1.) Answer: D
Dark green leafy vegetables are good sources of iron. Oranges are good sources of vitamin C that enhances iron absorption in the small intestines.
2.) Answer: B
Individuals with G6PD may exhibit hemolytic anemia when exposed to infection, certain medications or chemicals. Salicylates such as Aspirin damages plasma membranes of erythrocytes, leading to hemolytic anemia.
3.) Answer: B
Lower GI fluids are alkaline in nature and can be lost via ileostomy. Thus, loss of HCO3, results in metabolic acidosis.
4.) Answer: C
Initially, the respiratory system will try to compensate metabolic acidosis. Patients with metabolic acidosis have a high respiratory rate.
5.) Answer: A
Normal phosphorus level is 2.5 – 4.5 mg/dL .The level reflects hyperphosphatemia which is inversely proportional to calcium. Client should be assessed for tetany which is a prominent symptom of hypocalcemia.
6.) Answer: C
Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, constipation, and signs of dehydration, including a decrease in urine output.
7.) Answer: A, E, F, C, B, D
In accordance with the new guidelines, remember AB-CABS. A-airway B-breathing normally? − C-chest compression A-airway open B-breathing for patient S-serious bleeding, shock, spinal injury. The nurse should first assess the consciousness of the patient. Next, open the patient’s airway to check for breathing. When there is no breathing, immediately perform chest compression then give 2 breaths, do the cycle of care over. Finally, check for serious bleeding, shock, and spinal injury.
8.) Answer: D
Continuous bubbling seen in the water-seal bottle/ chamber indicates an air leak or loose connection, and the air is sucked continuously into the closed chest drainage system.
9.) Answer: C
Testicular cancer is most likely to affect males in late adolescence. Undescended testis is also one major risk for testicular cancer.
10.) Answer: D
Hypocalcemia occurs when there is accidental removal or destruction of parathyroid tissue during surgical removal of the thyroid gland. Laryngospasm is one of the clinical manifestations of tetany, an indicator of hypocalcemia.
11.) Answer: A
It’s normal for a toddler to have bowlegs and a protruding belly. The head still appears somewhat large in proportion from the rest of the body.
12.) Answer: D
13.) Answer: B
There is 6-8 months activity restriction following a spinal fusion. Sitting, lying, standing, normal stair climbing, walking, and gentle swimming is allowed. Bending and twisting at the waist should be avoided, along with lifting more than 10 lbs.
14.) Answer: D
Z-track technique is used to administer drugs especially irritating to the subcutaneous tissue. This method promotes absorption of the drug by preventing drug leakage into the subcutaneous layer.
15.) Answer: B
Establishing rapport is a way to gain trust that will lead for a patient to relax. You can get more insights and information from a patient when rapport is established.
16.) Answer: A
Low magnesium (hypomagnesemia) produces clinical manifestations like increased reflexes, tremors, and seizures. Magnesium Sulfate is the drug of choice to prevent seizures in pre-eclampsia and eclampsia.
17.) Answer: C
The ear canal of children ages 3years and above can be straightened by pulling the pinna up then backwards. For children below 3 years of age, the ear canal can be straightened by pulling the pinna down then backwards.
18.) Answer: A
Infants are nose breathers. A gastric tube may be inserted to facilitate lung expansion and stomach decompression, but not a nasogastric tube as it can occlude the nare, thus, making breathing difficult for the infant.
19.) Answer: B
20.) Answer: B
Blind finger sweeps are not recommended in all CPR cases especially for infants and children because the foreign object may be pushed back into the airway.
21.) Answer: B
The first step in cardiopulmonary resuscitation (CPR) is assessing the responsiveness of the patient.
22.) Answer: C
Priority nursing action is to administer oxygen to patients with chest pain. Chest pain is caused by insufficient myocardial oxygenation.
23.) Answer: D
Pneumococcal Vaccine is a priority immunization for the elderly. Seniors, ages 65 years old and above, have a higher risk for serious pneumococcal infection and likely have low immunity. This is administered every 5 years.
24.) Answer: A
Burns on the face and neck can cause swelling of the respiratory mucosa that can lead to airway obstruction manifested by hoarseness of voice and difficulty in breathing. Maintaining airway patency is the main concern.
25.) Answer: C
An in-line filter is required for blood transfusions.
26.) Answer: D
Negative outcome: Hemodialysis decreases red blood cell count which worsens anemia, because RBCs are lost in dialysis from anticoagulation during the procedure, and from residual blood that is left in the dialyzer.
27.) Answer: D
A decrease in level of consciousness and headache are early signs of increase in intracranial pressure (ICP). Altered level of consciousness is the most common symptom that indicates a deficit in brain function.
28.) Answer: B
Recall the anatomy of the colon. The appropriate position is left lateral to facilitate the flow of enema by gravity into the colon.
29.) Answer: D
Recall the 12 Rights of administration. Checking the patient’s name is critical for client-safety.
30.) Answer: A , D
Crohn’s disease is a chronic inflammation of the colon with symptoms of diarrhea, abdominal pain, and weight loss. Corticosteroid is a treatment for Crohn’s disease. Antidiarrheal can give relief to diarrheal episodes. Aspirin should be avoided as it can worsen inflammation. Those with Crohn’s disease are mostly lactose intolerant, so choice no. (2) is incorrect.