1. Answer: A
The most critical part upon admission is the hydration status of the patient. While all the answers were correct and important, the first objective is the hydration status of the child.
2. Answer: B
Promoting venous return flow may prevent thrombophlebitis. A sign that a patient may suffer from thrombophlebitis is called Homan’s sign. The other goals are not well indicated in the assessment.
3. Answer: D
The proper way to irrigate the nasogastric tube is to use gentle pressure during the instillation of the normal saline solution. Withdrawing the solution afterward can end the procedure. Gentle pressure is needed in order to preserve the integrity of the stomach walls.
4. Answer: A
Open-ended questions can help the patient verbalize his feelings. It helps the nurse explore the thoughts of the patient in order to provide a means of nursing care in terms of psychological support and as an active listener.
5. Answer: D
As a client advocate, the nurse protects the interests of the client. She represents the patient when the patient is not able to voice out his or her needs. She may also relay information to the physician when the patient is not able to represent himself.
6. Answer: D.
Being a teacher in this situation means that you must allow the patient to learn proper wound care on his own. As a teacher, the nurse helps the client to learn about their health and health care procedures.
7. Answer: C
As a part of the healthcare team, nurses should be able to know that they have responsibility for the situation above. In order to correct the behavior of the two nursing aides, they must understand the reason to change the beddings. Giving them information about germ transmission is the appropriate approach.
8. Answer: B
Lactated Ringer’s Solution must be used within the first 24 hours. Colloids such as D5Water and D5 NSS increase capillary permeability which may increase the risk of pulmonary edema.
9. Answer: C
Assertion of automony is seen in 2 to 21/2-year-old toddlers as they begin their language and social development. The stage of initiative vs. guilt (2) is more common in the preschool-age child, 3 to 6 years. At 3 to 4 years of age, children have imaginary playmates (1).
10. Answer: C
Stress does not always result in feelings of distress such as harmful or unpleasant stress. The others options definitely describe stress.
11. Answer: A
A 1-year-old child normally learns to walk. Any interruption on this development such as physical stress and hospitalization can affect the normal development. The child should sit (4) by 6 months and should already be crawling (1) by 1 year of age.
12. Answer: B
A regular diet with moderate sodium is suggested for children who are in acute glomerulonephritis. If the client’s condition progresses to renal failure, sodium, potassium, and protein are restricted
13. Answer: A
Clients who have been on anti-TB drug regimes for at least 2-3 weeks and have absence of AFB in at least two successive sputum cultures, no longer need to be on Respiratory Isolation. Taking medication alone, or the absence of adventitious breath sounds such as rhonchi, rales, etc, or the absence of infiltrates on chest x-ray, usually seen with Pneumonia would not be a reason to D/C Isolation, making choices (b), (c), and (d) incorrect.
14. Answer: C
Rales are defined as abnormal lung sounds which is crackling in nature. Rhonchi is characterized by dry coarse sounds which is present when the patient coughs. Wheezes is common upon expiration and denotes narrowed passages.
15. Answer: A
The classic finding when an appendix ruptures is a sudden cessation of pain. Options b, c and dare expected findings for a child of this age who is diagnosed with acute appendicitis.
16. Answer: C.
Blood pressure elevation signals a frequent complication associated with Acute Glomerulonephritis. The nurse should expect to assess blood pressure every 2 to 4 hours with vital signs. Options a, b and d are appropriate orders for a child with Acute Glomerulonephritis
17. Answer: D
Patients with renal failure should have a diet that provides (high biologic value) proteins rich foods such as eggs, dairy products and meats. These are necessary to maintain a positive nitrogen balance. Foods high in calories are also necessary, and sodium intake should be limited. Foods high in Potassium should be AVOIDED due to decreased ability of the kidney(s) to filter and excrete Potassium
18. Answer: C
The HIV virus has been found and isolated in all of the above body fluids, as well as in the stool and urine. However, the highest concentration is found in the blood of infected individuals.
19. Answer: A
Although abstinence is still the best protection against the spread of the HIV virus, the use of a latex condom with an H20 soluble lubricant is the most effective means. Other choices do not give assurance of preventing acquiring the HIV virus.
20. Answer: C.
Using open-ended questions can allow the patient with depression to voice out his or her problems or what is bothering him or her. Using silence at this time is not appropriate as well as with the other options.
21. Answer: A
Being talkative indicates that the patient may be developing dementia.
22. Answer: D
Elderly patients are at a higher risk for sustaining injuries, especially in unfamiliar surroundings. While other choices are potential interventions that the nurse could implement, choice (c.) would allow the patient to better visualize the surroundings, delimiting possible accidents or falls. Orienting the patient, as well as checking the patient, and keeping side rails up are also important , each patient must be assessed individually to determine which measure(s) should be employed
23. Answer: B
Percussion is first done in order to assess all the quadrants and the next is palpation which involves direct pressure. This step can also elicit pain or dullness.
24. Answer: C
The cranial nerve I or olfactory nerve is responsible to take in the scents and send signals to the brain.
25. Answer: D
Wheezes is continuous, lengthy, musical heard during inspiration or expiration. It is common to those with asthma since there is an active narrowing of the bronchioles.