1. Answer: C

Rationale: Initially, the respiratory system will try to compensate for metabolic acidosis. Patients with metabolic acidosis have high respiratory rates.

  1. Answer: A, E, F, C, B, D

Rationale: 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.

  1. Answer: B

Rationale: There is 6-8 months activity restriction following a spinal fusion. Sitting, lying, standing, normal stair climbing, walking, and gentle swimming are allowed. Bending and twisting at the waist should be avoided, along with lifting more than 10 lbs.

  1. Answer: D

Rationale: Z-track technique is used to administer drugs especially irritating to the subcutaneous tissue. This method promotes the absorption of the drug by preventing drug leakage into the subcutaneous layer.

  1. Answer: B

Rationale: 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.

  1. Answer: C

Rationale: Priority nursing action is to administer oxygen to patients with chest pain. Chest pain is caused by insufficient myocardial oxygenation.

  1. Answer: A

Rationale: Burns on the face and neck can cause swelling of the respiratory mucosa, leading to airway obstruction manifested by hoarseness of voice and difficulty in breathing. Maintaining an airway patency is the main concern.

  1. Answer: B

Rationale: Recall the anatomy of the colon. The appropriate position is left lateral to facilitate the flow of enema by gravity into the colon.

  1. Answer:  D

Rationale: In hypokalemia, the electrocardiogram may show flattening and inversion of the T wave, the appearance of a U wave, and ST depression. Hypercalcemia can cause a shortened ST and widened T wave. The electrocardiogram of a hyperkalemic client shows tall peak T waves, widened QRS complexes, prolonged PR intervals, or flat P waves.

  1.  Answer: D

Rationale: The lowest possible score for any response is 1. If a client is unresponsive to painful stimuli, the score is 1. A score lower than 8 indicates that the client is in a comatose state. The highest score for the GCS is 15. A score of 15 indicates an alert and oriented person. A score of 3-8 indicates severe head injury.

  1. Answer: C

Rationale: Ketoacidosis is associated with high levels of ketone bodies in the body brought by the breakdown of fatty acids and is not related to vomiting. Metabolic acidosis happens when the body produces an excessive quantity of acid. Severe vomiting will result in loss of HCL and acids coming from extracellular fluids which in turn lead to metabolic alkalosis. Respiratory alkalosis occurs when there is an increased respiration which elevates the blood pH beyond the normal range of 7.35-7.45.

  1. Answer: B

            Rationale: Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold.

  1. Answer: C

            Rationale: The three-point gait, in which the client advances the crutches and the affected leg at the same time while weight is supported on the unaffected extremity, is the appropriate gait of choice. This allows for non-weight-bearing on the affected extremity. The two-point, four-point, and swing-to gaits require some weight bearing on bot

  1. Answer: A

            Rationale: Health-promoting strategies for clients with a history of cardiovascular disease require knowledge in three areas: diet, exercise, and medication. Pain management and management of social activities do not usually feature health promotion activities for these clients.

  1. Answer: C

            Rationale: Physical activity is gradually increased after a myocardial infarction while the client is still hospitalized and through a period of rehabilitation. The client is progressing too rapidly if activity significantly changes respirations, causing dyspnea, chest pain, a rapid heartbeat, or fatigue. When any of these symptoms appear, the client should reduce activity and progress more slowly. Edema suggests a circulatory problem that must be addressed but doesn’t necessarily indicate overexertion. Cyanosis indicates the reduced oxygen-carrying capacity of red blood cells and indicates a severe pathology. It is not appropriate to use cyanosis as an indicator for overexertion. Weight loss indicates several factors but not overexertion.

  1. Answer: B

            Rationale: The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.

  1. Answer: A

            Rationale: When examining the tympanic membrane of a child younger than age 3 years, the nurse should pull the pinna down and back. For an older child, the nurse should pull the pinna up and back to view the tympanic membrane.

  1. Answer: D

            Rationale: Tingling and numbness of the toes would be the earliest indication of circulatory impairment. Inability to move the toes and cyanosis are later indicators. Complaints of cast tightness should be investigated because cast tightness can lead to circulatory impairment; it is not, however, an indicator of impairment.

  1. Answer: C

            Rationale: The baseline laboratory data that are established before a client is started on tissue plasminogen activator or alteplase recombinant include hematocrit, hemoglobin level, and platelet count.

  1. Answer: D

            Rationale: The antidote for heparin is 1% protamine sulfate. Vitamin K is the antidote for warfarin, an oral anticoagulant. Thrombin is a topical anticoagulant.

  1. Answer: C

            Rationale: A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drum-like sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.

  1. Answer: C

            Rationale: The bluish pigment on the buttocks and back of an African American infant is a common finding and should be documented as Mongolian spots in the child’s record. These spots typically fade by the time the child is 5 or 6 years. Additional assessment by the physician is not indicated. Laser therapy is not used. Rather, laser therapy is useful for port-wine stains, which are dark purple and disfiguring.

  1. Answer: D

            Rationale: A supine position in extension is the position most likely to prevent contractures. Clients who have experienced burns will find a flexed position most comfortable. However, flexion promotes the development of contractures. The high Fowler’s and semi-Fowler’s positions create hip flexion. The prone position is contraindicated because of head and neck burns. In clients with head and neck burns, pillows should not be used under the head or neck because it promotes neck flexion contractures.

  1. Answer: C

            Rationale: When the nurse cannot elicit the Moro reflex of a 4-day-old preterm infant and the Moro reflex was present at birth, intracranial hemorrhage or cerebral edema should be suspected. Other symptoms include lethargy, bulging fontanels, and seizure activity. Confirmation can be made by ultrasound. Postnatal asphyxia is suggested by respiratory distress, grunting, nasal flaring, and cyanosis. A skull fracture can be confirmed by radiography. However, it is unlikely to occur in a preterm neonate. Rather, it is more common in the large-for-gestational-age neonate. Facial nerve paralysis is indicated when there is no movement on one side of the face. This condition is more common in the large-for-gestational-age neonate.

  1. Answer: B

            Rationale: Exposure to moisture can lead to maceration and the development of pressure ulcers. It is important for the client’s skin to be kept clean and dry with prompt attention to cleanliness after incidents of incontinence. The client’s age and the presence of hypertension are not factors leading to pressure ulcers. Smoking affects the oxygen status of the client but does not directly lead to the development of pressure ulcers.

  1. Answer: B

            Rationale: Recommended restraints for a child who has had palate surgery is elbow restraints. They minimize the limitation placed on the child but still prevent the child from injuring the repair with fingers and hands. A safety jacket or wrist or body restraints restrict the child unnecessarily.

  1. Answer: D

            Rationale: During an episode of acute respiratory distress, it is important that the nurse focus the assessment on the client’s respiratory system and distress to quickly address the client’s problem. Conducting a complete health history and a comprehensive physical examination can be deferred until the client’s condition is stabilized. It is not appropriate to delay all assessments until the respiratory distress is resolved because the nurse must have data to guide treatment.

  1. Answer: D

            Rationale: The most likely indication of a dislocated hip is a shortening of the affected leg. Other indications of dislocation include increasing pain, loss of function to the extremity, and deformity. Abduction of the leg after total hip replacement is a desirable position to prevent dislocation. Loosening of the prosthesis does not necessarily indicate that the hip has dislocated. External rotation of the hip can occur without the hip’s being dislocated. However, a neutral position of rotation is the desired position.

  1. Answer: B

            Rationale: Cardiomyopathy is a broad term that includes three major forms: dilated, hypertrophic, and restrictive cardiomyopathies. The underlying etiology of hypertrophic cardiomyopathy is unknown; it is typically observed in young men but is not limited to them. Common symptoms are fatigue, low tolerance to activity related to the low ejection fraction, and shortness of breath. Angina may be observed if coronary artery disease is present. Abdominal pain and hypertension are not common.

  1. Answer: C

            Rationale: Establishing a patent airway is the priority intervention. Prophylactic intubation is initiated if heat has been inhaled or if the neck, head, or face is involved. Swelling of the upper airways can progress to obstruction. Fluid replacement can best be achieved using a large-caliber peripheral I.V. catheter, and morphine sulfate are appropriate for analgesia in a burn client. Although these are priorities, they are secondary to establishing a patent airway. Administering tetanus toxoid is a secondary priority.

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Nhiña Sandeep de Rosas, MAN, DIH, DSHRM, RN currently works for the Department of Health CHD Mimaropa as a Training Specialist. She is also a Nurse Licensure Exam and NCLEX-RN reviewer on her free time. She has her USRN licenses in New York and Vermont, having passed the NCLEX-RN in 2007.Since 2006, she has been a nurse educator and worked as a clinical instructor and classroom lecturer for Unciano Colleges (College of Nursing) in Antipolo City. She has earned her Master’s Degree in Nursing and Diploma in International Health at the University of the Philippines Open University; and her Diploma in Strategic Human Resource Management at the Ateneo de Manila University.

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