Question 1

A nurse is preparing to infuse 500 ml of 0.9% sodium chloride intravenous (IV) solution over 4 hours. The drip factor is 15 drops/ml. Which of the following values is the flow rate in drops/minute?

Accepted Answer

B

Explanation: To calculate the flow rate in drops per minute (gtt/min), use the formula: Flow rate (gtt/min) = (Total volume (ml) × Drop factor (gtt/ml)) / Time (minutes) Given: Total volume = 500 ml Drop factor = 15 gtt/ml Time = 4 hours (240 minutes) Flow rate (gtt/min) = (500 ml × 15 gtt/ml) / 240 minutes = 7500 gtt / 240 minutes = 31.25 gtt/min Rounded to the nearest whole number, the flow rate is 32 drops/minute.

Question 2

A circulating nurse is caring for a patient who is undergoing to laparotomy under a general
anesthesia in the Operating Room.
What is the PRIORITY nursing diagnosis the circulating nurse would include in the care plan?

Accepted Answer

C

Explanation: Role of Circulating Nurse: The circulating nurse manages the overall environment of the operating room, ensuring safety and coordination among the surgical team. They are responsible for maintaining patient safety, including correct positioning. Prioritizing Safety: Risk for anxiety: While relevant, managing anxiety is typically addressed preoperatively and postoperatively, not the immediate intraoperative period. Risk for bleeding: While bleeding is a concern, it is primarily monitored and managed by the surgical team. Risk for injury related to positioning: During surgery, improper positioning can lead to nerve damage, pressure sores, and musculoskeletal injuries. The circulating nurse must ensure that the patient is correctly positioned to avoid these injuries. Risk for infection: Preventing infection is crucial, but the sterile field and surgical techniques primarily address this risk. Conclusion: The highest priority for the circulating nurse is to ensure the patient is correctly positioned to prevent any injury related to positioning, as this is a direct and immediate responsibility during the surgical procedure. Reference: Surgical nursing textbooks, NCLEX-RN review guides, AORN (Association of periOperative Registered Nurses) guidelines.

Question 3

A mother of a newborn is diagnosed with breast cancer, the surgeon recommended to carry out an emergency operation. According to Freud's theory, which stage of newborn development is being affected?

Accepted Answer

A

Explanation: According to Freud's theory of psychosexual development, the stage affected in a newborn is the oral stage. Oral Stage: This stage occurs from birth to about 18 months of age, where the infant's pleasure centers on the mouth through activities like sucking and biting. Anal Stage: This stage follows the oral stage, from 18 months to 3 years, focusing on bowel and bladder control. Phallic Stage: This occurs from 3 to 6 years, focusing on the genitals and the differences between males and females. Latent Stage: This stage occurs from 6 years to puberty, characterized by dormant sexual feelings and a focus on social and intellectual skills. Reference: Freud, S. (1905). Three Essays on the Theory of Sexuality. National Institutes of Health (NIH): Child Development Theories

Question 4

A client with schizophrenia is placed on chlorpromazine 50 mg PO bid, and Benztropine 2 mg PO bid
PRN.
Which of the following nursing assessment findings would indicate a need to administer
Benztropine?

Accepted Answer

D

Explanation: Chlorpromazine is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), such as muscle spasms and tremors. Benztropine is an anticholinergic medication often prescribed to manage these side effects. If a client on chlorpromazine develops muscle spasms and tremors, it indicates EPS, and administering Benztropine would help alleviate these symptoms. The other options, such as severe agitation, sore throat, or suicidal thoughts, are not directly related to the need for Benztropine. Reference: Stahl, S. M. (2013). Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. Cambridge University Press.

Question 5

A nurse is monitoring a patient with Cushing syndrome who suffers from recurrent fractures and bruising. Which of the following is the BEST action the nurse would do?

Accepted Answer

B

Explanation: Cushing Syndrome Symptoms: Cushing syndrome is characterized by high levels of cortisol which can lead to brittle bones (osteoporosis), easy bruising, and muscle weakness. Best Nursing Actions: Review Calcium Level: Important but not the immediate priority to prevent fractures. Orthopedic Clinic Visit: Necessary for follow-up but not the immediate action. High Protein Diet: Important for muscle strength but secondary to immediate safety. Protective Environment: Preventing falls and injuries is the best immediate action to avoid further fractures and bruising. Ensuring the patient’s environment is safe and free from hazards is essential. Reference: Mayo Clinic guidelines on Cushing Syndrome American Association of Clinical Endocrinologists (AACE)

Question 6

A seven-year-old boy had tonsillectomy few hours ago. The mother asks the nurse about the type of food to be given when he awakes. The nurse replies as the following:

Accepted Answer

B

Explanation: Post-Tonsillectomy Care: After a tonsillectomy, the focus is on minimizing discomfort, preventing bleeding, and promoting healing. Food and Drink Recommendations: Citrus Juice and Carbonated Beverages: These can irritate the throat and should be avoided. Fruits Cut into Pieces: Solid foods can be difficult to swallow and may cause discomfort. Crushed Ice: Helps to soothe the throat, reduce swelling, and provide hydration without causing irritation. Reference: American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Mayo Clinic guidelines on tonsillectomy aftercare

Question 7

A nurse is caring for a patient who is admitted into the surgical ward and was diagnosed with
perforated appendix and is shifted to operation room for appendectomy.
The nurse understands that this procedure is classified as:

Accepted Answer

B

Explanation: A perforated appendix is a medical emergency requiring immediate surgical intervention to prevent complications such as peritonitis and sepsis. Therefore, an appendectomy in this context is classified as an emergent procedure. Emergent surgeries are those that need to be performed without delay to preserve the patient's life or health. Reference: Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.

Question 8

A nurse is visiting an Asian family and found that both parents have cardiac problems. The nurse is
aware of Asian genetic predisposition to cardiovascular diseases.
The nurse assessment falls below which of the following cultural assessment category?

Accepted Answer

A

Explanation: When assessing the health of a family, considering their genetic predispositions to certain conditions falls under the category of bio-cultural factors. These factors include genetic traits, physical characteristics, and biological variations that can influence health. In this case, the nurse's awareness of the genetic predisposition of Asian individuals to cardiovascular diseases helps in understanding the family's health risks. Reference: Spector, R. E. (2017). Cultural Diversity in Health and Illness. Pearson.

Question 9

A client refuses to take an oral dose of Dulcolax (Bisacodyl tablets). What is the nurse's BEST response?

Accepted Answer

A

Explanation: Handling Medication Refusal: When a patient refuses medication, the nurse must assess the reason and ensure the patient's safety and adherence to treatment plans. Best Actions: Report to the Physician: Ensures the healthcare provider is aware and can make necessary adjustments or provide alternatives. Crushing Medication and Mixing: Bisacodyl tablets should not be crushed as it can alter the drug's effectiveness and increase side effects. Informing about Dosing: Not helpful if the patient is already refusing. Ice Chips: Not relevant to enhancing medication compliance. Reference: American Nurses Association (ANA) on patient medication administration Pharmacology guidelines on Bisacodyl administration

Question 10

A staff nurse was entering patient's clinical notes in the computer, and had to leave to attend an
immediate call without completion of recording. Another nurse used the account of the previous
nurse to enter her notes.
Which of the following BEST describes the ethical issue that was committed?

Accepted Answer

D

Explanation: The situation describes a breach of confidentiality, which occurs when private patient information is accessed or disclosed without proper authorization. Negligence: This refers to the failure to provide the standard of care that a reasonably prudent person would provide in a similar situation, but it doesn't specifically address unauthorized access to patient information. Malpractice: This is a type of negligence by a professional, which results in harm to the patient, and usually involves direct patient care rather than record-keeping issues. Breach of Privacy: This involves the inappropriate disclosure of private information. In this case, using someone else's account does not directly disclose patient information to unauthorized parties. Breach of Confidentiality: This specifically addresses the unauthorized access or use of patient information, which is exactly what happened when another nurse used the first nurse's account to enter notes. Reference: Health Insurance Portability and Accountability Act (HIPAA) Guidelines American Nurses Association (ANA): Code of Ethics for Nurses with Interpretive Statements

Question 11

The nurse manager is conducting an annual disaster drill. Based on the disaster triage, which of the following types of injuries would have LESS priority to receive care?

Accepted Answer

D

Explanation: Disaster Triage Principles: In disaster scenarios, triage prioritizes patients based on the severity of their injuries and the likelihood of survival. The goal is to provide the greatest good for the greatest number of people. Triage Categories: Immediate (Red): Life-threatening injuries requiring immediate intervention. Delayed (Yellow): Serious injuries needing treatment but not immediately life-threatening. Minor (Green): Minor injuries that can wait for treatment. Expectant (Black): Injuries are so severe that survival is unlikely, even with treatment. Case Analysis: Conscious with Femur Fracture: Delayed category, serious but not immediately life-threatening. Conscious with Superficial Cuts: Minor category, least priority but still above expectant. Unconscious with Internal Bleeding: Immediate category, needs urgent intervention. Unconscious with Open Skull Fracture and Brain Matter Showing: Expectant category, very low chance of survival, thus least priority. Reference: American College of Emergency Physicians (ACEP) World Health Organization (WHO) on Mass Casualty Management Systems

Question 12

A nurse is providing education to a new parent about the psychosocial development of the newborn. Applying Erikson's psychosocial development theory, the nurse would BEST instruct the parents to:

Accepted Answer

C

Explanation: Applying Erikson's psychosocial development theory, the nurse should instruct the parents to observe and respond to the newborn's signals of needs. According to Erikson, the first stage of psychosocial development is "Trust vs. Mistrust," which occurs from birth to approximately 18 months. Trust vs. Mistrust: In this stage, infants learn to trust their caregivers when their needs for food, comfort, and affection are consistently met. If caregivers are responsive to the infant’s needs, the infant develops a sense of trust and security. Ignoring and Distracting the Newborn: This approach may lead to feelings of mistrust as the infant’s needs are not being adequately addressed. Anticipating and Planning for the Newborn's Demands: While planning is important, it is more crucial to be responsive to the infant's immediate signals. Providing a Comfortable Environment: This is beneficial but must be combined with responsive caregiving to establish trust. Reference: Erikson, E. H. (1963). Childhood and Society. American Psychological Association (APA): Erikson's Stages of Psychosocial Development

Question 13

A nurse must be aware that keeping an aggressive patient in a seclusion or restraint requires an order from the doctor. The renewal of such order for a patient aged 19 years old must be done:

Accepted Answer

C

Explanation: When a patient aged 19 years old is placed in seclusion or restraint, the renewal of the order must be done every 4 hours. This requirement is based on the guidelines provided by the Joint Commission and the Centers for Medicare & Medicaid Services (CMS), which regulate the use of seclusion and restraints in healthcare settings. Initial Order: The use of seclusion or restraint must be ordered by a licensed independent practitioner (LIP), such as a physician. Time Limits: For adults aged 18 and older, the order must be renewed every 4 hours. Renewal Process: This renewal must involve an assessment of the patient's condition and the need for continued seclusion or restraint. Documentation: The rationale for using seclusion or restraint and the patient's response to the intervention must be documented thoroughly in the patient's medical record. Reference: The Joint Commission: Standards for Behavioral Health Care Centers for Medicare & Medicaid Services (CMS): Conditions of Participation for Hospitals, 42 CFR 482.13(e)

Question 14

The destruction of the alveoli walls is defined as:

Accepted Answer

D

Explanation: Definition of Emphysema: Emphysema is a chronic lung condition characterized by the destruction of the alveoli (air sacs) walls. This leads to reduced surface area for gas exchange and difficulty in breathing. It is a major component of Chronic Obstructive Pulmonary Disease (COPD). Differentiation from Other Conditions: Asthma: A condition where the airways become inflamed and narrowed. Bronchitis: Inflammation of the bronchial tubes, often resulting in cough and mucus production. Bronchiolitis: Inflammation of the small airways (bronchioles), commonly seen in children. Reference: American Lung Association (ALA) National Heart, Lung, and Blood Institute (NHLBI)

Question 15

A nursing instructor provides a session to a group of nursing students about the importance of anion
gap in an acid base imbalance.
Which of the following statements if made by the nursing student would indicate the understanding
of the teaching?

Accepted Answer

C

Explanation: Understanding Anion Gap: The anion gap is a calculated value based on the concentrations of cations (positively charged ions) and anions (negatively charged ions) in the blood, used to identify the causes of metabolic acidosis. Normal and Abnormal Values: Normal Anion Gap: Typically ranges from 8-12 mEq/L, though some sources consider 6-12 mEq/L as normal. High Anion Gap (> 12): Indicates metabolic acidosis, often due to conditions like ketoacidosis, lactic acidosis, or ingestion of toxins. Low Anion Gap (< 8): Not typically associated with metabolic alkalosis; other conditions like hypoalbuminemia may cause it. Clinical Relevance: Anion gap helps clinicians determine the underlying cause of acid-base imbalances and guide appropriate treatment. Reference: American Association for Clinical Chemistry (AACC) Mayo Clinic on Anion Gap

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