has:
A. Been certified by the National League for Nursing.
B. Received credentials from the American Nurses’
Association.
C. Graduated from an associate degree program and is
a registered professional nurse.
D. Completed a master’s degree in the prescribed
clinical area and is a registered professional nurse.
A clinical nurse specialist must have completed a
master’s degree in a clinical specialty and be a
registered professional nurse. A clinical nurse specialist
(CNS) is a graduate-level registered nurse who is
certified in a specialty of choice. Obtaining specialty
certification demonstrates an advanced level of
knowledge as well as advanced clinical skills in a niche
area of nursing. There are differences between a nurse
practitioner (NP) and CNS.
Option A: The National League of Nursing accredits
educational programs in nursing and provides a testing
service to evaluate student nursing competence but it
does not certify nurses.
Option B: The American Nurses Association identifies
requirements for certification and offers examinations for
certification in many areas of nursing, such as medical-
surgical nursing. This certification (credentialing)
demonstrates that the nurse has the knowledge and the
ability to provide high-quality nursing care in the area of
her certification.
Option C: A graduate of an associate degree program
is not a clinical nurse specialist: however, she is
prepared to provide bedside nursing with a high degree
of knowledge and skill. She must successfully complete
the licensing examination to become a registered
professional nurse.
64. The purpose of increasing urine acidity through
dietary means is to:
A. Decrease burning sensations
B. Change the urine’s color
C. Change the urine’s concentration
D. Inhibit the growth of microorganisms
Microorganisms usually do not grow in an acidic
environment. A diet high in citrus fruits, vegetables, or
dairy products can increase urine pH. A diet high in
meat products or cranberries can decrease urine pH.
The acidity of urine — as well as the presence of small
molecules related to diet — may influence how well
bacteria can grow in the urinary tract, a new study
shows. The research, at Washington University School
of Medicine in St. Louis, may have implications for
treating urinary tract infections, which are among the
most common bacterial infections worldwide.
Option A: Henderson and his team, including first
author Robin R. Shields-Cutler, a graduate student in
Henderson’s lab, were interested in studying how the
body naturally fights bacterial infections. They cultured
E. coli in urine samples from healthy volunteers and
noted major differences in how well individual urine
samples could harness a key immune protein to limit
bacterial growth. The urine samples that prevented
bacterial growth supported more activity of this key
protein, which the body makes naturally in response to
infection, than the samples that permitted bacteria to
grow easily. The protein is called siderocalin, and past
research has suggested that it helps the body fight
infection by depriving bacteria of iron, a mineral
necessary for bacterial growth.
Option B: Importantly, the researchers also showed that
they could encourage or discourage bacterial growth in
urine simply by adjusting the pH, a finding that could
have implications for how patients with UTIs are treated.
Option C: Indeed, their results implicate cranberries
among other possible dietary interventions. Shield-
Cutler noted that many studies already have
investigated extracts or juices from cranberries as UTI
treatments but the results of such investigations have
not been consistent. “It’s possible that cranberries may
be more effective when paired with a treatment to make
the urine less acidic,” Henderson said. “And even then,
maybe cranberries only work in people who have the
right gut microbes.”
65. Clay-colored stools indicate:
A. Upper GI bleeding
B. Impending constipation
C. An effect of medication
D. Bile obstruction
Bile colors the stool brown. Any inflammation or
obstruction that impairs bile flow will affect the stool
pigment, yielding light, clay-colored stool. The liver
releases bile salts into the stool, giving it a normal brown
color. One may have clay-colored stools if they have a
liver infection that reduces bile production, or if the flow
of bile out of the liver is blocked. Yellow skin (jaundice)
often occurs with clay-colored stools.
Option A: Upper GI bleeding results in black or tarry
stool. Melena is a black, tarry stool that is caused by GI
bleeding. The black color is due to the oxidation of blood
hemoglobin during the bleeding in the ileum and colon.
Melena also refers to stools or vomit stained black by
blood pigment or dark blood products and may indicate
upper GI bleeding.
Option B: Constipation is characterized by small, hard
masses. The problem may arise in the colon or rectum
or it may be due to an external cause. In most people,
slow colonic motility that occurs after years of laxative
abuse is the problem. In a few patients, the cause may
be related to an outlet obstruction like rectal prolapse or
a rectocele. External causes of constipation may include
poor dietary habits, lack of fluid intake, overuse of
certain medications, an endocrine problem like
hypothyroidism or some type of an emotional issue.
Option C: Many medications and foods will discolor
stool – for example, drugs containing iron turn stool
black; beets turn stool red. Blue feces may be caused by
boric acid, chloramphenicol, or methylene blue.
Causative diseases for clay feces may include alcoholic
hepatitis, biliary cirrhosis, gallstones, sclerosing
cholangitis, biliary strictures, or viral hepatitis. Causative
medications for gray feces may include cocoa or
colchicines. Potential causes for green stools may
include spinach, Indomethacin, iron, or
medroxyprogesterone.
66. In which step of the nursing process would the nurse
ask a patient if the medication she administered relieved
his pain?
A. Assessment
B. Analysis
C. Planning
D. Evaluation
In the evaluation step of the nursing process, the nurse
must decide whether the patient has achieved the
expected outcome that was identified in the planning
phase. This final step of the nursing process is vital to a
positive patient outcome. Whenever a healthcare
provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has
been met. Reassessment may frequently be needed
depending upon the overall patient’s condition. The plan
of care may be adapted based on new assessment
data.
Option A: Assessment is the first step and involves
critical thinking skills and data collection; subjective and
objective. Subjective data involves verbal statements
from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake and
output, and height and weight.
Option B: Analysis can be a part of diagnosing. The
formulation of a nursing diagnosis by employing clinical
judgment assists in the planning and implementation of
patient care. The North American Nursing Diagnosis
Association (NANDA) provides nurses with an up to date
list of nursing diagnoses. A nursing diagnosis, according
to NANDA, is defined as a clinical judgment about
responses to actual or potential health problems on the
part of the patient, family, or community.
Option C: The planning stage is where goals and
outcomes are formulated that directly impact patient
care based on EDP guidelines. These patient-specific
goals and the attainment of such assist in ensuring a
positive outcome. Nursing care plans are essential in
this phase of goal setting. Care plans provide a course
of direction for personalized care tailored to an
individual’s unique needs. Overall condition and
comorbid conditions play a role in the construction of a
care plan. Care plans enhance communication,
documentation, reimbursement, and continuity of care
across the healthcare continuum.
67. All of the following are good sources of vitamin A
except:
A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks
Potatoes contain a good amount of carbs and fiber, as
well as vitamin C, vitamin B6, potassium and
manganese. Their nutrient contents can vary depending
on the type of potato and cooking method. The main
sources of vitamin A are yellow and green vegetables
(such as carrots, sweet potatoes, squash, spinach,
collard greens, broccoli, and cabbage) and yellow fruits
(such as apricots, and cantaloupe). Animal sources
include liver, kidneys, cream, butter, and egg yolks.
Option B: They’re rich in beta-carotene, a compound
the body changes into vitamin A, which helps keep the
eyes healthy. And beta-carotene helps protect the eyes
from the sun and lowers the chances of cataracts and
other eye problems. Yellow carrots have lutein, which is
also good for the eyes.
Option C: Apricots are a great source of many
antioxidants, including beta carotene and vitamins A, C,
and E. What’s more, they’re high in a group of
polyphenol antioxidants called flavonoids, which have
been shown to protect against illnesses, including
diabetes and heart disease.
Option D: Egg yolks contain vitamins A, D, E, and K
along with omega-3 fats. Compared to the whites, egg
yolks are also rich in folate and vitamin B12. The yolks
are also packed with tryptophan and tyrosine, and amino
acids that help prevent heart diseases.
68. Which of the following is a primary nursing
intervention necessary for all patients with a Foley
Catheter in place?
A. Maintain the drainage tubing and collection bag level
with the patient’s bladder.
B. Irrigate the patient with 1% Neosporin solution three
times a day.
C. Clamp the catheter for 1 hour every 4 hours to
maintain the bladder’s elasticity.
D. Maintain the drainage tubing and collection bag
below bladder level to facilitate drainage by gravity.
To prevent obstruction, the catheter and collecting tube
should be kept free from kinking, the collecting bag
should be positioned below the level of the bladder at all
times and never placed on the floor. The collecting bag
should be emptied regularly using a clean collecting
container (HICPAC, 2009). In ambulatory patients,
collecting bags may be disguised in bags and pouches.
Option A: Maintaining the drainage tubing and
collection bag level with the patient’s bladder could
result in reflux of urine into the kidney. The indwelling
catheter should be secured to the thigh or abdomen
after insertion to prevent movement and the exertion of
excessive force on the bladder neck or urethra (Gray,
2008). Unsecured and displaced catheters can also
cause pressure ulcers on the perineum and buttock
(Siegel, 2008).
Option B: Irrigating the bladder with Neosporin must be
indicated and ordered by the physician. Nash (2003)
conducted a recent review of the literature on self-
cleaning of catheter training bags. The study showed
that patients whose bags were irrigated with vinegar
showed a significant reduction of bacteriuria compared
with patients whose bags were irrigated with the
hydrogen peroxide solutions (Washington, 2001).
Authors concluded that more research is needed on the
self-cleaning of Foley bags.
Option C: Clamping the catheter for 1 hour every 4
hours must be prescribed by a physician. Patients
practicing intermittent catheterization should pay close
attention to the catheterization schedule and avoid
bladder overdistension and unnecessary
catheterizations. As CAUTIs are more prevalent for
intermittent catheterization in patients with high residual
urine volumes at the time of catheterization, urine
volume should determine the catheterization schedule.
69. The ELISA test is used to:
A. Screen blood donors for antibodies to human
immunodeficiency virus (HIV).
B. Test blood to be used for transfusion for HIV
antibodies.
C. Aid in diagnosing a patient with AIDS.
D. All of the above.
The ELISA test of venous blood is used to assess blood
and potential blood donors to human immunodeficiency
virus (HIV). A positive ELISA test combined with various
signs and symptoms helps to diagnose acquired
immunodeficiency syndrome (AIDS). Enzyme-linked
immunosorbent assay (ELISA) is a labeled
immunoassay that is considered the gold standard of
immunoassays. This immunological test is very sensitive
and is used to detect and quantify substances, including
antibodies, antigens, proteins, glycoproteins, and
hormones. The detection of these products is
accomplished by the complexing of antibodies and
antigens to produce a measurable result.
Option A: ELISAs are performed in polystyrene plates,
typically in 96-well plates that are coated to bind protein
very strongly. Depending on the ELISA type, testing
requires a primary and/or secondary detection antibody,
analyte/antigen, coating antibody/antigen, buffer, wash,
and substrate/chromogen. The primary detection
antibody is a specific antibody that only binds to the
protein of interest, while a secondary detection antibody
is a second enzyme-conjugated antibody that binds a
primary antibody that is not enzyme-conjugated.
Option B: In HIV testing, a blood or saliva specimen is
collected for testing typically by the use of indirect
ELISA-based tests. The ELISA is a screening tool for
HIV detection, but not diagnostic. Diagnosis requires
further testing by Western blot due to potential false
positives. Another virus, Molluscum contagiosum virus
(MCV) that commonly infects the skin of children and
young adults, can be detected by ELISA testing. ELISA
testing in this setting is currently being evaluated for the
assessment of global MCV seroprevalence.
Option C: ELISA testing is used in the diagnosis of HIV
infection, pregnancy tests, and blood typing, among
others. The first ELISA methodology involved
chromogenic reporter molecules and substrates to
generate observable color change that monitors the
presence of antigen. Further advancement in the ELISA
technique leads to the development of fluorogenic,
quantitative PCR, and electrochemiluminescent
reporters to generate signals. However, some of these
techniques do not rely on using enzyme-linked
substrates but non-enzymatic reporters that utilize the
principle of ELISA.
70. The two blood vessels most commonly used for TPN
infusion are the:
A. Subclavian and jugular veins
B. Brachial and subclavian veins
C. Femoral and subclavian veins
D. Brachial and femoral veins
Total Parenteral Nutrition (TPN) requires the use of a
large vessel, such as the subclavian or jugular vein, to
ensure the rapid dilution of the solution and thereby
prevent complications, such as hyperglycemia. TPN is a
mixture of separate components that contain lipid
emulsions, dextrose, amino acids, vitamins, electrolytes,
minerals, and trace elements. TPN composition should
be adjusted to fulfill individual patients’ needs. The main
three macronutrients are lipids, emulsions, proteins, and
dextrose.
Option B: Total parenteral nutrition is not administered
through a peripheral intravenous catheter (Peripheral
Parenteral Nutrition, PPN) because it has high
osmolarity. PPN osmolarity needs to be less than 900
mOsm. The lower concentration necessitates larger
volume feedings, and high-fat content is necessary.
High osmolarity irritates peripheral veins; hence TPN is
given through central venous access. PPN is used to
provide additional nutrition to patients with functional gut
and enteral feedings.
Option C: Historically, total parenteral nutrition (TPN)
has been administered by the central venous route
because of the rapid development of thrombophlebitis
when TPN solutions are administered into peripheral
veins. The insertion and placement of central venous
catheters are, however, associated with morbidity and
mortality and is the main cause of TPN-related
complications.
Option D: The brachial and femoral veins usually are
contraindicated because they pose an increased risk of
thrombophlebitis. By avoiding central venous
catheterization, TPN can be made safer. Current
awareness about the pathophysiology of peripheral vein
thrombophlebitis and the use of a number of techniques
that prevent or delay the onset of peripheral vein
thrombophlebitis means it is now possible to administer
TPN via the peripheral route.
71. Effective skin disinfection before a surgical
procedure includes which of the following methods?
A. Shaving the site on the day before surgery.
B. Applying a topical antiseptic to the skin in the
evening before surgery.
C. Having the patient take a tub bath on the morning of
surgery.
D. Having the patient shower with an antiseptic
soap on the evening before and the morning of
surgery.
Studies have shown that showering with an antiseptic
soap before surgery is the most effective method of
removing microorganisms from the skin. Procedural and
surgical site infections create difficult and complex
clinical scenarios. A source for pathogens is often
thought to be the skin surface, making skin preparation
at the time of the procedure critical. The antiseptic used
for bathing should be approved using the testing criteria
from the FDA’s Tentative Final Monograph (TFM) for
Antiseptic Drug Products for preoperative skin
preparation. The goal for this recommendation would be
to reduce the number of bacterial flora at the patient’s
incision site.
Option A: Shaving the site of the intended surgery
might cause breaks in the skin, thereby increasing the
risk of infection; however, if indicated, shaving, should
be done immediately before surgery, not the day before.
The purpose of surgical skin preparation is to reduce the
number of microorganisms on the skin’s surface. This is
accomplished by removing dirt and oil without causing
damage to the skin’s natural protective function or
interfering with postoperative wound healing. The CDC’s
1999 guideline recommends that hair not be removed
unless it interferes with the surgical procedure and is a
Category IA recommendation.12 Also, according to
AORN standards, “Whenever possible, hair should be
left at the surgical site.”13 Hair-removal methods
discussed are depilatory; dry clipped using an electric
clipper and wet using a disposable razor.
Option B: A topical antiseptic would not remove
microorganisms and would be beneficial only after
proper cleaning and rinsing. The most common skin
preparation agents used today include products
containing iodophors or chlorhexidine gluconate (CHG).
CHG has more sustained antimicrobial activity and is
more resistant to neutralization by blood products than
the iodophors. CHG is applied in a similar manner to
PVP-I, but should not be used in the genital region. This
agent has gained popularity as a hand-scrubbing and
showering antiseptic prior to surgery, but also continues
to be used as a patient skin preparation agent.
Option C: Tub bathing might transfer organisms to
another body site rather than rinse them away. The
CDC’s 1999 guideline states that the incision site should
be clean before surgical skin preparation and has
labeled this a Category IB.10 In the Standards,
Recommended Practices, and Guidelines of the
Association of periOperative Registered Nurses (AORN)
it states, “The surgical site and surrounding areas
should be clean.”
72. When transferring a patient from a bed to a chair,
the nurse should use which muscles to avoid back
injury?
A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles
The leg muscles are the strongest muscles in the body
and should bear the greatest stress when lifting.
Muscles of the abdomen, back, and upper arms may be
easily injured. Place the patient’s outside leg (the one
farthest from the wheelchair) between the knees for
support. Bend the knees and keep the back straight.
Patient safety is often the main concern when moving
patients from bed. But remember not to lift at the
expense of your own back. This transfer often requires
the patient’s help, so clear communication is essential. If
the patient can’t help much, you’ll need two people or a
full body sling lift.
Option A: Allow the patient to help as much as possible.
Estimate the patient’s weight and mentally practice.
Make sure that the floor is free of any obstacles or
liquids. Keep the feet shoulder width apart. Keep the
person (or object) as close to your body as possible.
Tighten your stomach muscles. Bend knees and hips,
and keep your back straight throughout the movement.
Lift with your legs, NOT your back.
Option B: Keep the back straight throughout the
transfer to avoid bending or straining the back. Get as
close to the person as possible while still allowing
him/her to lean forward as needed to assist with the
transfer. Do not twist your back as you lift. To turn when
lifting, pivot your feet. If you have doubts, ASK FOR
HELP!
Option D: To get the patient into a seated position, roll
the patient onto the same side as the chair. Put one of
the arms under the patient’s shoulders and one behind
the knees. Bend the knees. Swing the patient’s feet off
the edge of the bed and use the momentum to help the
patient into a sitting position. Move the patient to the
edge of the bed and lower the bed so the patient’s feet
are touching the ground.
73. Thrombophlebitis typically develops in patients with
which of the following conditions?
A. Increases partial thromboplastin time
B. Acute pulsus paradoxus
C. An impaired or traumatized blood vessel wall
D. Chronic Obstructive Pulmonary Disease (COPD)
The factors, known as Virchow’s triad, collectively
predispose a patient to thrombophlebitis; impaired
venous return to the heart, blood hypercoagulability, and
injury to a blood vessel wall. The three factors of
Virchow’s triad include intravascular vessel wall
damage, stasis of flow, and the presence of a
hypercoagulable state. Understanding the factors
involved in the thrombus formation and subsequent
thromboembolic events enables the clinician to stratify
risk, direct clinical decision making regarding treatment,
and establish preventative measures.
Option A: Increased partial thromboplastin time
indicates a prolonged bleeding time during fibrin clot
formation, commonly the result of anticoagulant
(heparin) therapy. A prolonged PTT may be due to:
underlying conditions that cause low levels of clotting
factors, such as: liver disease—most coagulation factors
are produced by the liver, thus liver disease may cause
prolonged PT and PTT. However, PT is more likely to be
prolonged than PTT.
Option B: Pulsus Paradoxus refers to an exaggerated
fall in a patient’s blood pressure during inspiration by
greater than 10 mm Hg. Pulsus Paradoxus results from
alterations in the mechanical forces imposed on the
chambers of the heart and pulmonary vasculature often
due to pericardial disease, particularly cardiac
tamponade and to a lesser degree constrictive
pericarditis. However, it is important to understand that
pulsus paradoxus may be seen in non-pericardial
cardiac diseases such as right ventricular myocardial
infarction and restrictive cardiomyopathy.
Option D: Chronic obstructive pulmonary disease
(COPD) is estimated to affect 32 million persons in the
United States and is the third leading cause of death in
this country. Patients typically have symptoms of chronic
bronchitis and emphysema, but the classic triad also
includes asthma or a combination of the above.
74. In a recumbent, immobilized patient, lung ventilation
can become altered, leading to such respiratory
complications as:
A. Respiratory acidosis, atelectasis, and hypostatic
pneumonia
B. Apneustic breathing, atypical pneumonia and
respiratory alkalosis
C. Cheyne-Stokes respirations and spontaneous
pneumothorax
D. Kussmaul’s respirations and hypoventilation
Because of restricted respiratory movement, a
recumbent, immobilize patient is at particular risk for
respiratory acidosis from poor gas exchange; atelectasis
from reduced surfactant and accumulated mucus in the
bronchioles, and hypostatic pneumonia from bacterial
growth caused by stasis of mucus secretions.
Option B: Apneustic respiration (a.k.a. apneusis) is an
abnormal pattern of breathing characterized by deep,
gasping inspiration with a pause at full inspiration
followed by a brief, insufficient release. Pneumonia is
acquired when a sufficient volume of a pathogenic
organism bypasses the body’s cough and laryngeal
reflexes and makes its way into the parenchyma. In
almost every scenario, respiratory alkalosis is induced
by a process involving hyperventilation. These include
central causes, hypoxemic causes, pulmonary causes,
and iatrogenic causes. Central sources are a head
injury, stroke, hyperthyroidism, anxiety-hyperventilation,
pain, fear, stress, drugs, medications such as
salicylates, and various toxins.
Option C: Cheyne-Stokes respiration is a specific form
of periodic breathing (waxing and waning amplitude of
flow or tidal volume) characterized by a crescendo-
decrescendo pattern of respiration between central
apneas or central hypopneas. Unlike obstructive sleep
apnea (OSA), which can be the cause of heart failure,
Cheyne-Stokes respiration is believed to be a result of
heart failure. Spontaneous pneumothorax refers to the
abnormal collection of gas in the pleural space between
the lungs and the chest wall. Spontaneous
pneumothorax occurs without an obvious etiology such
as trauma or iatrogenic causes.
Option D: Kussmaul respirations were originally
observed and described by Dr. Adolf Kussmaul in 1874.
He made his observation in diabetic patients who were
comatose and in the late stages of diabetic ketoacidosis.
As classically described, Kussmaul respirations are a
deep, sighing respiratory pattern. Dr. Kussmaul actually
described it as “air hunger.” Hypoventilation is breathing
that is too shallow or too slow to meet the needs of the
body. If a person hypoventilates, the body’s carbon
dioxide level rises. This causes a buildup of acid and too
little oxygen in the blood. A person with hypoventilation
might feel sleepy.
75. Immobility impairs bladder elimination, resulting in
such disorders as:
A. Increased urine acidity and relaxation of the perineal
muscles, causing incontinence
B. Urine retention, bladder distention, and infection
C. Diuresis, natriuresis, and decreased urine specific
gravity
D. Decreased calcium and phosphate levels in the urine
The immobilized patient commonly suffers from urine
retention caused by decreased muscle tone in the
perineum. This leads to bladder distention and urine
stagnation, which provide an excellent medium for
bacterial growth leading to infection.
Option A: Urea is the main nitrogenous waste product
resulting from protein breakdown (catabolism) and is
rapidly eliminated in the urine by the kidneys. During
bed rest, the concentration of urea in the blood
increases, and the kidneys eliminate larger amounts of
urea.
Option C: As food intake usually decreases during bed
rest, it is speculated that these higher concentrations of
urea in blood and urine can only come from the
catabolic breakdown of endogenous protein sources,
such as muscle and other lean tissues (Bilancio et al,
2014). This correlates with the reduction in lean tissue
mass and sarcopenia that are characteristic of
prolonged immobility.
Option D: Immobility is independently associated with
the development of a series of complications, including
pressure ulcer, deep vein thrombosis (DVT),
pneumonia, and urinary tract infection (UTI) Immobility
also results in more alkaline urine with excessive
amounts of calcium, sodium, and phosphate, a gradual
decrease in urine production, and increased specific
gravity.