NCLEX-RN Exam Pack

NLP LICENSE EXAM Set 8 (75

MONROVIA
Questions & Answers
COLLEGE 2022 Updated
$ 2021
2022) AND ANSWERS
300 QUESTIONS
1. 1. Question
A 21-year-old male with Hodgkin’s lymphoma is a senior at the
local university. He is engaged to be married and is to begin a
new job upon graduation. Which of the following diagnoses would
be a priority for this client?

o A. Sexual dysfunction related to radiation therapy

o B. Anticipatory grieving related to terminal illness

o C. Tissue integrity related to prolonged bed rest

o D. Fatigue related to chemotherapy

Correct Answer: A. Sexual dysfunction related to radiation

therapy
Radiation therapy often causes sterility in male clients and would
be of primary importance to this client. The psychosocial needs of
the client are important to address in light of the age and life
choices. Hodgkin’s disease, however, has a good prognosis when
diagnosed early. Know the importance of sex to individual,
partner, and patient’s motivation for change. Because
lymphomas often affect the relatively young who are in their
productive years, these people may be affected more by these
problems and may be less knowledgeable about the possibilities
of change.
o Option B: Grieving may not be an appropriate
diagnosis since the client would be experiencing new
milestones in his life despite his condition. Let the
patient describe the problem in own words. Provides a
more accurate picture of patient experience with
which to develop a plan of care.
 o Option C: Option B is not applicable since the client is
not on bed rest. Encourage the patient to share
thoughts and concerns with his partner and to clarify
values and impact of condition on relationship. Helps
the couple begin to deal with issues that can
strengthen or weaken the relationship.
o Option D: Fatigue may occur during chemotherapy,
but it is not the priority diagnosis. Identify pre-existing
and current stress factors that may be affecting the
relationship. The patient may be concerned about
other issues, such as job, financial, and illness-related
problems.
 2. Question
A client has autoimmune thrombocytopenic purpura. To
determine the client’s response to treatment, the nurse would
monitor:

o A. Platelet count

o B. White blood cell count

o C. Potassium levels

o D. Partial prothrombin time (PTT)

Correct Answer: A. Platelet count

Clients with autoimmune thrombocytopenic purpura (ATP) have
low platelet counts, making answer A the correct answer. The
laboratory tests will show low platelet count, usually <40×10^9/L
for over three months. Blood film shows large platelets and tiny
platelet fragments. Bone marrow examination shows an
increased number of megakaryocytes.
o Option B: Often associated with the CBC is a
differential, which refers to the relative amounts of
white blood cell types (i.e., neutrophil, lymphocyte,
eosinophil, etc.) as a percentage of the total number
of WBCs. Of note, if a subtype of white blood cells
seems to be elevated based on the differential, the
actual value of the type of white blood cells should be
 calculated by multiplying the percentage listed on the
differential by the total number of white blood cells.
o Option C: Potassium disorders are related to cardiac
arrhythmias. Hypokalemia occurs when serum
potassium levels under 3.6 mmol/L—weakness,
fatigue, and muscle twitching present in hypokalemia.
Hyperkalemia occurs when the serum potassium
levels above 5.5 mmol/L, which can result in
arrhythmias. Muscle cramps, muscle weakness,
rhabdomyolysis, myoglobinuria are presenting signs
and symptoms in hyperkalemia.
o Option D: Patients with a propensity for bleeding
should undergo testing to determine the presence of a
clotting disorder. For patients with deficiencies or
defects of the intrinsic clotting cascade, the PTT will be
elevated. Normal PTT values can vary between
laboratories but 25 to 35 seconds is considered
normal.
 3. Question
The home health nurse is visiting a client with autoimmune
thrombocytopenic purpura (ATP). The client’s platelet count
currently is 80, it will be most important to teach the client and
family about:

o A. Bleeding precautions

o B. Prevention of falls

o C. Oxygen therapy

o D. Conservation of energy

Correct Answer: A. Bleeding precautions

The normal platelet count is 120,000–400, Bleeding occurs in
clients with low platelets. The priority is to prevent and minimize
bleeding. Review laboratory results for coagulation status as
appropriate: platelet count, prothrombin time/international
normalized ratio (PT/INR), activated partial thromboplastin time
(aPTT), fibrinogen, bleeding time, fibrin degradation products,
vitamin K, activated coagulation time (ACT); and educate the at-
risk patient and caregivers about precautionary measures to
prevent tissue trauma or disruption of the normal clotting
mechanisms.
o Option B: Thoroughly conform patient to
surroundings; put call light within reach and teach how
to call for assistance; respond to call light
immediately; avoid use of restraints; obtain a
physician’s order if restraints are needed; and
eliminate or drop all possible hazards in the room such
as razors, medications, and matches.
o Option C: Option C is important, but platelets do not
carry oxygen. Wash hands and teach patient and SO to
wash hands before contact with patients and between
procedures with the patient; encourage fluid intake of
2,000 to 3,000 mL of water per day, unless
contraindicated.
o Option D: Option D is of lesser priority and is in this
instance. Recommend the use of soft-bristled
toothbrushes and stool softeners to protect mucous
membranes; and if infection occurs, teach the patient
to take antibiotics as prescribed; instruct the patient to
take the full course of antibiotics even if symptoms
improve or disappear.
 4. Question
A client with a pituitary tumor has had transsphenoidal
hypophysectomy. Which of the following interventions would be
appropriate for this client?

o A. Place the client in Trendelenburg position for postural

drainage

o B. Encourage coughing and deep breathing every 2

hours

o C. Elevate the head of the bed 30°

o D. Encourage the Valsalva maneuver for bowel

movements

Correct Answer: C. Elevate the head of the bed 30°

Elevating the head of the bed 30° avoids pressure on the sella
turcica and alleviates headaches. A, B, and D are . In the
immediate postoperative period, patients are monitored in an
intensive care unit with monitoring for neurological deterioration,
epistaxis, visual dysfunction, diabetes insipidus (DI), and
hypotension secondary to acute hypocortisolism.
o Option A: Placing the patient in Trendelenburg will
increase the intracranial pressure. The most common
complications are CSF leak, sinusitis, and meningitis.
CSF leaks, occurring in 6 in every 100 cases, is usually
prevented by a multilayer closure at the end of
surgery. In the occurrence of a leak in the
postoperative period, the patient is advised bed rest,
and a lumbar drain is placed. If the leak does not
improve in 24 hours, exploration and closure of the
defect are to be done.
o Option B: Coughing and deep breathing causes
increase in intracranial pressure. Worsening of vision
as a result of bleeding or manipulation and arterial
hemorrhage are other immediate complications. A
detailed study of preoperative imaging is essential to
avoid catastrophes like optic nerve and carotid artery
injury.
o Option D: Valsalva maneuver increases the
intracranial pressure. The first follow up visit is 1 week
after the procedure, where postoperative day 7 serum
sodium levels are reviewed to rule out occult
hyponatremia. Serial nasal endoscopies are done for
debridement and to assess healing. The frequency of
follow-up visits is determined by nasal crusting and
maintenance of nasal hygiene with irrigation. Routine
early postoperative imaging is not done in most
patients.
 5. Question
The client with a history of diabetes insipidus is admitted with
polyuria, polydipsia, and mental confusion. The priority
intervention for this client is:

o A. Measure the urinary output

 o B. Check the vital signs

o C. Encourage increased fluid intake

o D. Weigh the client

Correct Answer: B. Check the vital signs

A large amount of fluid loss can cause fluid and electrolyte
imbalance that should be corrected. The loss of electrolytes
would be reflected in the vital signs. Monitor for signs of
hypovolemic shock (e.g., tachycardia, tachypnea, hypotension).
Frequent assessment can detect changes early for rapid
intervention. Polyuria causes decreased circulatory blood volume.
o Option A: Measuring the urinary output is important,
but the stem already says that the client has polyuria.
Monitor intake and output. Report urine volume
greater than 200 mL for each of 2 consecutive hours
or 500 mL in a 2-hour period. With DI, the patient
voids large urine volumes independent of the fluid
intake. Urine output ranges from 2 to 3 L/day with
renal DI to greater than 10 L/day with central DI.
o Option C: Encouraging fluid intake will not correct the
problem. Allow the patient to drink water at will.
Patients with intact thirst mechanisms may maintain
fluid balance by drinking huge quantities of water to
compensate for the amount they urinate. Patients
prefer cold or ice water.
o Option D: Weighing the client is not necessary at this
time. Monitor serum and urine osmolality. Urine
osmolality will be decreased and serum osmolality will
increase. Monitor urine-specific gravity. This may be
1.005 or less.
 6. Question
A client with hemophilia has a nosebleed. Which nursing action
is most appropriate to control the bleeding?

o A. Place the client in a sitting position with the head

hyperextended
 o B. Pack the nares tightly with gauze to apply pressure to
the source of bleeding

o C. Pinch the soft lower part of the nose for a

minimum of 5 minutes

o D. Apply ice packs to the forehead and back of the neck

Correct Answer: C. Pinch the soft lower part of the nose

for a minimum of 5 minutes
The client should be positioned upright and leaning forward, to
prevent aspiration of blood. Usual sites of external bleeding may
include the bleeding in the mouth from a cut, bite, or from cutting
or losing a tooth; nosebleeds for no obvious reasons; heavy
bleeding from a minor cut, or bleeding from a cut that resumes
after stopping for a short time. Hemophiliacs do not bleed faster
or more frequently. Instead, they bleed longer due to a deficiency
of clotting factor. Clients are often aware of bleeding before
clinical manifestation. Bleeding can be life-threatening to these
clients.
o Option A: Direct pressure to the nose stops the
bleeding. Apply manual or mechanical pressure if
active bleeding is noted. If spontaneous or traumatic
bleeding is evident, monitor vital signs.
o Option B: If a pack is necessary, the nares are loosely
packed. Controlling bleeding is a nursing priority. Nasal
packing should be avoided, because the subsequent
removal of the packing may precipitate further
bleeding.
o Option D: Ice packs should be applied directly to the
nose as well. Assess for any signs of bruising and
bleeding (note the extent of bleeding). Assess for
prolonged bleeding after minor injuries.
 7. Question
A client has had a unilateral adrenalectomy to remove a tumor. To
prevent complications, the most important measurement in the
immediate postoperative period for the nurse to take is:

o A. Blood pressure
 o B. Temperature

o C. Output

o D. Specific gravity

Correct Answer: A. Blood pressure

Blood pressure is the best indicator of cardiovascular collapse in
the client who has had an adrenal gland removed. The remaining
gland might have been suppressed due to the tumor activity.
Primary adrenal insufficiency occurs after bilateral
adrenalectomy. Signs and symptoms are volume depletion,
hypotension, hyponatremia, hyperkalemia, fever, abdominal pain.
Patients are managed by replacement therapy based on
glucocorticoids (hydrocortisone or cortisone), mineralocorticoids
(fludrocortisone) in cases of confirmed corticoids or aldosterone
deficiency, respectively.
o Option B: Temperature would be an indicator of
infection. Patients in the adrenal crisis typically
present with profoundly impaired well-being,
hypotension, nausea and vomiting, and fever
responding well to parenteral hydrocortisone
administration. Infections are the major precipitating
causes of adrenal crisis.
o Option C: Decreased output would be a clinical
manifestation but would take longer to occur than
blood pressure changes. The clinician must be able to
work-up and manage patients with adrenal masses,
both functional and non-functional, to treat these
patients with minimal morbidity. When planning for
adrenalectomy, considerations of hormonal changes
and preoperative preparation for these changes is as
important and demands as much of the surgeon’s
attention as the technical aspects of the case.
o Option D: Specific gravity changes occur with other
disorders. Adrenalectomy has been shown to have a
relatively low risk of postoperative complications, with
an overall rate of 3.6%. Improved patient outcomes
and decreased hospital costs have been demonstrated
when adrenalectomy is performed by a high-volume
adrenal surgeon (>/=6 adrenalectomies/year).
  8. Question
A client with Addison’s disease has been admitted with a history
of nausea and vomiting for the past 3 days. The client is receiving
IV glucocorticoids (Solu-Medrol). Which of the following
interventions would the nurse implement?

o A. Daily weights

o B. Intake/output measurements

o C. Sodium and potassium levels monitored

o D. Glucometer readings as ordered

Correct Answer: D. Glucometer readings as ordered

IV glucocorticoids raise the glucose levels and often require
coverage with insulin. Cortisone and prednisone replace cortisol
deficits, which will promote sodium reabsorption. Fludrocortisone
is a mineralocorticoid for patients who require aldosterone
replacement to promote sodium and water replacement. Acute
adrenal insufficiency is a medical emergency requiring immediate
fluid and corticosteroid administration. If treated for adrenal
crisis, the patient requires IV hydrocortisone initially; usually by
the second day, administration can be converted to an oral form
of replacement.
o Option A: Daily weights are unnecessary. Monitor
trends in weight. This provides documentation of
weight loss trends. Weight loss is a common
manifestation of adrenal insufficiency.
o Option B: Intake/output measurements are not
necessary at this time. Assess vital signs, especially
noting BP and HR for orthostatic changes. A BP drop of
more than 15 mm Hg when changing from supine to
sitting position, with a concurrent elevation of 15
beats per min in HR, indicates reduced circulating
fluids.
o Option C: Sodium and potassium levels would be
monitored when the client is receiving
mineralocorticoids. Abnormal laboratory findings
include hyperkalemia (related to aldosterone
 deficiency and decreased renal perfusion),
hyponatremia (related to decreased aldosterone and
impaired free water clearance), and increase in blood
urea nitrogen (related to decreased glomerular
filtration from ).
 9. Question
A client had a total thyroidectomy yesterday. The client is
complaining of tingling around the mouth and in the fingers and
toes. What would the nurse’s next action be?

o A. Obtain a crash cart

o B. Check the calcium level

o C. Assess the dressing for drainage

o D. Assess the blood pressure for hypertension

Correct Answer: B. Check the calcium level

The parathyroid glands are responsible for calcium production
and can be damaged during a thyroidectomy. The tingling is due
to low calcium levels. Evaluate reflexes periodically. Observe for
neuromuscular irritability: twitching, numbness, paresthesias,
positive Chvostek’s and Trousseau’s signs, seizure activity.
o Option A: The crash cart would be needed in
respiratory distress but would not be the next action to
take. Hypocalcemia with tetany (usually transient)
may occur 1–7 days postoperatively and indicates
hypoparathyroidism, which can occur as a result of
inadvertent trauma to or partial-to-total removal of the
parathyroid gland(s) during surgery.
o Option C: The drainage would occur in hemorrhage.
Check dressing frequently, especially the posterior
portion. If bleeding occurs, the anterior dressing may
appear dry because blood pools dependently.
o Option D: Hypertension occurs in a thyroid storm.
Monitor vital signs noting elevated temperature,
tachycardia, arrhythmias, respiratory distress,
cyanosis. Manipulation of the gland during subtotal
 thyroidectomy may result in increased hormone
release, causing thyroid storm.
 10. Question
A 32-year-old mother of three is brought to the clinic. Her pulse is
52, there is a weight gain of 30 pounds in 4 months, and the
client is wearing two sweaters. The client is diagnosed with
hypothyroidism. Which of the following nursing diagnoses is
of highest priority?

o A. Impaired physical mobility related to decreased

endurance

o B. Hypothermia r/t decreased metabolic rate

o C. Disturbed thought processes r/t interstitial edema

o D. Decreased cardiac output r/t bradycardia

Correct Answer: D. Decreased cardiac output r/t

bradycardia
The decrease in pulse can affect the cardiac output and lead to
shock, which would take precedence over the other choices.
Protect against coldness. Provide extra layers of clothing or extra
blankets. Discourage and avoid the use of external heat sources.
Monitor patient’s body temperature.
o Option A: Impaired physical mobility is not applicable
to a client with hypothyroidism. Promote rest. Space
activities to promote rest and exercise as tolerated.
Assess the client’s ability to perform activities of daily
living (ADLs). The client may experience fatigue with
minimal exertion due to a slow metabolic rate. This
symptom hinder the client’s ability to perform daily
activities (e.g., self-care, eating)
o Option B: Hypothermia is correct but not a priority.
Teach the expected benefits and possible side effects.
The client should report symptoms such as chest
pain/palpitations; these happen due to the increased
metabolic and oxygen consumption.
o Option C: Disturbed thought processes is not a
related diagnosis. Assess the client’s appetite. Clients
 with hypothyroidism have decreased appetite. This
opposite relationship between weight gain and
decreased appetite is a manifestation found in
hypothyroidism.
 11. Question
The client is having an arteriogram. During the procedure, the
client tells the nurse, “I’m feeling really hot.” Which response
would be best?

o A. "You are having an allergic reaction. I will get an order

for Benadryl."

o B. "That feeling of warmth is normal when the dye

is injected."

o C. "That feeling of warmth indicates that the clots in the

coronary vessels are dissolving."

o D. "I will tell your doctor and let him explain to you the
reason for the hot feeling that you are experiencing."

Correct Answer: Answer: B. “That feeling of warmth is

normal when the dye is injected.”
It is normal for the client to have a warm sensation when dye is
injected. The client may have some discomfort from a needle
stick. He/she may feel symptoms such as flushing in the face or
other parts of the body when the dye is injected. The exact
symptoms will depend on the part of the body being examined.
o Option A: An area of the groin or the artery in the
wrist or hand will be cleaned for the procedure. The
client will be given a mild sedative and pain
medication to keep them comfortable throughout the
procedure. The Radiologist will numb the insertion site
and a very small tube called a catheter will be inserted
into the vessel. A rapid sequence of X-rays is taken
when the dye is injected into the vessel. Each time the
contrast is injected, the client may experience a
sensation of warmth.
o Option C: Warmth does not indicate that clots are
dissolving. If the angiogram reveals a narrowed vessel,
 a balloon angioplasty or stent placement may be
performed at the same time. When the procedure is
completed, the catheter will be removed, and pressure
will be held on the entry site for 10-20 minutes to stop
any bleeding. The client may have a compression
device applied to stop the bleeding from the
angiogram site. This device may stay in place for 1-1
½ hours.
o Option D: This statement indicates that the nurse
believes that the hot feeling is abnormal, so it is .
Once the angiogram is completed the client may be on
bedrest for 4-6 hours or until he has recovered from
sedation. The client will be allowed to eat and will be
encouraged to drink fluids to flush the contrast dye
from the system. During this time, the catheter
insertion site will be watched closely, and blood
pressure and pulse will be monitored.
 12. Question
The nurse is observing several healthcare workers providing care.
Which action by the healthcare worker indicates a need for
further teaching?

o A. The nursing assistant wears gloves while giving the

client a bath.

o B. The nurse wears goggles while drawing blood from

the client.

o C. The doctor washes his hands before examining the

client.

o D. The nurse wears gloves to take the client’s

vital signs.

Correct Answer: D. The nurse wears gloves to take the

client’s vital signs.
It is not necessary to wear gloves to take the vital signs of the
client. If the client has an active infection with methicillin-
resistant Staphylococcus aureus, gloves should be worn. Wash
hands or perform hand hygiene before having contact with the
patient. Also impart these duties to the patient and their
significant others. Know the instances when to perform hand
hygiene or “5 moments for hand hygiene”.
o Option A: Wear personal protective equipment (PPE)
properly. Wear gloves when providing direct care;
perform hand hygiene after properly disposing of
gloves. Initiate specific precautions for suspected
agents as determined by CDC protocol.
o Option B: Use masks, goggles, face shields to protect
the mucous membranes of your eyes, mouth, and
nose during procedures and in direct-care activities
(e.g., suctioning secretions) that may generate
splashes or sprays of blood, body fluids, secretions,
and excretions.
o Option C: The health care workers indicate
knowledge of infection control by their actions. Friction
and running water effectively remove microorganisms
from hands. Washing between procedures reduces the
risk of transmitting pathogens from one area of the
body to another. Wash hands with antiseptic soap and
water for at least 15 seconds followed by an alcohol-
based hand rub. If hands were not in contact with
anyone or anything in the room, use an alcohol-based
hand rub and rub until dry. Plain soap is good at
reducing bacterial counts but antimicrobial soap is
better, and alcohol-based hand rubs are the best.
 13. Question
The client is having electroconvulsive therapy for treatment of
severe depression. Which of the following indicates that the
client’s ECT has been effective?

o A. The client loses consciousness.

o B. The client vomits.

o C. The client’s ECG indicates tachycardia.

o D. The client has a grand mal seizure.

Correct Answer: D. The client has a grand mal seizure.

During ECT, the client will have a grand mal seizure. This
indicates completion of electroconvulsive therapy. Seizure
threshold is established via trial and error via incrementally
higher doses of current during the primary treatment session.
Following initial dose calculation, the dose at subsequent ECT
sessions for bilateral ECT is 1.5 to 2 times seizure threshold, and
for right unilateral is six times the seizure threshold. During the
course of ECT treatment, the seizure threshold commonly
increases as the patient develops tolerance.
o Option A: Once the patient is rendered unconscious,
administration of a muscle relaxant follows, along with
bag valve mask ventilation with 100 percent oxygen. A
nerve stimulator is utilized to determine the adequacy
of muscle relaxation along with the clinical
assessment of plantar reflexes and fasciculations in
the calves and left foot.
o Option B: Physiologically, during the tonic phase of
the seizure, a 15- to 20-second parasympathetic
discharge occurs, which can lead to bradyarrhythmias
including premature atrial and ventricular
contractions, atrioventricular block, and asystole.
Patients with sub convulsive seizures are at higher risk
for asystole.
o Option C: Paradoxically, patients with heart block or
underlying arrhythmias are less likely to develop
asystole. The clonic phase of the seizure correlates
with a catecholamine surge that causes tachycardia
and hypertension, which lasts temporally with seizure
duration. Hypertension and tachycardia resolve within
10 to 20 minutes of the seizure, although some
patients exhibit persistent hypertension that requires
medical intervention.
 14. Question
The 5-year-old is being tested for enterobiasis (pinworms). To
collect a specimen for assessment of pinworms, the nurse should
teach the mother to:

o A. Examine the perianal area with a flashlight 2 or

3 hours after the child is asleep
 o B. Scrape the skin with a piece of cardboard and bring it
to the clinic

o C. Obtain a stool specimen in the afternoon

o D. Bring a hair sample to the clinic for evaluation

Correct Answer: A. Examine the perianal area with a

flashlight 2 or 3 hours after the child is asleep
Infection with pinworms begins when the eggs are ingested or
inhaled. The eggs hatch in the upper intestine and mature in 2–8
weeks. The females then mate and migrate out the anus, where
they lay up to 17,000 eggs. This causes intense itching. The
mother should be told to use a flashlight to examine the rectal
area about 2–3 hours after the child is asleep. Placing clear tape
on a tongue blade will allow the eggs to adhere to the tape. The
specimen should then be brought in to be evaluated.
o Option B: Pinworms do not burrow under the skin,
therefore scraping the skin for examination would not
reveal pinworms. Enterobius can be diagnosed through
a cellophane tape test or pinworm paddle test where
an adhesive tape-like material is applied to the
perianal area and then examined under a microscope.
o Option C: Pinworms are not usually detected in
stools. Stool examination is not helpful in the diagnosis
of E. vermicularis as they are only occasionally
excreted in the stool usually. Sometimes analysis of
the stool specimen is recommended to rule out other
causes.
o Option D: Taking a hair sample is inappropriate
because pinworms do not live in hair. The examination
might reveal characteristic ova which are 50 by 30
microns in size and have a flattened surface on one
side or may reveal the worms. Female worms are
around 8 to 13 mm long while male worms are 2 to 5
mm long. The examination is usually done in the early
morning for higher diagnostic yield.
 15. Question
The nurse is teaching the mother regarding treatment for
enterobiasis. Which instruction should be given regarding the
medication?

o A. Treatment is not recommended for children less than

10 years of age.

o B. The entire family should be treated.

o C. Medication therapy will continue for 1 year.

o D. Intravenous antibiotic therapy will be ordered.

Correct Answer: B. The entire family should be treated.

Enterobiasis, or pinworms, is treated with Vermox (mebendazole)
or Antiminth (pyrantel pamoate). The entire family should be
treated to ensure that no eggs remain. Because a single
treatment is usually sufficient, there is usually good compliance.
The family should then be tested again in 2 weeks to ensure that
no eggs remain. Enterobiasis can cause recurrent reinfection, so
treating the entire household, whether symptomatic or not is
recommended to prevent a recurrence.
o Option A: Enterobiasis usually occurs in children
under 10 years of age. The male-to-female infection
frequency is 2 to 1. However, a female predominance
of infection is seen in those between the ages of 5 and
14 years. It most commonly affects children younger
than 18 years of age. It is also commonly seen in
adults who take care of children and institutionalized
children.
o Option C: The medications used for the treatment of
pinworm are either mebendazole, pyrantel pamoate,
or albendazole. Any of these drugs are given in one
dose initially, and then another single dose of the
same drug two weeks later.
o Option D: Oral antibiotics are the most recommended
form of treatment for enterobiasis. Young pinworms
tend to be resistant to treatment and hence two doses
of medication, two weeks apart are recommended. At
the same time, all members of the infected child must
be treated. If a large number of children are infected in
 a class, everyone should be treated twice at 2-week
intervals. Follow-up is vital to ensure that a cure has
been obtained.
 16. Question
The registered nurse is making assignments for the day. Which
client should be assigned to the pregnant nurse?

o A. The client receiving linear accelerator radiation

therapy for lung cancer

o B. The client with a radium implant for cervical cancer

o C. The client who has just been administered soluble

brachytherapy for thyroid cancer

o D. The client who returned from placement of iridium

seeds for prostate cancer

Correct Answer: A. The client receiving linear accelerator

radiation therapy for lung cancer
The pregnant nurse should not be assigned to any client with
radioactivity present. The client receiving linear accelerator
therapy travels to the radium department for therapy. The
radiation stays in the department, so the client is not radioactive.
These clients are radioactive in very small doses, especially upon
returning from the procedures. For approximately 72 hours, the
clients should dispose of urine and feces in special containers and
use plastic spoons and forks.
o Option B: When brachytherapy is used to treat
cervical cancer, the radioactive substance is usually
put inside a special hollow applicator. This applicator is
called an intracavitary implant because it is placed
inside the vagina, or through the vagina and cervix
into the uterus, or both.
o Option C: Brachytherapy is a type of internal
radiation. It uses a radioactive material called a
radioactive isotope. The material is placed right into
the tumor or very close to it or in the area where the
tumor was removed.
 o Option D: Radioactive seed implants are a form of
radiation therapy for prostate cancer. Permanent
radioactive seed implants are a form of radiation
therapy for prostate cancer. The terms
“brachytherapy” or “internal radiation therapy” might
also be used to describe this procedure. During the
procedure, radioactive (iodine-125 or I-125) seeds are
implanted into the prostate gland using ultrasound
guidance.
 17. Question
The nurse is planning room assignments for the day. Which client
should be assigned to a private room if only one is available?

o A. The client with Cushing’s disease

o B. The client with diabetes

o C. The client with acromegaly

o D. The client with myxedema

Correct Answer: A. The client with Cushing’s disease

The client with Cushing’s disease has adrenocortical
hypersecretion. This increase in the level of cortisone causes the
client to be immunosuppressed. High cortisol levels also cause
immune disruptions; this hormone leads to a decrease in
lymphocyte levels and increases the neutrophils. It causes
detachment of the marginating pool of neutrophils in the
bloodstream and increases the circulating neutrophil levels
although there is no increased production of the neutrophils.
o Option B: The client with diabetes poses no risk to
other clients. Hyperglycemia alone can impair
pancreatic beta-cell function and contributes to
impaired insulin secretion. Consequently, there is a
vicious cycle of hyperglycemia leading to the impaired
metabolic state. Blood glucose levels above 180
mg/dL are often considered hyperglycemic in this
context, though because of the variety of
mechanisms, there is no clear cutoff point.
 o Option C: The client has an increase in growth
hormone and poses no risk to himself or others. The
common effect of the abnormal rise in growth
hormone is the production of IGF-1 from the liver. The
effect of IGF-1 on body tissues results in the
multisystemic manifestation of acromegaly. IGF-1 also
known as somatomedin C, is encoded by the IGF-1
gene on chromosome 12q23.2.
o Option D: The client has hypothyroidism or
myxedema and poses no risk to others or himself.
Thyroid hormone influences virtually all cells in the
body by activating or repressing a variety of genes
after binding to thyroid hormone receptors. Ninety
percent of the intracellular thyroid hormone that binds
to and influences cellular function is T3, which has
been converted from T4 by the removal of an iodide
ion.
 18. Question
The nurse caring for a client in the neonatal intensive care unit
administers adult-strength Digitalis to the 3-pound infant. As a
result of her actions, the baby suffers permanent heart and brain
damage. The nurse can be charged with:

o A. Negligence

o B. Tort

o C. Assault

o D. Malpractice

Correct Answer: D. Malpractice

The nurse could be charged with malpractice, which is failing to
perform, or performing an act that causes harm to the client.
Giving the infant an overdose falls into this category. In the
United States, a patient may allege medical malpractice against a
clinician, which is typically defined by the failure the provide the
degree of care another clinician in the same position with the
same credentials would have performed that resulted in injury to
the patient.
 o Option A: Negligence is failing to perform care for the
client. a tort is a wrongful act committed. Negligence,
in law, the failure to meet a standard of behaviour
established to protect society against unreasonable
risk. Negligence is the cornerstone of tort liability and
a key factor in most personal injury and property-
damage trials.
o Option B: A tort is a wrongful act committed on the
client or their belongings. A tort is a civil wrong that
causes harm to another person by violating a
protected right. A civil wrong is an act or omission that
is intentional, accidental, or negligent, other than a
breach of contract. The specific rights protected give
rise to the unique “elements” of each tort. Tort
requires the presence of four elements that are the
essential facts required to prove a civil wrong.
o Option C: Assault is a violent physical or verbal
attack. Assault is the intentional act of making
someone fear that you will cause them harm. You do
not have to actually harm them to commit assault.
Threatening them verbally or pretending to hit them
are both examples of assault that can occur in a
nursing home.
 19. Question
Which assignment should not be performed by the licensed
practical nurse?

o A. Inserting a Foley catheter

o B. Discontinuing a nasogastric tube

o C. Obtaining a sputum specimen

o D. Starting a blood transfusion

Correct Answer: D. Starting a blood transfusion

The licensed practical nurse should not be assigned to begin a
blood transfusion. An LPN works under the supervision of doctors
and RNs, performing duties such as taking vital signs, collecting
samples, administering medication, ensuring patient comfort, and
reporting the status of their patients to the nurses.
o Option A: Most LPNs work in healthcare facilities,
including hospitals, doctors’ offices, and nursing
homes. Their duties generally include providing
routine care, observing patients’ health, assisting
doctors and registered nurses, and communicating
with patients and their families.
o Option B: An LPN can insert NG tube for Levin suction
or gavage feedings; give meds through NG and PEG
tubes, and discontinue NG tubes. In general, LPN’s
provide patient care in a variety of settings within a
variety of clinical specializations. Insert and care for
patients that need nasogastric tubes. Give feedings
through a nasogastric or gastrostomy tube.
o Option C: The licensed practical nurse can collect
sputum specimens. Obtaining a specimen involves
collecting tissue or fluids for laboratory analysis or
near-patient testing, and may be a first step in
determining a diagnosis and treatment (Dougherty
and Lister, 2015). Specimens must be collected at the
right time, using the correct technique and equipment,
and be delivered to the laboratory in a timely manner
(Dougherty and Lister, 2015).
 20. Question
The client returns to the unit from surgery with a blood pressure
of 90/50, pulse 132, and respirations 30. Which action by the
nurse should receive priority?

o A. Continuing to monitor the vital signs

o B. Contacting the physician

o C. Asking the client how he feels

o D. Asking the LPN to continue the post-op care

Correct Answer: B. Contacting the physician

The vital signs are abnormal and should be reported immediately.
The early detection of changes in vital signs typically correlates
with faster detection of changes in the cardiopulmonary status of
the patient as well as up-gradation of the level of service if
needed. Patient safety is a fundamental concern in any
healthcare organization, and early detection of any clinical
deterioration is of paramount importance whether the patient is
in the emergency department or on the hospital floor.
o Option A: Continuing to monitor the vital signs can
result in deterioration of the client’s condition. The
degree of vital sign abnormalities may also predict the
long-term patient health outcomes, return emergency
room visits, and frequency of readmission to hospitals,
and utilization of healthcare resources.
o Option C: Asking the client how he feels will only
provide subjective data. Selected parameters are more
important during various stages of the recovery
period. Initially, respiratory rate and blood pressure
are of greater significance during recovery from
anesthesia, as it reflects hemodynamic stability and
level of anesthetic reversal. Later, after adequate
analgesia and pulmonary function has been obtained,
pulse rate correlates better with intravascular volume
status.
o Option D: Assigning an unstable client to an LPN is
inappropriate. Much information can be obtained by
close monitoring of the vital signs, including blood
pressure, pulse, and respiratory rate. More
importantly, the trend and changes of these
measurements more accurately reflect the patient’s
ongoing condition. In the immediate postoperative
period, frequent measurements are usually obtained
by the recovery room staff.
 21. Question
Which nurse should be assigned to care for the postpartum client
with preeclampsia?

o A. The RN with 2 weeks of experience in postpartum

o B. The RN with 3 years of experience in labor and

delivery
 o C. The RN with 10 years of experience in surgery

o D. The RN with 1 year of experience in the neonatal

intensive care unit

Correct Answer: B. The RN with 3 years of experience in

labor and delivery
The nurse with 3 years of experience in labor and delivery knows
the most about possible complications involving preeclampsia.
Registered nurses need to know their rights and responsibilities
when considering a patient assignment. The nurse-patient
assignment process is also often a manual process in which the
charge nurse must sort through multiple decision criteria in a
limited amount of time.
o Option A: The nurse is a new staff to the unit hence
lacking the experience needed. Most nurse-patient
assignment models have focused on balancing patient
acuity measures. This focus on patient acuity
concentrates workload measures on direct patient
care activities. While this is very important for the care
of the patient, it does not necessarily take into
account all of the activities comprising a nurse’s
workload.
o Option C: The nurse with experience in surgery does
not have the same experience in labor and delivery.
Balancing workload among nurses on a hospital unit is
important for the satisfaction and safety of nurses and
patients. To balance nurse workloads, direct patient
care activities, indirect patient care activities, and non-
patient care activities that occur throughout a shift
must be considered.
o Option D: This nurse lacks sufficient experience with
a postpartum client. Limitations in experience and
knowledge may not require refusal of the assignment,
but rather an agreement regarding supervision or a
modification of the assignment to ensure patient
safety. If no accommodation for limitations is
considered, the nurse has an obligation to refuse an
assignment for which she or he lacks education or
experience.
  22. Question
Which information should be reported to the state Board of
Nursing?

o A. The facility fails to provide literature in both Spanish

and English.

o B. The narcotic count has been on the unit for the

past 3 days.

o C. The client fails to receive an itemized account of his

bills and services received during his hospital stay.

o D. The nursing assistant assigned to the client with

hepatitis fails to feed the client and give the bath.

Correct Answer: B. The narcotic count has been on the

unit for the past 3 days.
General advice from the Department of Health is that stocks of
controlled drugs should be kept to the minimum required to meet
the clinical needs of patients. They should be stored securely in a
locked cabinet or safe to prevent unauthorised access, with the
keys held in a safe place.
o Option A: The Joint Commission conducts inspections
with two main objectives: To evaluate the healthcare
organization using TJC performance measures and
standards. To educate and guide the organization’s
staff in “good practices” to help improve the
organization’s performance.
o Option C: The Joint Commission on Accreditation of
Hospitals will probably be interested in the problem in
answer A. The Joint Commission offers many benefits
to their members. They help members organize and
strengthen their patient improvement programs and
safety efforts. They raise health care consumer and
community confidence in the quality of the
organization’s care, services and treatment. This
provides a competitive edge in the healthcare industry
and a proven framework for organizational
management. The Joint Commission helps to reduce
 risk management, liability insurance, and employee
turnover costs.
o Option D: The failure of the nursing assistant to care
for the client with hepatitis might result in termination
but is not of interest to the Joint Commission. The Joint
Commission monitors and advocates for legislation
that promotes better patient safety. When it comes to
state legislation, The Joint Commission collaborates
with patient safety authorities and state regulatory
bodies to minimize unrealistic expectations and reform
outdated rules. They push state regulatory bodies to
rely more on private accreditation instead of
mandatory state licensure inspections.
 23. Question
The nurse is suspected of charting medication administration that
he did not give. After talking to the nurse, the charge nurse
should:

o A. Call the Board of Nursing

o B. File a formal reprimand

o C. Terminate the nurse

o D. Charge the nurse with a tort

Correct Answer: B. File a formal reprimand

The next action after discussing the problem with the nurse is to
document the incident by filing a formal reprimand. As a rule of
thumb, nurses should avoid making assumptions when they
notice gaps or missing information in a patient’s treatment
documentation. Healthcare professionals have exceedingly
demanding schedules, but it’s always better to take the time and
double-check the details than to make assumptions and be
wrong.
o Option A: If the behavior continues, the nurse should
be reported to the Board of Nursing. Understanding
these realities can add hours to the day, so the
practical approach is to be strategic with efforts. Look
for efficiency, work with colleagues, and use best
 judgment and ingenuity to find ways to get everything
done while still doing it right. It’s not easy, but it’s also
not impossible.
o Option C: If the behavior continues or if harm has
resulted to the client, the nurse may be terminated,
but these are not the first actions requested in the
stem. Details save lives, and consistently getting them
right is what makes people feel safe when they go to
the doctor. Moreover, it’s also what keeps nurses from
having to defend their actions in a courtroom
someday.
o Option D: A tort is a wrongful act to the client or his
belongings and is not indicated in this instance. A tort
is a civil wrong that causes harm to another person by
violating a protected right. A civil wrong is an act or
omission that is intentional, accidental, or negligent,
other than a breach of contract. The specific rights
protected give rise to the unique “elements” of each
tort. Tort requires the presence of four elements that
are the essential facts required to prove a civil wrong.
 24. Question
The home health nurse is planning for the day’s visits. Which
client should be seen first?

o A. The 78-year-old who had a gastrectomy 3 weeks ago

and has a PEG tube

o B. The 5-month-old discharged 1 week ago with

pneumonia who is being treated with amoxicillin liquid
suspension

o C. The 50-year-old with MRSA being treated with

Vancomycin via a PICC line

o D. The 30-year-old with an exacerbation of

multiple sclerosis being treated with cortisone via a
centrally placed venous catheter
Correct Answer: Answer: D. The 30-year-old with an
exacerbation of multiple sclerosis being treated with
cortisone via a centrally placed venous catheter
The client at highest risk for complications is the client with
multiple sclerosis who is being treated with cortisone via the
central line. Multiple sclerosis is a complex disease process. In
addition to sensory and visual changes, weakness, coordination
problems, or spasticity can present. Other complaints relating to
overall health include bladder and bowel dysfunction, depression,
cognitive impairment, fatigue, sexual dysfunction, sleep
disturbances, and vertigo. The others are more stable.
o Option A: This client is more stable and can be seen
later. Although PEG is a relatively safe procedure,
acute and chronic complications have been reported,
including early mortality. Pih et al conducted a single-
center study aimed at determining risk factors
associated with complications and 30-day mortality
after pull-type (n = 139) and introducer-type (n = 262)
PEG.
o Option B: The client is already discharged and has
discharge medications given. Prognosis of pneumonia
depends on many factors including age, comorbidities,
and hospital setting (inpatient or outpatient).
Generally, the prognosis is promising in otherwise
healthy patients. Patients older than 60 years or
younger than 4 years of age have relatively poorer
prognosis than young adults.
o Option C: MRSA is Methicillin-Resistant
Staphylococcus Aureus. Vancomycin is the drug of
choice and is given at scheduled times to maintain
blood levels of the drug. Intravenous vancomycin is
the drug of choice for most MRSA infections seen in
hospitalized patients. It can be used both as empiric
and definitive therapy as most MRSA infections are
susceptible to vancomycin. There are sporadic cases
of vancomycin-resistant MRSA. The dosage depends
upon the type and severity of the infection.
 25. Question
The emergency room is flooded with clients injured in a tornado.
Which clients can be assigned to share a room in the emergency
department during the disaster?
 o A. A schizophrenic client having visual and auditory
hallucinations and the client with ulcerative colitis

o B. The client who is 6 months pregnant with

abdominal pain and the client with facial lacerations
and a broken arm

o C. A child whose pupils are fixed and dilated and his

parents, and a client with a frontal head injury

o D. The client who arrives with a large puncture wound to

the abdomen and the client with chest pain

Correct Answer: B. The client who is 6 months pregnant

with abdominal pain and the client with facial lacerations
and a broken arm
The pregnant client and the client with a broken arm and facial
lacerations are the best choices for placing in the same room.
Cohorting of patients according to the presence or absence of
specific pathogens coupled with conventional hygienic
precautions can lead to a decrease in incidence and prevalence
of chronic infections with these two species, wherefore patient
cohorting is now an integral component of infection control in
patients.
o Option A: Schizophrenia is a brain disorder that
probably comprises multiple etiologies. The hallmark
symptom of schizophrenia is psychosis, such as
experiencing auditory hallucinations (voices) and
delusions (fixed false beliefs). Impaired cognition or a
disturbance in information processing is an
underappreciated symptom that interferes with day-
to-day life. Hospitalizations are usually brief and are
typically oriented towards crisis management or
symptom stabilization.
o Option C: The goals of care are for the child and their
loved ones are to be free of complicated grieving and
to have access to adequate resources to allow for the
natural grieving process. It is important for them to
verbalize and express their true feelings and seek the
help and support of others. Having privacy from other
patients would be most appropriate.
 o Option D: This group of clients needs to be placed in
separate rooms due to the serious nature of their
injuries. The client with chest pain should be placed in
a private room to allow him to rest. Promote
expression of feelings and fears. Let the patient/SO
know these are normal reactions. Verbalization of
concerns reduces tension, verifies the level of coping,
and facilitates dealing with feelings. The presence of
negative self-talk can increase the level of anxiety and
may contribute to the exacerbation of angina attacks.
 26. Question
The nurse is caring for a 6-year-old client admitted with a
diagnosis of conjunctivitis. Before administering eye drops, the
nurse should recognize that it is essential to consider which of the
following?

o A. The eye should be cleansed with warm water,

removing any exudate, before instilling the
eyedrops.

o B. The child should be allowed to instill his own eye

drops.

o C. The mother should be allowed to instill the eyedrops.

o D. If the eye is clear from any redness or edema, the eye

drops should be held.

Correct Answer: A. The eye should be cleansed with warm

water, removing any exudate, before instilling the
eyedrops.
Before instilling eye drops, the nurse should cleanse the area with
water. Cleanse the eyelids and lashes with cotton balls or gauze
pledgets moistened with normal saline or water. This prevents
debris to be carried into the eye when the conjunctival sac is
exposed.
o Option B: A 6-year-old child is not developmentally
ready to instill his own eye drops. An ophthalmic
assistant, technician, nurse or physician instills eye
 drops during a routine eye examination or during
treatment for ocular disease.
o Option C: Although the mother of the child can instill
the eye drops, the area must be cleansed before
administration. Use each cotton ball or pledget for
only one stroke, moving from the inner to the outer
canthus of the eye.
o Option D: Although the eye might appear to be clear,
the nurse should instill the eyedrops, as ordered, so
answer D is . Allow the prescribed number of drops to
fall in the lower conjunctival sac but do not allow to
fall onto the cornea. Release the lower lid after the
drops are instilled. Instruct the patient to close eyes
slowly, move the eye and not to squeeze or rub.
 27. Question
The nurse is discussing meal planning with the mother of a 2-
year-old toddler. Which of the following statements, if made by
the mother, would require a need for further instruction?

o A. "It is okay to give my child white grape juice for

breakfast."

o B. "My child can have a grilled cheese sandwich for

lunch."

o C. "We are going on a camping trip this weekend,

and I have bought hot dogs to grill for his lunch."

o D. "For a snack, my child can have ice cream."

Correct Answer: C. “We are going on a camping trip this

weekend, and I have bought hot dogs to grill for his
lunch.”
Remember the ABCs (airway, breathing, circulation) when
answering this question. A hotdog is the size and shape of the
child’s trachea and poses a risk of aspiration. It is important to
avoid foods that may cause choking like slippery foods such as
whole grapes; large pieces of meat, poultry, and hot dogs; candy,
and cough drops.
 o Option A: A white grape juice does not pose a risk for
aspiration. The toddler years are full of exploring and
discovery. The best thing you can do is offer your
toddler a variety of foods from each food group with
different tastes, textures, and colors.
o Option B: A grilled cheese sandwich would not
aspirate a toddler. Always cut up foods into small
pieces and watch your child while he or she is eating.
Offer new foods one at a time, and remember that
children may need to try a new food 10 or more times
before they accept it.
o Option D: Ice cream does not pose a risk of aspiration
for a child. Make food simple, plain, and recognizable.
Some kids don’t like food that is mixed (like a
casserole) or food that is touching. Plan regular meals
and snacks and give kids enough time to eat.
 28. Question
A 2-year-old toddler is admitted to the hospital. Which of the
following nursing interventions would you expect?

o A. Ask the parent/guardian to leave the room when

assessments are being performed.

o B. Ask the parent/guardian to take the child’s favorite

blanket home because anything from the outside should not
be brought into the hospital.

o C. Ask the parent/guardian to room-in with the

child.

o D. If the child is screaming, tell him this is inappropriate

behavior.

Correct Answer: C. Ask the parent/guardian to room-in

with the child.
The nurse should encourage rooming-in to promote parent-child
attachment. It is okay for the parents to be in the room for
assessment of the child. Toddlers have a strong fear of strangers
and they may feel like they are losing control and autonomy
when at the hospital. Explain the procedures to them at the level
of their understanding to further prevent anxiety.
o Option A: Toddlers are afraid of strangers, so asking
the parents to leave the room would increase the
anxiety. The initial assessment of the interplay of key
variables such as anxiety, coping and play can inform
healthcare professionals by serving as a guide in order
to determine a child’s risk for negative psychological
outcomes due to hospitalization, to plan appropriate
interventions and to provide substantial assistance to
hospitalized children in the future.
o Option B: Hospitalization for children means leaving
their home and their caregivers and siblings and an
interruption of their daily activities and routines.
Moreover, hospital wards are often associated with
staying in a “cold and medical” setting, facing fear of
medical examinations, pain, uncertainty, and loss of
control and safeness. Allowing the child to have items
that are familiar to him is allowed and encouraged.
o Option D: Telling the child that screaming is
inappropriate behavior is not part of the nurse’s
responsibilities. Usually, children feel anxious before
encountering medical professionals, as well as
experiencing a hospitalization. Empirical studies
suggest that children express anxiety through
regression in behaviors, aggression, lack of
cooperation, withdrawal, and difficulty recovering from
procedures.
 29. Question
Which instruction should be given to the client who is fitted for a
behind-the-ear hearing aid?

o A. Remove the mold and clean every week.

o B. Store the hearing aid in a warm place.

o C. Clean the lint from the hearing aid with a toothpick.

o D. Change the batteries weekly.

Correct Answer: B. Store the hearing aid in a warm place.
The hearing aid should be stored in a warm, dry place. Proper
maintenance and care will extend the life of your hearing aid.
Make it a habit to keep hearing aids away from heat and
moisture. Avoid using hairspray or other hair care products while
wearing hearing aids. When it’s exposed to moisture it can cause
serious damage. Although hearing aids are now being made to be
water resistant it’s recommended that they are removed when
showering or swimming. If they do come in contact with water,
dry them immediately with a towel. Never attempt to dry them
with a hair drier or other heated device, since the high heat can
damage them.
o Option A: It should be cleaned daily but should not be
moldy. Clean hearing aids as instructed. Earwax and
ear drainage can damage a hearing aid. Turn off
hearing aids when they are not in use. Always take the
hearing aids out before having a shower, taking a bath
or going swimming. It’s best to leave the hearing aids
out of humid environments like the bathroom, as
moisture can damage the electronic components in
the hearing aid.
o Option C: A toothpick is inappropriate to use to clean
the aid; the toothpick might break off in the hearing
aid. A whistling sound can be caused by a hearing aid
that does not fit or work well or is clogged by earwax
or fluid. When cleaning your hearing aids, use a dry,
soft cloth. Hearing aid care products are available
through audiologists and audiometrists. They will also
check for ear wax build up and the general working
order of the hearing aid.
o Option D: Changing the batteries weekly is not
necessary. Replace dead batteries immediately. Keep
replacement batteries and small aids away from
children and pets. Also when changing out batteries,
remember to clean the battery contacts in the
devices. This can be done by gently wiping them down
with a dry cotton swab. If the battery contacts on the
devices are dirty, it can create a poor connection and
lower performance.
 30. Question
A priority nursing diagnosis for a child being admitted from
surgery following a tonsillectomy is:

o A. Body image disturbance

o B. Impaired verbal communication

o C. Risk for aspiration

o D. Pain

Correct Answer: C. Risk for aspiration

Always remember your ABCs (airway, breathing, circulation)
when selecting an answer. Place the child prone or side-lying
position. Promotes drainage of blood and unswallowed saliva
from the mouth that can potentially be aspirated.
o Option A: Does not apply for a child who has
undergone a tonsillectomy. Assess for signs and
symptoms of inadequate oxygenation. Early signs of
hypoxia include confusion, irritability, headaches,
pallor, tachycardia, and tachypnea.
o Option B: Observe the child for nonverbal indications
of pain such as crying, grimacing, irritability. Provides
additional information about pain. The child may find
discomfort in speaking.
o Option D: Although these nursing diagnoses might be
appropriate for this child, risk for aspiration should
have the highest priority. Apply an ice collar on the
neck or encourage the child to eat popsicles. Cold
promotes vasoconstriction and decreases swelling that
contributes to pain.
 31. Question
A client with bacterial pneumonia is admitted to the pediatric
unit. What would the nurse expect the admitting assessment to
reveal?

o A. High fever

o B. Nonproductive cough
 o C. Rhinitis

o D. Vomiting and diarrhea

Correct Answer: A. High fever

If the child has bacterial pneumonia, a high fever is usually
present. Increased temperature (usually more than 38 C or 100.4
F) or fever with tachycardia and/or chills and sweats is a major
clinical finding. Physical findings also vary from patient to patient
and mainly depend on the severity of lung consolidation, the type
of organism, the extent of the infection, host factors, and
existence or nonexistence of pleural effusion.
o Option B: Bacterial pneumonia usually presents with
a productive cough, not a nonproductive cough. The
presence of a productive cough is the most common
and significant presenting symptom. The lower
respiratory tract is not sterile, and it always is exposed
to environmental pathogens. Invasion and propagation
of the above-mentioned bacteria into lung
parenchyma at alveolar level causes bacterial
pneumonia, and the body’s inflammatory response
against it causes the clinical syndrome of pneumonia.
o Option C: Rhinitis is often seen with viral pneumonia.
Features in the history of bacterial pneumonia may
vary from indolent to fulminant. Clinical manifestation
includes both constitutional findings and findings due
to damage to the lung and related tissue.
o Option D: Vomiting and diarrhea are usually not seen
with pneumonia. Atypical pneumonia presents with
pulmonary and extrapulmonary manifestations, such
as Legionella pneumonia, often presents with altered
mentation and gastrointestinal symptoms.
 32. Question
The nurse is caring for a client admitted with epiglottitis. Because
of the possibility of complete obstruction of the airway, which of
the following should the nurse have available?

o A. Intravenous access supplies

 o B. A tracheostomy set

o C. Intravenous fluid administration pump

o D. Supplemental oxygen

Correct Answer: B. A tracheostomy set

For a child with epiglottitis and the possibility of complete
obstruction of the airway, emergency tracheostomy equipment
should always be kept at the bedside. Prepare for intubation or
tracheostomy; Anticipate the need of an artificial airway. An
artificial airway is required to promote oxygenation and
ventilation and prevent aspiration.
o Option A: Administer IV antibiotics as ordered. After
obtaining blood and epiglottic cultures, second-or-third
generation cephalosporins and beta-lactamase-
resistant antibiotics should be started as soon as
possible.
o Option C: Discourage examining throat with a tongue
blade or taking throat culture unless immediate
emergency equipment and personnel at hand. Position
the child in a sitting up and leaning forward position
with mouth open and tongue out (“tripod” position).
Allows maximum entry of air into the lungs for
improved oxygenation.
o Option D: Oxygen will not treat an obstruction.
Endotracheal intubation must be readily available;
assist with tracheostomy if needed or prepare for the
procedure in surgery. Establishes airway if obstruction
present and respiratory failure and asphyxia are
imminent.
 33. Question
A 25-year-old client with Grave’s disease is admitted to the unit.
What would the nurse expect the admitting assessment to
reveal?

o A. Bradycardia

o B. Decreased appetite
 o C. Exophthalmos

o D. Weight gain

Correct Answer: C. Exophthalmos

Exophthalmos (protrusion of eyeballs) often occurs with
hyperthyroidism. Graves’ orbitopathy (ophthalmopathy) is caused
by inflammation, cellular proliferation and increased growth of
extraocular muscles and retro-orbital connective and adipose
tissues due to the actions of thyroid stimulating antibodies and
cytokines released by cytotoxic T lymphocytes (killer cells). These
cytokines and thyroid stimulating antibodies activate periorbital
fibroblasts and preadipocytes, causing synthesis of excess
hydrophilic glycosaminoglycans (GAG) and retro-orbital fat
growth.
o Option A: Physical signs of hyperthyroidism include
tachycardia, systolic hypertension with increased
pulse pressure, signs of heart failure (like edema,
rales, jugular venous distension, tachypnea), atrial
fibrillation, fine tremors, hyperkinesia, hyperreflexia,
warm and moist skin, palmar erythema and
onycholysis, hair loss, diffuse palpable goiter with
thyroid bruit and altered mental status.
o Option B: Hyperthyroidism usually increases the
appetite. If the client is taking in a lot more calories,
they can gain weight even if their body is burning
more energy. Make sure to eat healthy foods, get
regular exercise, and work with a doctor on a nutrition
plan. These steps can all help combat weight gain
from an increased appetite.
o Option D: In younger patients, common presentations
include heat intolerance, sweating, fatigue, weight
loss, palpitation, hyper defecation, and tremors. Other
features include insomnia, anxiety, nervousness,
hyperkinesia, dyspnea, muscle weakness, pruritus,
polyuria, oligomenorrhea or amenorrhea in the female,
loss of libido, and neck fullness.
 34. Question
The nurse is providing dietary instructions to the mother of an 8-
year-old child diagnosed with celiac disease. Which of the
following foods, if selected by the mother, would indicate her
understanding of the dietary instructions?

o A. Ham sandwich on whole-wheat toast

o B. Spaghetti and meatballs

o C. Hamburger with ketchup

o D. Cheese omelet

Correct Answer: D. Cheese omelet

The child with celiac disease should be on a gluten-free diet.
When a child has celiac disease, gluten causes the immune
system to damage or destroy villi. Villi are the tiny, fingerlike
tubules that line the small intestine. The villi’s job is to get food
nutrients to the blood through the walls of the small intestine. If
villi are destroyed, the child may become malnourished, no
matter how much he eats. This is because they aren’t able to
absorb nutrients. Complications of the disorder include anemia,
seizures, joint pain, thinning bones, and cancer.
o Option A: Be careful of corn and rice products. These
don’t contain gluten, but they can sometimes be
contaminated with wheat gluten if they’re produced in
factories that also manufacture wheat products. Look
for such a warning on the package label.
o Option B: Avoid all products with barley, rye, triticale
(a cross between wheat and rye), farina, graham flour,
semolina, and any other kind of flour, including self-
rising and durum, not labeled gluten-free.
o Option C: Substitute potato, rice, soy, amaranth,
quinoa, buckwheat, or bean flour for wheat flour. You
can also use sorghum, chickpea or Bengal gram,
arrowroot, and corn flour, as well as tapioca starch
extract. These act as thickeners and leavening agents.
 35. Question
The nurse is caring for an 80-year-old with chronic bronchitis.
Upon the morning rounds, the nurse finds an O2 sat of 76%.
Which of the following actions should the nurse take first?
 o A. Notify the physician

o B. Recheck the O2 saturation level in 15 minutes

o C. Apply oxygen by mask

o D. Assess the pulse

Correct Answer: C. Apply oxygen by mask

Remember the ABCs (airway, breathing, circulation) when
answering this question. Administer oxygen first to increase the
O2 saturation level. Provide humidified oxygen as ordered.
Administering humidified oxygen prevents drying out the airways,
decreases convective moisture losses, and improves compliance.
o Option A: Monitor vital signs and cardiac rhythm.
Tachycardia, dysrhythmias, and changes in BP can
reflect the effect of systemic hypoxemia on cardiac
function. Auscultate breath sounds, noting areas of
decreased airflow and adventitious sounds. Breath
sounds may be faint because of decreased airflow or
areas of consolidation. Presence of wheezes may
indicate bronchospasm or retained secretions.
Scattered moist crackles may indicate interstitial fluid
or cardiac decompensation.
o Option B: The normal oxygen saturation for a child is
92%–100%. Monitor O2 saturation and titrate oxygen
to maintain Sp02 between 88% to 92%. Pulse oximetry
reading of 87% below may indicate the need for
oxygen administration while a pulse oximetry reading
of 92% or higher may require oxygen titration.
o Option D: Before assessing the pulse, oxygen should
be applied to increase the oxygen saturation. Monitor
vital signs and cardiac rhythm. Tachycardia,
dysrhythmias, and changes in BP can reflect the effect
of systemic hypoxemia on cardiac function.
 36. Question
A gravida 3 para 0 is admitted to the labor and delivery unit. The
doctor performs an amniotomy. Which observation would the
nurse be expected to make after the amniotomy?
 o A. Fetal heart tones 160bpm

o B. A moderate amount of straw-colored fluid

o C. A small amount of greenish fluid

o D. A small segment of the umbilical cord

Correct Answer: B. A moderate amount of straw-colored

fluid
An amniotomy is an artificial rupture of membranes and normal
amniotic fluid is straw-colored and odorless. Successful rupture of
membranes most commonly is determined by the immediate
return of amniotic fluid from the vagina. This fluid usually is clear
and odorless.
o Option A: Fetal heart tones of 160 indicate
tachycardia. Monitoring of the fetal heart rate as well
as uterine activity can be easily obtained via external
monitoring systems. However, in certain
circumstances, more direct evaluation of the fetal
heart rate or uterine activity is required during labor.
o Option C: Greenish fluid is indicative of meconium. In
certain circumstances, the fluid may either contain
meconium or may be blood-tinged. It is important to
note the color of the fluid at the time of rupture.
o Option D: If the nurse notes the umbilical cord, the
client is experiencing a prolapsed cord and would need
to be reported immediately. Typically, following
artificial rupture of membranes, the practitioner
should not immediately remove their hand from the
vagina because it is at this point that the highest risk
of potential cord prolapse can occur and will be noted
as the amniotic fluid continues to drain. After the
immediate flow of amniotic fluid ceases, and there is
no palpable cord in the vagina, the vaginal hand then
can be removed.
 37. Question
The client is admitted to the unit. A vaginal exam reveals that she
is 2cm dilated. Which of the following statements would the nurse
expect her to make?
 o A. "We have a name picked out for the baby."

o B. "I need to push when I have a contraction."

o C. "I can’t concentrate if anyone is touching me."

o D. "When can I get my epidural?"

Correct Answer: D. “When can I get my epidural?”

Dilation of 2 cm marks the end of the latent phase of labor.
During the latent phase, the cervix dilates slowly to
approximately 6 centimeters. The latent phase is generally
considerably longer and less predictable with regard to the rate of
cervical change than is observed in the active phase. A normal
latent phase can last up to 20 hours and 14 hours in nulliparous
and multiparous women respectively, without being considered
prolonged.
o Option A: This is a vague answer. The latent phase is
commonly defined as the 0 to 6 cm, while the active
phase commences from 6 cm to full cervical dilation.
The presenting fetal part also begins the process of
engagement into the pelvis during the first stage.
Throughout the first stage of labor, serial cervical
exams are done to determine the position of the fetus,
cervical dilation, and cervical effacement. Cervical
effacement refers to the cervical length in the anterior-
posterior plane. When the cervix is completely thinned
out and no length is left, this is referred to as 100
percent effacement.
o Option B: This indicates the end of the first stage of
labor. The first stage of labor begins when labor starts
and ends with full cervical dilation to 10 centimeters.
Labor often begins spontaneously or may be induced
medically for a variety of maternal or fetal indications.
o Option C: This indicates the transition phase. The
second stage of labor commences with complete
cervical dilation to 10 centimeters and ends with the
delivery of the neonate. This was also defined as the
pelvic division phase by Friedman. After cervical
dilation is complete, the fetus descends into the
vaginal canal with or without maternal pushing efforts.
  38. Question
The client is having fetal heart rates of 90–110 bpm during the
contractions. The first action the nurse should take is:

o A. Reposition the monitor

o B. Turn the client to her left side

o C. Ask the client to ambulate

o D. Prepare the client for delivery

Correct Answer: B. Turn the client to her left side

The normal fetal heart rate is 120–160 bpm; 100–110bpm is
bradycardia. The first action would be to turn the client to the left
side and apply oxygen. A slow heart rate, or bradycardia, may
indicate the baby is not getting enough oxygen delivery to the
brain. A fast heart rate, or tachycardia, may indicate oxygen
deprivation. There is an acceptable range of acceleration and
deceleration – or speeding up and slowing down – of fetal heart
rates during contractions and labor.
o Option A: Repositioning the monitor is not indicated
at this time. Obstetricians and nurses must carefully
review fetal monitor strips throughout labor and
delivery to ensure fetal heart tones are reassuring and
the baby is getting enough oxygen. If non-reassuring
conditions occur, appropriate and timely actions must
be taken.
o Option C: Asking the client to ambulate is not the
best action for clients experiencing bradycardia.
Generally, nursing interventions are attempted first to
restore normal oxygenation to the baby. These include
the administration of supplemental oxygen, changes in
maternal position, increasing intravenous fluids, and
the administration of medications that subdue
contractions and maximize placental blood flow.
o Option D: There is no data to indicate the need to
move the client to the delivery room at this time. If
fetal heart tones remain non-reassuring despite
nursing interventions, the fetus should be delivered by
 emergency cesarean section. Emergency cesarean
section should be performed within 5 to 30 minutes
depending on the circumstances.
 39. Question
In evaluating the effectiveness of IV Pitocin for a client with
secondary dystocia, the nurse should expect:

o A. A painless delivery

o B. Cervical effacement

o C. Infrequent contractions

o D. Progressive cervical dilation

Correct Answer: D. Progressive cervical dilation

The expected effect of Pitocin is cervical dilation. Oxytocin is
indicated and approved by the FDA for two specific time frames
in the obstetric world: antepartum and postpartum. In the
antepartum period, exogenous oxytocin is FDA-approved for
strengthening uterine contractions with the aim of successful
vaginal delivery of the fetus.
o Option A: Pitocin causes more intense contractions,
which can increase the pain. When oxytocin is
released, it stimulates uterine contractions, and these
uterine contractions, in turn, cause more oxytocin to
be released; this is what causes the increase in both
the intensity and frequency of contractions and
enables a mother to carry out vaginal delivery
completely.
o Option B: Cervical effacement is caused by pressure
on the presenting part. During the later stages of
pregnancy, the fetus’s head drops into the pelvis,
pushing it against the cervix. This process stretches
the cervix, causing it to thin and shorten.
Measurement of effacement is usually in percentages.
For example, when the cervix is 100% effaced, it
means that it is completely thinned and shortened.
o Option C: Infrequent contractions is opposite the
action of Pitocin. Exogenous oxytocin causes the same
 response in the female reproductive system as that of
endogenous oxytocin. Both types of oxytocin stimulate
uterine contractions in the myometrium by causing G-
protein coupled receptors to stimulate a rise in
intracellular calcium in uterine myofibrils.
 40. Question
A vaginal exam reveals a footling breech presentation. The nurse
should take which of the following actions at this time?

o A. Anticipate the need for a Caesarean section

o B. Apply the fetal heart monitor

o C. Place the client in Genupectoral position

o D. Perform an ultrasound exam

Correct Answer: B. Apply the fetal heart monitor

Applying a fetal heart monitor is the correct action at this time.
Fetal heart sounds are heard high in the abdomen in breech
presentation. Be certain to monitor the FHR and uterine
contractions continuously to detect fetal distress early and
provide prompt intervention.
o Option A: In a breech birth, the birth of the head is
the most dangerous part because a loop of umbilical
cord that has passed down alongside the head may be
compressed. Intracranial hemorrhage is another
danger of breech birth because of the pressure
changes that has occurred spontaneously. There is no
need to prepare for a Caesarean section because
vaginal delivery is still possible.
o Option C: It is unnecessary to place the client in
Genupectoral position (knee-chest). An infant born
from a frank breech position usually extends his or her
legs continuously during the first 2 or 3 days of life, so
be sure to point out to the parents that this is normal.
o Option D: There is no need for an ultrasound based
on the finding. An anesthesiologist and a pediatrician
should be immediately available for all vaginal breech
deliveries. A pediatrician is needed because of the
 higher prevalence of neonatal depression and the
increased risk for unrecognized fetal anomalies. An
anesthesiologist may be needed if intrapartum
complications develop and the patient requires
general anesthesia.
 41. Question
A vaginal exam reveals that the cervix is 4cm dilated, with intact
membranes and a fetal heart tone rate of 160–170 bpm. The
nurse decides to apply an external fetal monitor. The rationale for
this implementation is:

o A. The cervix is closed.

o B. The membranes are still intact.

o C. The fetal heart tones are within normal limits.

o D. The contractions are intense enough for insertion of

an internal monitor.

Correct Answer: B. The membranes are still intact.

The nurse decides to apply an external monitor because the
membranes are intact. The test is used to determine if a fetus is
at risk for intrauterine death or neonatal complications, usually
secondary to high-risk pregnancies or suspected fetal hypoxemia.
The frequency of use is based on clinical judgment, but is
common because it is non-invasive and presents a low maternal
and fetal risk; however, the test does not hold predictive value
and only indicates fetal hypoxia at time of the test.
o Option A: The cervix is dilated enough to use an
internal monitor, if necessary. Fetal heart rate is
monitored using the Doppler ultrasound transducer,
and the tocodynamometer is applied to detect uterine
contractions or fetal movement. Fetal activity may be
recorded by the patient using an event marker or
noted by the staff performing the test.
o Option C: An internal monitor can be applied if the
client is at 0-station. The Non-Stress Test (NST) is an
assessment tool used from 32 weeks of gestation to
term to evaluate fetal health through the use of
 electronic fetal monitors that continuously record the
fetal heart rate (FHR). The test is used to determine if
a fetus is at risk for intrauterine death or neonatal
complications, usually secondary to high-risk
pregnancies or suspected fetal hypoxemia.
o Option D: Contraction intensity has no bearing on the
application of the fetal monitor. The NST involves 20
minutes of monitoring the FHR while assessing the
number, amplitude, and duration of accelerations that
usually correlate with fetal movement. A normal test
result, as defined by the American College of
Obstetrics and Gynecologist, is one in which two or
more accelerations peak at 15 bpm or more above
baseline, each lasting 15 seconds or more, and all
occurring within 20 minutes of beginning the test.
 42. Question
The following are all nursing diagnoses appropriate for a gravida
1 para 0 in labor. Which one would be most appropriate for the
primigravida as she completes the early phase of labor?

o A. Impaired gas exchange related to hyperventilation

o B. Alteration in placental perfusion related to maternal

position

o C. Impaired physical mobility related to fetal-monitoring

equipment

o D. Potential fluid volume deficit related to

decreased fluid intake

Correct Answer: D. Potential fluid volume deficit related

to decreased fluid intake
Clients admitted in labor are told not to eat during labor, to avoid
nausea and vomiting. Ice chips may be allowed, but this amount
of fluid might not be sufficient to prevent fluid volume deficit.
Provide clear fluids (e.g., clear broth, tea, cranberry juice, jell-O,
popsicles) and ice chips, as permitted. Helps promote hydration
and may provide some calories for energy production.
 o Option A: Impaired gas exchange related to
hyperventilation would be indicated during the
transition phase. Assess FHR changes during a
contraction, noting decelerations and accelerations.
Detects severity of hypoxia and possible cause. The
fetus is vulnerable to potential injury during labor,
owing to situations that reduce oxygen levels, such as
cord prolapse, prolonged head compression, or
uteroplacental insufficiency.
o Option B: Instead of Impaired physical mobility, Risk
for ineffective coping would be more appropriate at
this stage of labor. Reinforce breathing and relaxation
techniques during contractions. Minimizes anxiety and
provides a distraction, which may block the perception
of pain impulses within the cerebral cortex.
o Option C: Fluid volume deficit is not correct in relation
to the stem. Monitor intake & output. Note urine
specific gravity. Encourage the client to empty the
bladder at least once every 1 1/2–2 hr. Intake and
output should be approximately equal, depending on
degree of hydration. Concentration of urine increases
as urine output decreases and may warn of
dehydration. Fetal descent may be impaired if the
bladder is distended.
 43. Question
As the client reaches 8 cm dilation, the nurse notes late
decelerations on the fetal monitor. The FHR baseline is 165–175
bpm with variability of 0–2bpm. What is the most likely
explanation of this pattern?

o A. The baby is asleep.

o B. The umbilical cord is compressed.

o C. There is a vagal response.

o D. There is uteroplacental insufficiency.

Correct Answer: D. There is uteroplacental insufficiency.

This information indicates a late deceleration. This type of
deceleration is caused by uteroplacental lack of oxygen. Late
decelerations are one of the precarious decelerations among the
three types of fetal heart rate decelerations during labor. They
are caused by decreased blood flow to the placenta and can
signify an impending fetal acidemia.
o Option A: Has no relation to the readings. The
primary etiology of a late declaration is found to be
uteroplacental insufficiency. Decreased blood flow to
the placenta causes a reduced amount of blood and
oxygen to the fetus.
o Option B: Compressed umbilical cord results in a
variable deceleration. The central pathophysiology
behind late deceleration involves uterine contraction
constricting blood vessels in the wall of the uterus
which decreases blood flow through the intervillous
space of the placenta, reducing diffusion of oxygen
into fetal capillaries causing decreased fetal PO2.
o Option C: A vagal response is indicative of an early
deceleration. When fetal PO2 decreases,
chemoreceptors initiate an autonomic response in the
fetus causing intense vasoconstriction with increased
blood pressure. The elevated blood pressure is
perceived by the baroreceptors which ultimately
stimulate the parasympathetic system to decrease the
fetal heart rate, causing late deceleration.
 44. Question
The nurse notes variable decelerations on the fetal monitor strip.
The most appropriate initial action would be to:

o A. Notify her doctor

o B. Start an IV

o C. Reposition the client

o D. Readjust the monitor

Correct Answer: C. Reposition the client

The initial action by the nurse observing a late deceleration
should turn the client to the side—preferably, the left side.
Administering oxygen is also indicated. Initial management of
recurrent variable decelerations should have a target of relieving
potential cord compression. Maternal repositioning is a
reasonable first maneuver. Variable decelerations can be seen
resulting from fetal movement if the fetus is premature.
o Option A: Notifying the physician might be necessary
but not before turning the client to her side. Recurrent
variable decelerations during labor require evaluation.
Initial evaluation includes characterization of the
decelerations themselves, including their frequency,
depth, and duration. It is also important to assess the
uterine contraction pattern and the other fetal heart
tracing characteristics.
o Option B: Starting an IV is not necessary at this time.
In specific clinical scenarios that may result in
concerning variable decelerations, management
should be directed by the etiology of those
decelerations. If a patient is having uterine
tachysystole, reducing the number of contractions by
decreasing oxytocin or administration of a beta-
agonist may be appropriate.
o Option D: Readjusting the fetal monitor is
inappropriate since there is no data to indicate that
the monitor has been applied ly. Electronic fetal
monitoring is utilized in approximately 85% of live
births in the United States, making it the most
common procedure in obstetrics. This frequency
represents an increase since 1980 when its use was
about only 45% of women in labor. Intermittent,
variable decelerations, defined as decelerations
occurring with less than half of contractions, are the
most common fetal heart rate abnormality that takes
place in labor.
 45. Question
Which of the following is a characteristic of a reassuring fetal
heart rate pattern?

o A. A fetal heart rate of 170–180 bpm

 o B. A baseline variability of 25–35 bpm

o C. Ominous periodic changes

o D. Acceleration of FHR with fetal movements

Correct Answer: D. Acceleration of FHR with fetal

movements
Accelerations with movement are normal. Accelerations are
transient increases in the FHR. They are usually associated with
fetal movement, vaginal examinations, uterine contractions,
umbilical vein compression, fetal scalp stimulation or even
external acoustic stimulation. The presence of accelerations is
considered a reassuring sign of fetal well-being.
o Option A: The average fetal heart rate is between
110 and 160 beats per minute. The normal FHR range
is between 120 and 160 beats per minute (bpm). The
baseline rate is interpreted as changed if the
alteration persists for more than 15 minutes.
Prematurity, maternal anxiety and maternal fever may
increase the baseline rate, while fetal maturity
decreases the baseline rate.
o Option B: Baseline variability is defined as
fluctuations in the fetal heart rate of more than 2
cycles per minute. Marked variability is at >25 BPM.
The FHR is under constant variation from the baseline.
This variability reflects a healthy nervous system,
chemoreceptors, baroreceptors and cardiac
responsiveness. Prematurity decreases variability;
therefore, there is little rate fluctuation before 28
weeks. Variability should be normal after 32 weeks.
o Option C: If there are ominous periodic changes, it
would indicate an abnormality in the fetal heart rate
pattern. Fetal hypoxia, congenital heart anomalies and
fetal tachycardia also cause decreased variability.
Beat-to-beat or short-term variability is the oscillation
of the FHR around the baseline in amplitude of 5 to 10
bpm. Long-term variability is a somewhat slower
oscillation in heart rate and has a frequency of three
to 10 cycles per minute and an amplitude of 10 to 25
bpm.
  46. Question
The rationale for inserting a French catheter every hour for the
client with epidural anesthesia is:

o A. The bladder fills more rapidly because of the

medication used for the epidural.

o B. Her level of consciousness is such that she is in a

trancelike state.

o C. The sensation of the bladder filling is

diminished or lost.

o D. She is embarrassed to ask for the bedpan that

frequently.

Correct Answer: C. The sensation of the bladder filling is

diminished or lost.
Epidural anesthesia decreases the urge to void and sensation of a
full bladder. A full bladder will decrease the progression of labor.
Under the influence of epidural analgesia, patients may not feel
the urge to urinate, which can result in urinary retention and
bladder overdistension. Overfilling of the bladder can stretch and
damage the detrusor muscle. For example, the use of lumbar
epidural analgesia for labor and delivery has frequently been
implicated as a causative factor for postpartum urinary retention.
This is supported by the fact that these patients demonstrate a
difficulty voiding.
o Option A: The medication used for the epidural does
not have a diuretic effect. Spinal and epidural opioid
administration influence the function of the lower
urinary tract by direct spinal action on the sacral
nociceptive neurons and autonomic fibres. Long-acting
local anesthetics administered intrathecally rapidly
block the micturition reflex. Detrusor contraction is
restored approximately 7-8 hours after spinal injection
of bupivacaine. For this reason, bladder
catheterization is a common practice in patients with
spinal or epidural anesthesia.
 o Option B: An epidural does not create a trancelike
state for the client. Acute urinary retention is one of
the most common complications after surgery and
anesthesia. It can occur in patients of both sexes and
all age groups and after all types of surgical
procedures. It is linked to several factors including
increased intravenous fluids, postoperative pain, and
type of anesthesia. Micturition depends on coordinated
actions between the detrusor muscle and the external
urethral sphincter.
o Option D: Embarrassed or not, the client would still
need to have a French catheter inserted to manage
her voiding. The risk of infection with a single
catheterization is 1-2% and can rise by 3 to 7 % for
every additional day with an indwelling catheter.
Traumatic or prolonged catheterization may lead to
urethritis and to urethral strictures. There has yet been
no consensus for appropriate catheterization strategy
during regional anesthesia.
 47. Question
A client in the family planning clinic asks the nurse about the
most likely time for her to conceive. The nurse explains that
conception is most likely to occur when:

o A. Estrogen levels are low.

o B. Luteinizing hormone is high.

o C. The endometrial lining is thin.

o D. The progesterone level is low.

Correct Answer: B. Luteinizing hormone is high.

Luteinizing hormone released by the pituitary is responsible for
ovulation. At about day 14, the continued increase in estrogen
stimulates the release of luteinizing hormone from the anterior
pituitary. The LH surge is responsible for ovulation, or the release
of the dominant follicle in preparation for conception, which
occurs within the next 10–12 hours after the LH levels peak.
 o Option A: Estrogen levels are high at the beginning of
ovulation. At about day 14 in the menstrual cycle, a
sudden surge in luteinizing hormone causes the ovary
to release its egg. The egg begins its five-day travel
through a narrow, hollow structure called the fallopian
tube to the uterus. As the egg is traveling through the
fallopian tube, the level of progesterone, another
hormone, rises, which helps prepare the uterine lining
for pregnancy.
o Option C: The endometrial lining is thick, not thin.
The blastocyst then attaches itself to the lining of the
uterus (the endometrium). This attachment process is
called implantation. Release of the hormones estrogen
and progesterone causes the endometrium to thicken,
which provides the nutrients the blastocyst needs to
grow and eventually develop into a baby.
o Option D: The progesterone levels are high, not low.
As cells continue to divide — some developing into the
baby, others forming the nourishment and oxygen
supply structure called the placenta — hormones are
released that signal the body that a baby is growing
inside the uterus. These hormones also signal the
uterus to maintain its lining rather than shedding it.
 48. Question
A client tells the nurse that she plans to use the rhythm method
of birth control. The nurse is aware that the success of the
rhythm method depends on the:

o A. Age of the client

o B. Frequency of intercourse

o C. Regularity of the menses

o D. Range of the client’s temperature

Correct Answer: C. Regularity of the menses

The success of the rhythm method of birth control is dependent
on the client’s menses being regular. Women are only fertile (an
egg is present) for a few days each month. Women using the
rhythm method monitor their body and analyze their past
menstrual cycles to try to determine when their fertile days are.
They can then either choose to not have sex during those days,
or can use a “barrier” form of birth control, such as condoms or
spermicide.
o Option A: The rhythm method is not dependent on
the age of the client. The rhythm method works best
for women whose cycles are consistent because it is
easier to predict when she ovulates (releases an egg
from her ovaries).
o Option B: Rhythm method is not successful when
based entirely on the frequency of intercourse. Most
women will have a period 14 to 16 days after
ovulation, regardless of the length of their overall
cycle. Counting backward from the day their period
begins can be a good way to know when they
ovulated.
o Option D: Basal temperature method relies on the
client’s temperature during ovulation period. The basal
body temperature method is a method of natural
family planning that requires only the purchase of a
very accurate thermometer. The method, which calls
for tracking the woman’s body temperature on a daily
basis, helps to determine which days of the month she
is fertile.
 49. Question
A client with diabetes asks the nurse for advice regarding
methods of birth control. Which method of birth control
is most suitable for the client with diabetes?

o A. Intrauterine device

o B. Oral contraceptives

o C. Diaphragm

o D. Contraceptive sponge

Correct Answer: C. Diaphragm

The best method of birth control for the client with diabetes is the
diaphragm. The diaphragm is a birth control (contraceptive)
device that prevents sperm from entering the uterus. The
diaphragm is a small, reusable rubber or silicone cup with a
flexible rim that covers the cervix. Before sex, the diaphragm is
inserted deep into the vagina so that part of the rim fits snugly
behind the pubic bone. The diaphragm is effective at preventing
pregnancy only when used with spermicide.
o Option A: Permanent intrauterine device can cause a
continuing inflammatory response in diabetics that
should be avoided. Fibrinolytic activity is due in part to
prostaglandin synthetase activation which was
thought to be required for the efficacy of the copper
IUD. Its absence was thought to be a possible reason
why copper IUDs were less effective in diabetics (and
in nondiabetics who became pregnant).
o Option B: Oral contraceptives tend to elevate blood
glucose levels. Choice of contraception should be
made on the preference of the woman and individual
risk factors identified such as the presence of vascular,
nephropathy, neuropathy, or retinal disease. Choosing
a safe and reliable method of contraception for a
woman with DM needs careful consideration and
practitioners need to make reference to the WHO
Medical Eligibility Criteria for Contraceptive Use.
o Option C: Contraceptive sponges are not good at
preventing pregnancy. The contraceptive sponge is a
type of birth control (contraceptive) that prevents
sperm from entering the uterus. It is soft and disk-
shaped, and made of polyurethane foam. The
contraceptive sponge contains spermicide, which
blocks or kills sperm.
 50. Question
The doctor suspects that the client has an ectopic pregnancy.
Which symptom is consistent with a diagnosis of ectopic
pregnancy?

o A. Painless vaginal bleeding

o B. Abdominal cramping
 o C. Throbbing pain in the upper quadrant

o D. Sudden, stabbing pain in the lower quadrant

Correct Answer: D. Sudden, stabbing pain in the lower

quadrant
The signs of an ectopic pregnancy are vague until the fallopian
tube ruptures. The client will complain of sudden, stabbing pain in
the lower quadrant that radiates down the leg or up into the
chest. Patient’s presenting with vaginal bleeding would likely
benefit from a pelvic exam to assess for infections as well as
assess the cervical os. Bimanual pelvic exams additionally allow
for palpation of bilateral adnexa to assess for any abnormal
masses/structures or to elicit adnexal tenderness.
o Option A: Painless vaginal bleeding is a sign of
placenta previa. Painless vaginal bleeding during the
second or third trimester of pregnancy is the usual
presentation. The bleeding may be provoked from
intercourse, vaginal examinations, labor, and at times
there may be no identifiable cause.
o Option B: Abdominal cramping is a sign of labor.
Women will often self-present to obstetrical triage with
concern for the onset of labor. Common chief
complaints include painful contractions, vaginal
bleeding/bloody show, and leakage of fluid from the
vagina. It is up to the clinician to determine if the
patient is in labor, defined as regular, clinically
significant contractions with an objective change in
cervical dilation and/or effacement.
o Option C: Throbbing pain in the upper quadrant is not
a sign of an ectopic pregnancy. After obtaining a
thorough history, an attentive physical exam is the
next step. Evaluation of vital signs to assess for
tachycardia and hypotension is pivotal in determining
the patient’s hemodynamic stability. When examining
the abdomen and suprapubic regions, attention should
focus on the location of tenderness as well as any
exacerbating factors.
 51. Question
The nurse is teaching a pregnant client about nutritional needs
during pregnancy. Which menu selection will best meet the
nutritional needs of the pregnant client?

o A. Hamburger patty, green beans, French fries, and iced

tea

o B. Roast beef sandwich, potato chips, baked beans, and

cola

o C. Baked chicken, fruit cup, potato salad,

coleslaw, yogurt, and iced tea

o D. Fish sandwich, gelatin with fruit, and coffee

Correct Answer: C. Baked chicken, fruit cup, potato salad,

coleslaw, yogurt, and iced tea
All of the choices are tasty, but the pregnant client needs a diet
that is balanced and has increased amounts of calcium. This food
item contains meat, fruit, potato salad, and yogurt, which has
about 360 mg of calcium. To maintain a healthy pregnancy,
approximately 300 extra calories are needed each day. These
calories should come from a balanced diet of protein, fruits,
vegetables and whole grains. Sweets and fats should be kept to a
minimum.
o Option A: These food items are lacking in fruits and
milk. Fruits like cantaloupe, honeydew, mangoes,
prunes, bananas, apricots, oranges, and red or pink
grapefruit (for potassium) are beneficial for the
pregnant woman. Fat-free or low-fat yogurt, skim or
1% milk, soymilk (for calcium, potassium, vitamins A
and D) are the appropriate milk during pregnancy.
o Option B: The potato chips, which contain a large
amount of sodium. An optimal pregnancy eating plan
should mainly consist of whole foods, with plenty of
nutrients to fulfill the woman’s and baby’s needs.
Processed junk food is generally low in nutrients and
high in calories, sugar, and added fats.
o Option D: These food items are lacking vegetables
and milk products. Vegetables like carrots, sweet
potatoes, pumpkin, spinach, cooked greens, tomatoes
 and red sweet peppers (for vitamin A and potassium)
are essential for fetal growth and development.
 52. Question
The client with hyperemesis gravidarum is at risk for developing:

o A. Respiratory alkalosis without dehydration

o B. Metabolic acidosis with dehydration

o C. Respiratory acidosis without dehydration

o D. Metabolic alkalosis with dehydration

Correct Answer: B. Metabolic acidosis with dehydration

The client with hyperemesis has persistent nausea and vomiting.
With vomiting comes dehydration. When the client is dehydrated,
she will have metabolic acidosis. In severe cases of hyperemesis,
complications include vitamin deficiency, dehydration, and
malnutrition, if not treated appropriately. Wernicke’s
encephalopathy, caused by vitamin-B1 deficiency, can lead to
death and permanent disability if it goes untreated.
o Option A: Electrolyte abnormalities such as
hypokalemia can also cause significant morbidity and
mortality. Additionally, patients with hyperemesis may
have higher rates of depression and anxiety during
pregnancy. Electrolytes should be replaced as needed.
Severe refractory cases of hyperemesis gravidarum
may respond to intravenous or intramuscular
chlorpromazine 25 to 50 mg or methylprednisolone 16
mg every 8 hours, orally or intravenously.
o Option C: A vomiting pregnant client will ultimately
develop dehydration. Additionally, there have been
case reports of injuries secondary to forceful and
frequent vomiting, including esophageal rupture and
pneumothorax. Initial treatment should begin with
non-pharmacologic interventions such as switching the
patient’s prenatal vitamins to folic acid
supplementation only, using ginger supplementation
(250 mg orally 4 times daily) as needed, and by
applying acupressure wristbands.
 o Option D: The client will not be in alkalosis with
persistent vomiting. There is no single accepted
definition for hyperemesis gravidarum. However, it
generally refers to extreme cases of nausea and
vomiting during pregnancy. It is a clinical diagnosis.
The criteria for diagnosis include vomiting that causes
significant dehydration (as evidenced by ketonuria or
electrolyte abnormalities) and weight loss (the most
commonly cited marker for this is the loss of at least
five percent of the patient’s pre-pregnancy weight) in
the setting of pregnancy without any other underlying
pathological cause for vomiting.
 53. Question
A client tells the doctor that she is about 20 weeks pregnant.
The most definitive sign of pregnancy is:

o A. Elevated human chorionic gonadotropin

o B. The presence of fetal heart tones

o C. Uterine enlargement

o D. Breast enlargement and tenderness

Correct Answer: B. The presence of fetal heart tones

The most definitive diagnosis of pregnancy is the presence of
fetal heart tones. The signs in answers A, C, and D are subjective
and might be related to other medical conditions. Fetal heart
tones can be appreciated between six and eight weeks of
gestation. Between eight and ten weeks of gestation, important
information about the pregnancy can be obtained by the
provider, including placental location, fetal position and anatomy,
amniotic fluid volume, and maternal anatomy, including
dimensions of the cervix and uterus.
o Option A: It is important to note that an elevated
beta-HCG level is not definitive of a normal or viable
pregnancy. Conditions that result in elevated beta-HCG
levels must be considered, including ectopic and
heterotopic pregnancy; miscarriage; and the presence
 of abnormal germ cell, placental, and embryonal
tissues.
o Option C: Uterine enlargement may be related to a
hydatidiform mole. The list of early pregnancy
complications is vast, including ectopic pregnancy,
heterotopic pregnancy, molar pregnancy, and
miscarriage. The provider needs to visualize an
intrauterine pregnancy for reasons discussed in prior
sections.
o Option D: Breast enlargement and tenderness is
often present before menses or with the use of oral
contraceptives. Early in pregnancy hormonal changes
might make your breasts sensitive and sore. The
discomfort will likely decrease after a few weeks as
your body adjusts to hormonal changes.
 54. Question
The nurse is caring for a neonate whose mother is diabetic. The
nurse will expect the neonate to be:

o A. Hypoglycemic, small for gestational age

o B. Hyperglycemic, large for gestational age

o C. Hypoglycemic, large for gestational age

o D. Hyperglycemic, small for gestational age

Correct Answer: C. Hypoglycemic, large for gestational

age
The infant of a diabetic mother is usually large for gestational
age. After birth, glucose levels fall rapidly due to the absence of
glucose from the mother. Hypoglycemia is caused by
hyperinsulinemia due to hyperplasia of fetal pancreatic beta cells
consequent to maternal-fetal hyperglycemia. Because the
continuous supply of glucose is stopped after birth, the neonate
develops hypoglycemia because of insufficient substrate.
o Option A: The infant will not be small for gestational
age. Fetal macrosomia (>90th percentile for
gestational age or >4000 g in the term infant) occurs
in 15-45% of diabetic pregnancies. It is most
 commonly observed as a consequence of maternal
hyperglycemia. When macrosomia is present, the
infant appears puffy, fat, ruddy, and often hypotonic.
o Option B: The infant will not be hyperglycemic.
Stimulation of fetal insulin release by maternal
hyperglycemia during labor significantly increases the
risk of early hypoglycemia in these infants. Perinatal
stress may have an additive effect on hypoglycemia
due to catecholamine release and glycogen depletion.
o Option D: The infant will be large, not small, and will
be hypoglycemic, not hyperglycemic. The overall risk
of hypoglycemia is anywhere from 25-40%, with LGA
and preterm infants at the highest risk. Fetal growth is
assessed by plotting birth weight against gestational
age on standard growth curves. Infants whose weight
exceeds the 90th percentile for gestational age are
classified as large for gestational age (LGA).
 55. Question
Which of the following instructions should be included in the
nurse’s teaching regarding oral contraceptives?

o A. Weight gain should be reported to the physician.

o B. An alternate method of birth control is needed

when taking antibiotics.

o C. If the client misses one or more pills, two pills should

be taken per day for 1 week.

o D. Changes in the menstrual flow should be reported to

the physician.

Correct Answer: B. An alternate method of birth control is

needed when taking antibiotics.
When the client is taking oral contraceptives and begins
antibiotics, another method of birth control should be used.
Antibiotics decrease the effectiveness of oral contraceptives.
Antibiotics are suspected to diminish oral contraceptive efficacy
by two main mechanisms: induction of the cytochrome P450
group of hepatic microsomal enzymes and interference with
enterohepatic cycling of ethinylestradiol.
o Option A: Approximately 5–10 pounds of weight gain
is not unusual. Women who stop taking the pill often
do so because they think it has been causing them to
gain weight. Clinical studies in this area are
contradictory: Some women said that they gained
weight, while others reported losing weight. This is
why both weight gain and weight loss are listed as
possible side effects on the product information of
hormonal contraceptives.
o Option C: If the client misses a birth control pill, she
should be instructed to take the pill as soon as she
remembers the pill. If she misses two, she should take
two; if she misses more than two, she should take the
missed pills but use another method of birth control
for the remainder of the cycle.
o Option D: Changes in menstrual flow are expected in
clients using oral contraceptives. Often these clients
have lighter menses. All hormonal contraceptives are
associated with changes in menstrual bleeding
patterns. When beginning a new hormonal
contraception method, some people may experience
irregular bleeding or spotting. Others may notice
changes in the length or heaviness of bleeding, and
some may stop bleeding entirely.
 56. Question
The nurse is discussing breastfeeding with a postpartum client.
Breastfeeding is contraindicated in the postpartum client with:

o A. Diabetes

o B. Positive HIV

o C. Hypertension

o D. Thyroid disease

Correct Answer: B. Positive HIV

Clients with HIV should not breastfeed because the infection can
be transmitted to the baby through breast milk. The best way to
prevent transmission of HIV to an infant through breast milk is to
not breastfeed. In the United States, where mothers have access
to clean water and affordable replacement feeding (infant
formula), the CDC and the American Academy of Pediatrics
recommend that HIV-infected mothers completely avoid
breastfeeding their infants, regardless of ART and maternal viral
load.
o Option A: Among women who had gestational
diabetes, breastfeeding was associated with a lower
rate of type 2 diabetes for up to 2 years after
childbirth. The results suggest that breastfeeding after
gestational diabetes may have lasting effects that
reduce a woman’s chance of developing type 2
diabetes.
o Option C: More children breastfed and longer
duration of breastfeeding were associated with a lower
risk of hypertension in postmenopausal women, and
the degree of obesity and insulin resistance
moderated the breastfeeding-hypertension
association.
o Option D: The client with thyroid disease can be
allowed to breastfeed. Some breastfeeding mothers
with hypothyroidism struggle to make a full milk
supply. Thyroid hormones play a role in normal breast
development and helping breasts to make milk. When
not enough thyroid hormones are made, a mother’s
milk supply may be affected.
 57. Question
A client is admitted to the labor and delivery unit complaining of
vaginal bleeding with very little discomfort. The
nurse’s first action should be to:

o A. Assess the fetal heart tones

o B. Check for cervical dilation

o C. Check for firmness of the uterus

 o D. Obtain a detailed history

Correct Answer: A. Assess the fetal heart tones

The symptoms of painless vaginal bleeding are consistent with
placenta previa. Assess fetal heart sounds so the mother would
be aware of the health of her baby. Assess any bleeding or
spotting that might occur to give adequate measures. Most cases
are diagnosed early on in pregnancy via sonography and others
may present to the emergency room with painless vaginal
bleeding in the second or third trimester of pregnancy.
o Option B: Cervical check for dilation is
contraindicated because this can increase the
bleeding. A patient presenting with vaginal bleeding in
the second or third trimester should receive a
transabdominal sonogram before a digital
examination. If there is a concern for placenta previa,
then a transvaginal sonogram should be performed to
confirm the location of the placenta.
o Option C: Checking for firmness of the uterus can be
done, but the first action should be to check the fetal
heart tones. Painless vaginal bleeding during the
second or third trimester of pregnancy is the usual
presentation. The bleeding may be provoked from
intercourse, vaginal examinations, labor, and at times
there may be no identifiable cause. On speculum
examination, there may be minimal bleeding to active
bleeding.
o Option D: A detailed history can be done later. The
relationship between advanced maternal age and
placenta previa may be confounded by higher parity
and a higher probability of previous uterine procedures
or fertility treatment. However, it may also represent
an altered hormonal or implantation environment.
 58. Question
A client telephones the emergency room stating that she thinks
that she is in labor. The nurse should tell the client that labor has
probably begun when:

o A. Her contractions are 2 minutes apart.

 o B. She has back pain and a bloody discharge.

o C. She experiences abdominal pain and frequent

urination.

o D. Her contractions are 5 minutes apart.

Correct Answer: D. Her contractions are 5 minutes apart.

The client should be advised to come to the labor and delivery
unit when the contractions are every 5 minutes and consistent.
She should also be told to report to the hospital if she
experiences rupture of membranes or extreme bleeding. True
labor consists of contractions at regular intervals. As labor
progresses, these contractions become stronger, and the time
between each contraction decreases.
o Option A: She should not wait until the contractions
are every 2 minutes. The first stage of labor is divided
into two phases, which are defined by the degree of
cervical dilation. The latent phase is during the dilation
from 0 to 6 cm, while the active phase starts from 6
cm to full cervical dilation of 10 cm.
o Option B: The woman should not wait until she has a
bloody discharge. It is essential to call the healthcare
provider at any time if there is bright red vaginal
bleeding; continuous leaking of fluid or wetness, or if
your water breaks (can be felt as a “gushing” of fluid);
strong contractions every five minutes for one hour;
and contractions that the woman is unable to “walk
through”.
o Option C: Has a vague answer and can be related to
a urinary tract infection. The way a contraction feels is
different for each woman and might feel different from
one pregnancy to the next. Labor contractions cause
discomfort or a dull ache in your back and lower
abdomen, along with pressure in the pelvis. Some
women might also feel pain in their sides and thighs.
Some women describe contractions as strong
menstrual cramps, while others describe them as
strong waves that feel like diarrhea cramps.
 59. Question
The nurse is teaching a group of prenatal clients about the effects
of cigarette smoke on fetal development. Which characteristic is
associated with babies born to mothers who smoked during
pregnancy?

o A. Low birth weight

o B. Large for gestational age

o C. Preterm birth, but appropriate size for gestation

o D. Growth retardation in weight and length

Correct Answer: A. Low birth weight

Infants of mothers who smoke are often low in birth weight.
Smoking during pregnancy increases the risk of health problems
for developing babies, including preterm birth, low birth weight,
and birth defects of the mouth and lip. Smoking during and after
pregnancy also increases the risk of sudden infant death
syndrome (SIDS).
o Option B: Infants who are large for gestational age
are associated with diabetic mothers. The reason for
excessive growth of the fetus varies but primarily
results from an abundance of nutrients combined with
hormones in the fetus that stimulate growth. In
pregnant women who have diabetes, a large amount
of sugar (glucose) crosses the placenta (the organ that
provides nourishment to the fetus), resulting in high
levels of glucose in the fetus’s blood. The high levels
of glucose trigger the release of increased amounts of
the hormone insulin from the fetus’s pancreas. The
increased amount of insulin results in accelerated
growth of the fetus, including almost all organs except
the brain, which grows normally.
o Option C: Preterm births are associated with smoking,
but not with appropriate size for gestation. Mothers
who smoke are more likely to deliver their babies
early. Preterm delivery is a leading cause of death,
disability, and disease among newborns. One in every
five babies born to mothers who smoke during
pregnancy has low birth weight.
 o Option D: Growth retardation is associated with
smoking, but this does not affect the infant length.
Both babies whose mothers smoke while pregnant and
babies who are exposed to secondhand smoke after
birth are more likely to die from sudden infant death
syndrome (SIDS) than babies who are not exposed to
cigarette smoke. Babies whose mothers smoke are
about three times more likely to die from SIDS.
 60. Question
The physician has ordered an injection of RhoGam for the
postpartum client whose blood type is A negative but whose baby
is O positive. To provide postpartum prophylaxis, RhoGam should
be administered:

o A. Within 72 hours of delivery

o B. Within 1 week of delivery

o C. Within 2 weeks of delivery

o D. Within 1 month of delivery

Correct Answer: A. Within 72 hours of delivery

To provide protection against antibody production, RhoGam
should be given within 72 hours. One dose of RhoGAM is usually
given around week 28 of pregnancy and lasts about 12 weeks. If
the fetus is Rh-positive, the mother will also be given RhoGAM
within 72 hours of birth. The baby’s blood type can be
determined easily after birth by cord blood samples.???
o Option B: RhoGAM may also be given after an
amniocentesis, miscarriage, abortion, or postpartum
sterilization (tubal ligation). This is because there is a
small chance of blood contamination and potential
sensitization even after these procedures or
occurrences.
o Option C: Because a small number of unsensitized
women may have problems with the end of
pregnancy, many practitioners recommend that she
be given a RhoGAM injection at 28 weeks gestation to
 prevent the few cases of sensitization that occur at the
end of pregnancy.
o Option D: These durations are too late to provide
antibody protection. RhoGam can also be given during
pregnancy. Hemolytic disease can be prevented in
women who are not already sensitized. Rh
immunoglobulin (RhoGAM) is a prescription medicine
given by intramuscular injection that stops an Rh-
negative mother from making antibodies that attack
Rh-positive red cells.
 61. Question
After the physician performs an amniotomy, the
nurse’s first action should be to assess the:

o A. Degree of cervical dilation

o B. Fetal heart tones

o C. Client’s vital signs

o D. Client’s level of discomfort

Correct Answer: B. Fetal heart tones

When the membranes rupture, there is often a transient drop in
the fetal heart tones. The heart tones should return to baseline
quickly. Any alteration in fetal heart tones, such as bradycardia or
tachycardia, should be reported. The nurse plays a vital role
during the procedure in monitoring the mother as well as the
fetus, she also notes the color of the draining amniotic fluid and
documents the findings in the medical chart.
o Option A: Amniotomy is easily performed with the
use of specially designed hooks intended to grab and
tear the amniotic membrane. The two most commonly
used devices are (1) an approximately 10-inch rod
with a hook on the end of the rod or (2) a finger cot
with a hook on the end of the cot. With either device,
the practitioner assesses cervical dilation through the
performance of a sterile digital exam.
o Option C: After the procedure, she assesses the
maternal temperature every two hours and watches
 out for any signs of infection. The nurse also monitors
the fetal heart rate via continuous electronic fetal
monitoring and communicates the findings to the
provider.
o Option D: After the fetal heart tones are assessed,
the nurse should evaluate the cervical dilation, vital
signs, and level of discomfort. The nurse needs to
frequently change underpads. One of the most crucial
roles of the nurse is to educate the woman about the
amniotomy procedure and address the patient’s
concerns at all times.
 62. Question
A client is admitted to the labor and delivery unit. The nurse
performs a vaginal exam and determines that the client’s cervix
is 5 cm dilated with 75% effacement. Based on the nurse’s
assessment the client is in which phase of labor?

o A. Active

o B. Latent

o C. Transition

o D. Early

Correct Answer: A. Active

The active phase of labor occurs when the client is dilated 4–7cm.
Active labor with more rapid cervical dilation generally starts
around 6 centimeters of dilation. During the active phase, the
cervix typically dilates at a rate of 1.2 to 1.5 centimeters per
hour. Multiparas, or women with a history of prior vaginal
delivery, tend to demonstrate more rapid cervical dilation. The
absence of cervical change for greater than 4 hours in the
presence of adequate contractions or six hours with inadequate
contractions is considered the arrest of labor and may warrant
clinical intervention.
o Option B: The latent phase is commonly defined as
the 0 to 6 cm, while the active phase commences from
6 cm to full cervical dilation. The presenting fetal part
also begins the process of engagement into the pelvis
 during the first stage. Throughout the first stage of
labor, serial cervical exams are done to determine the
position of the fetus, cervical dilation, and cervical
effacement.
o Option C: The transition phase of labor is 8–10cm in
dilation. The second stage of labor commences with
complete cervical dilation to 10 centimeters and ends
with the delivery of the neonate. This was also defined
as the pelvic division phase by Friedman. After cervical
dilation is complete, the fetus descends into the
vaginal canal with or without maternal pushing efforts.
o Option D: The latent or early phase of labor is from
1cm to 3cm in dilation. During the latent phase, the
cervix dilates slowly to approximately 6 centimeters.
The latent phase is generally considerably longer and
less predictable with regard to the rate of cervical
change than is observed in the active phase. A normal
latent phase can last up to 20 hours and 14 hours in
nulliparous and multiparous women respectively,
without being considered prolonged.
 63. Question
A newborn with narcotic abstinence syndrome is admitted to the
nursery. Nursing care of the newborn should include:

o A. Teaching the mother to provide tactile stimulation

o B. Wrapping the newborn snugly in a blanket

o C. Placing the newborn in the infant seat

o D. Initiating an early infant-stimulation program

Correct Answer: B. Wrapping the newborn snugly in a

blanket
The infant of an addicted mother will undergo withdrawal. Snugly
wrapping the infant in a blanket will help prevent the muscle
irritability that these babies often experience. Non-
pharmacological care, like rooming-in and control of
environmental factors, is the first clinical management strategy
and should continue even after discharge from the hospital.
Breastfeeding should be strongly encouraged unless there is
maternal polysubstance abuse or maternal medical
contraindication.
o Option A: Treatment should always begin with non-
pharmacological care while maintaining the mother-
infant dyad and should continue even after discharge
from the hospital. The goal of non-pharmacological
treatment is to assist the self-organization of the
neonate and support the neuronal-maturation. AAP
has also recommended it as first-line in the
management of NAS. These may include changes to
the physical environment like darkening the room and
quieting the surroundings, to decrease visual and
auditory stimuli.
o Option C: Placing the infant in an infant seat is
because this will also cause movement that can
increase muscle irritability. It is essential to understand
that these infants have neurobehavioral dysfunction
with disorganized behavior rather than adaptation
problems. Because of this, individualizing the non-
pharmacological care specific to the infant may be
beneficial. Health care professionals should involve the
mother and help her identify these interventions that
alleviate the dysfunctional behaviors specific to her
baby.
o Option D: Teaching the mother to provide for early
infant stimulation is because he is irritable and needs
quiet and little stimulation at this time. Techniques
such as gentle vertical rocking, side-lying C-position,
containment with hands held, swaddling, and swaying
can be soothing and may help reduce irritability and
hypertonicity. Avoiding unnecessary tactile stimuli by
clustering care and providing skin to skin is effective.
 64. Question
A client elects to have epidural anesthesia to relieve the
discomfort of labor. Following the initiation of epidural anesthesia,
the nurse should give priority to:

o A. Checking for cervical dilation

 o B. Placing the client in a supine position

o C. Checking the client’s blood pressure

o D. Obtaining a fetal heart rate

Correct Answer: C. Checking the client’s blood pressure

Following epidural anesthesia, the client should be checked for
hypotension and signs of shock every 5 minutes for 15 minutes.
Monitoring the patient’s hemodynamic status during and after the
procedure is very important. The minimum monitors required are
pulse oximeter for pulse and oxygen saturation as well as blood
pressure cuff and continuous EKG to assess cardiovascular status.
o Option A: The client can be checked for cervical
dilation later after she is stable. A certified nurse
presence is very important during and after the
procedure to monitor the patient and baby (labor
epidural analgesia) and to detect early signs of
complications.
o Option B: The client should not be positioned supine
because the anesthesia can move above the
respiratory center and the client can stop breathing.
The patient’s position plays a pivotal role in the
procedure’s success. Epidural placement can be
performed more commonly in a lateral decubitus and
sitting position or less frequently in the prone position.
In the lateral decubitus position, the patient is
completely resting on their side on the bed surface,
and the spine is parallel to that surface as well. Thighs
and neck are flexed forward, imitating fetal position.
o Option D: Fetal heart tones should be assessed after
the blood pressure is checked. The physical exam
focused on the spine is important to notice infection of
the area and anatomical abnormalities or variations
that can potentially affect the procedure. All the
monitors must be placed and working, intravenous
access placed, time out should take place before the
procedure, and asepsis and antisepsis must be
maintained. Risks must be discussed, and informed
consent obtained.
  65. Question
The nurse is aware that the best way to prevent postoperative
wound infection in the surgical client is to:

o A. Administer a prescribed antibiotic

o B. Wash her hands for 2 minutes before care

o C. Wear a mask when providing care

o D. Ask the client to cover her mouth when she coughs

Correct Answer: B. Wash her hands for 2 minutes before

care
The best way to prevent postoperative wound infection is hand
washing. Up to 60% of SSI can be prevented. Prevention of
postoperative wound infection is done by good general hygiene,
operative sterility and effective barriers against transmission of
infections, before, during and after surgery.
o Option A: Use of prescribed antibiotics will treat
infection, not prevent infections. The prophylaxis
should only cover the current operating time and start
at the beginning of anaesthesia (1A). The prophylaxis
should reach high enough tissue doses before incision
(1A). Short half-life preparations (e.g. cefalotin) must
be followed up with a new dose if prolonged operating
time.
o Option C: Perform good hand hygiene throughout
your stay. If bedridden, ask for wipes for hand
disinfection. Ask visitors to carry out hand hygiene on
arrival and when they leave the hospital. Ask health
professionals to carry out hand hygiene if this fails—
before and after your examination.
o Option D: Asking the client to cover her mouth are
good practices but will not prevent wound infections.
Ensure the eradication of infections, urinary tract
infections, skin infections, and other local infections
prior to admission. Check the dental status, especially
before larger elective interventions with implants and
 the like. Postpone surgery, if possible, until the
infection is cleared.
 66. Question
The elderly client is admitted to the emergency room. Which
symptom is the client with a fractured hip most likely to exhibit?

o A. Pain

o B. Misalignment

o C. Cool extremity

o D. Absence of pedal pulses

Correct Answer: B. Misalignment

The client with a hip fracture will most likely have a
misalignment. Most hip fractures can be diagnosed, or at least
suspected, from history alone. Classically a fall leads to a painful
hip with an associated inability to walk. Clinicians should explore
potentially sinister causes of the fall, such as syncope, stroke, or
myocardial infarction.
o Option A: Pain is a prominent feature in all fractures.
The physical examination will demonstrate pain,
immobility, and potentially a deformed limb. The
degree of deformity seen is dependent on both the
anatomical configuration of the fracture and the
degree of displacement. The classically described
presentation is a shortened and externally rotated
limb due to the unopposed pull of the iliopsoas muscle
that attaches to the lesser trochanter.
o Option C: Coolness of the extremities is indicative of
compartment syndrome. Further examination often
reveals pain on any, or all, of the following: palpation
in the groin or greater trochanter, axial loading of the
hip, and ‘pin rolling of the leg. It is recommended that
a cognitive assessment be performed in all patients
presenting with hip fractures. Ideally, this should be
done both on admission and post-operatively. The aim
of this is to recognize patients with underlying
dementia or those who are developing an acute
 delirium, both of which are associated with a poorer
prognosis.
o Option D: The absence of pulses is indicative of
peripheral vascular disease. A full primary trauma and
secondary trauma assessment should be performed to
assess the patient for other injuries. It is always useful
to assess the patient’s cardiovascular and respiratory
status prior to undergoing surgery. Specific
examinations to identify the cause of the fall should
also be considered.
 67. Question
The nurse knows that a 60-year-old female client’s susceptibility
to osteoporosis is most likely related to:

o A. Lack of exercise

o B. Hormonal disturbances

o C. Lack of calcium

o D. Genetic predisposition

Correct Answer: B. Hormonal disturbances

After menopause, women lack hormones necessary to absorb and
utilize calcium. Primary osteoporosis is related to the aging
process in conjunction with decreasing sex hormones. The bones
have deterioration in microarchitecture leading to loss of bone
mineral density and increased risk of a fracture. Osteoporosis is
defined as low bone mineral density caused by altered bone
microstructure ultimately predisposing patients to low-impact,
fragility fractures. Osteoporotic fractures lead to a significant
decrease in quality of life, with increased morbidity, mortality,
and disability.
o Option A: Risk factors for osteoporosis include
increasing age, body weight less than 128 pounds,
smoking, family history of osteoporosis, white or Asian
race, early menopause, low levels of physical activity
and a personal history of a fracture from a ground-
level fall or minor trauma after the age of forty.
Patients afflicted with conditions affecting overall
 mobility level, such as spinal cord injuries (SCI), can
experience rapid deterioration of bone mineral density
levels within the first 2 weeks following these
debilitating injuries.
o Option C: Taking calcium supplements can help to
prevent osteoporosis but are not causes. Osteoporosis
is caused by an imbalance of bone resorption and
bone remodeling leading to decreased skeletal mass.
In most individuals, bone mass peaks in the third
decade, after which bone resorption exceeds bone
formation. Failure to reach a normal peak bone mass
or acceleration of bone loss can lead to osteoporosis.
o Option D: Body types that frequently experience
osteoporosis are thin Caucasian females, but they are
not most likely related to osteoporosis. In white men,
the risk of an osteoporotic fracture is 20%, but the
one-year mortality in men who have a hip fracture is
twice that of women. Black males and females have
less osteoporosis than their white counterparts, but
those diagnosed with osteoporosis have similar
fracture risks. The aging of the American population is
expected to triple the number of osteoporotic
fractures.
 68. Question
A 2-year-old is admitted for repair of a fractured femur and is
placed in Bryant’s traction. Which finding by the nurse indicates
that the traction is working properly?

o A. The infant no longer complains of pain.

o B. The buttocks are 15° off the bed.

o C. The legs are suspended in the traction.

o D. The pins are secured within the pulley.

Correct Answer: B. The buttocks are 15° off the bed.

The infant’s hips should be off the bed approximately 15° in
Bryant’s traction. Bryant’s traction is a form of orthopedic
traction. It is mainly used in young children who have fractures of
the femur or congenital abnormalities of the hip. Both the
patient’s limbs are suspended in the air vertically at a ninety-
degree angle from the hips and knees slightly flexed. Over a
period of days, the hips are gradually moved outward from the
body using a pulley system. The patient’s body provides the
counter-traction.
o Option A: Absence of pain is not an indication that
the traction is working properly. The child’s toes and
feet should be warm and pink and the toes should
move when touched. Check for these signs of good
circulation every four hours the first few days, every
four hours after rewrapping the legs, and then
whenever the child is fed, changed, or played with.
o Option C: The child’s body and the weights are used
as tension to keep the end of the femur in the hip
socket. The legs are wrapped in adhesive tape
attached to a gauze adhesive elastic bandage, then
connected to ropes and weights.
o Option D: Bryant’s traction is a skin traction, not a
skeletal traction. Take the ace wraps (the outer elastic
bandage) off the legs. Inspect any skin for redness or
irritation. Rewrap the legs with the ace bandages.
Start at the feet. Overlap each loop of the wrap
halfway. Do not stretch it tight. Stretch with mild
tension only (1/3 tight).
 69. Question
A client with a fractured hip has been placed in Buck’s traction.
Which statement is true regarding balanced skeletal traction?
Balanced skeletal traction:

o A. Utilizes a Steinman pin

o B. Requires that both legs be secured

o C. Utilizes Kirschner wires

o D. Is used primarily to heal the fractured hips

Correct Answer: A. Utilizes a Steinman pin

Balanced skeletal traction uses pins and screws. A Steinman pin
goes through large bones and is used to stabilize large bones
such as the femur. For some types of femur fractures, a pin is
placed in the child’s broken bone and the pin is connected to the
weights. This is called “balanced skeletal traction.” The weights
keep the parts of the bone in the proper place so the bone can
heal well.
o Option B: Only the affected leg is in traction. Weights,
ropes and pulleys are used to balance and hold the leg
up for best healing. The equipment cradles the leg to
help the child relax and feel more comfortable while
the ends of the bones are healing together.
o Option C: Kirschner wires are used to stabilize small
bones such as fingers and toes. The nurses will also
check the skin around the pin for these signs: redness,
flaking, and blisters. These are signs of skin
breakdown and irritation.
o Option D: Buck’s traction is not used for fractured
hips. For people with hip fractures, traction involves
either using tapes (skin traction) or pins (skeletal
traction) attached to the injured leg and connected to
weights via a pulley. The application of traction before
surgery is thought to relieve pain and make the
subsequent surgery easier.
 70. Question
The client is admitted for an open reduction internal fixation of a
fractured hip. Immediately following surgery, the nurse should
give priority to assessing the:

o A. Serum collection (Davol) drain

o B. Client’s pain

o C. Nutritional status

o D. Immobilizer

Correct Answer: A. Serum collection (Davol) drain

Bleeding is a common complication of orthopedic surgery. The
blood-collection device should be checked frequently to ensure
that the client is not hemorrhaging. Maintain patency of drainage
devices when present. Note characteristics of wound drainage.
Reduces the risk of infection by preventing the accumulation of
blood and secretions in the joint space (medium for bacterial
growth). Purulent, non serous, odorous drainage is indicative of
infection, and continuous drainage from incision may reflect
developing skin tract, which can potentiate the infectious
process.
o Option B: The client’s pain should be assessed, but
this is not life-threatening. Provide comfort measures
(frequent repositioning, back rub) and diversional
activities. Encourage stress management techniques
(progressive relaxation, guided imagery, visualization,
meditation). Provide Therapeutic Touch as appropriate.
Reduces muscle tension, refocuses attention,
promotes a sense of control, and may enhance coping
abilities in the management of discomfort or pain,
which can persist for an extended period.
o Option C: When the client is in less danger, the
nutritional status should be assessed. Encourage
intake of a balanced diet, including roughage and
adequate fluids. Enhances healing and feeling of
general well-being. Promotes bowel and bladder
function during a period of altered activity.
o Option D: An immobilizer is unnecessary in this case.
Demonstrate and assist with transfer techniques and
use of mobility aids, e.g., trapeze, walker. Facilitates
self-care and patient’s independence. Proper transfer
techniques prevent shearing abrasions of skin and fall.
 71. Question
Which statement made by the family member caring for the
client with a percutaneous gastrostomy tube indicates an
understanding of the nurse’s teaching?

o A. "I must flush the tube with water after feedings

and clamp the tube."

o B. "I must check placement four times per day."

o C. "I will report to the doctor any signs of indigestion."

 o D. "If my father is unable to swallow, I will discontinue
the feeding and call the clinic."

Correct Answer: A. “I must flush the tube with water after

feedings and clamp the tube.”
The client’s family member should be taught to flush the tube
after each feeding and clamp the tube. PEG stands for
percutaneous endoscopic gastrostomy, a procedure in which a
flexible feeding tube is placed through the abdominal wall and
into the stomach. PEG allows nutrition, fluids and/or medications
to be put directly into the stomach, bypassing the mouth and
esophagus.
o Option B: A dressing will be placed on the PEG site
following the procedure. This dressing is usually
removed after one or two days. After that you should
clean the site once a day with diluted soap and water
and keep the site dry between cleansings. No special
dressing or covering is needed.
o Option C: The placement should be checked before
feedings, and indigestion can occur with the PEG tube,
just as it can occur with any client. Complications can
occur with the PEG placement. Possible complications
include pain at the PEG site, leakage of stomach
contents around the tube site, and dislodgement or
malfunction of the tube. Possible complications include
infection of the PEG site, aspiration (inhalation of
gastric contents into the lungs), bleeding and
perforation (an unwanted hole in the bowel wall).
o Option D: Medications can be ordered for indigestion,
but it is not a reason for alarm. A percutaneous
endoscopic gastrostomy tube is used for clients who
have experienced difficulty swallowing. The tube is
inserted directly into the stomach and does not require
swallowing.
 72. Question
The nurse is assessing the client with a total knee replacement 2
hours postoperative. Which information requires notification of
the doctor?
 o A. Bleeding on the dressing is 3cm in diameter.

o B. The client has a temperature of 100.6°F (38.1°C).

o C. The client’s hematocrit is 26%.

o D. The urinary output has been 60 during the last 2

hours.

Correct Answer: C. The client’s hematocrit is 26%.

The client with a total knee replacement should be assessed for
anemia. A hematocrit of 26% is extremely low and might require
a blood transfusion. Results from a hematocrit test are reported
as the percentage of blood cells that are red blood cells. Normal
ranges vary substantially with race, age, and sex. The definition
of normal red-blood-cell percentage also varies from one medical
practice to another.
o Option A: Bleeding of 2cm on the dressing is not
extreme. Circle and date and time the bleeding and
monitor for changes in the client’s status. Healthline
analyzed data on over 1.5 million Medicare and
privately insured people to take a closer look. They
found that 4.5 percent of people who are aged under
65 experience complications while in the hospital after
a knee replacement.
o Option B: A low-grade temperature is not unusual
after surgery. Ensure that the client is well hydrated,
and recheck the temperature in 1 hour. If the
temperature is above 100.6°F (38.1°C), report this
finding to the doctor. Tylenol will probably be ordered.
Infections are rare after knee replacement surgery, but
they can occur. Infection is a severe complication, and
it needs immediate medical attention.
o Option D: Voiding after surgery is also not uncommon
and no need for concern. In rare cases, a person may
have osteolysis. This is inflammation that occurs due
to microscopic wear of the plastic in the knee implant.
The inflammation causes bone to essentially dissolve
and weaken.
 73. Question
The nurse is caring for the client with a 5-year-old diagnosis of
plumbism. Which information in the health history is most likely
related to the development of plumbism?

o A. The client has traveled out of the country in the last 6

months.

o B. The client’s parents are skilled stained-glass

artists.

o C. The client lives in a house built in one.

o D. The client has several brothers and sisters.

Correct Answer: B. The client’s parents are skilled

stained-glass artists.
Plumbism is lead poisoning. One factor associated with the
consumption of lead is eating from pottery made in Central
America or Mexico that is unfired. The child lives in a house built
after 1976 (this is when lead was taken out of paint), and the
parents make stained glass as a hobby. Stained glass is put
together with lead, which can drop on the work area, where the
child can consume the lead beads.
o Option A: Traveling out of the country does not
increase the risk of plumbism. Because lead is not
biodegradable, it demonstrates remarkable
environmental persistence. Despite the fact that the
amount of lead in paint intended for use in or on
residential buildings, furniture, or children’s toys in the
United States has been restricted to 0.06% since 1978
and was further reduced to 0.009% in 2008, lead-
based paint continues to be a major source of lead
exposure in young children.
o Option C: The house was built after the lead was
removed with the paint. Several million young children
in the United States live in older homes in which lead-
based paint was previously used, and as this old paint
ages, it peels, flakes, and crumbles into dust that
settles on the interior surfaces of homes and in the soil
surrounding the exterior of the home. The dust and
soil containing these tiny paint particles inevitably
 make their way into children’s mouths as a result of
normal childhood exploratory hand-to-mouth behavior.
o Option D: Having several siblings is unrelated to the
stem. A variety of occupations and hobbies may
expose adults to lead, and working parents may
inadvertently bring lead home where they can expose
their children second-hand. Some of the highest risk
occupations and hobbies include metal welding,
battery manufacturing, and recycling, shipbuilding and
shipbreaking, firing range use or instruction as well as
bullet salvaging, lead smelting and refining, painting
and construction work, and pipefitting and plumbing.
 74. Question
A client with a total hip replacement requires special equipment.
Which equipment would assist the client with a total hip
replacement with activities of daily living?

o A. High-seat commode

o B. Recliner

o C. TENS unit

o D. Abduction pillow

Correct Answer: A. High-seat commode

The equipment that can help with activities of daily living is the
high-seat commode. The hip should be kept higher than the knee.
There is also equipment available for patients to help them follow
their newly prescribed hip precautions. Some patients purchase
raised toilet seats and chairs to prevent them from bending at the
hip more than 90 degrees.
o Option B: The recliner is good because it prevents
90° flexion but not daily activities. Sock aids and
dressing sticks are often used to make dressing and
changing clothing easier for the patient. Reachers or
“pinchers” can also be used by a patient following a
total hip arthroplasty to help them grab items from the
ground and other areas without breaking the hip
precautions.
 o Option C: A TENS (Transcutaneous Electrical Nerve
Stimulation) unit helps with pain management.
Compliance with hip precautions can be challenging
for patients to follow. Many activities that were once
simple to perform are instantly complicated. Activities
of daily living can be significantly affected. Examples
of activities of daily living include bathing, grooming,
dressing, toileting, and transferring. Lack of
independence can leave patients very upset and
disheartened further affecting the rate of compliance.
o Option D: An abduction pillow is used to prevent
adduction of the hip and possibly dislocation of the
prosthesis. There are also environmental modifications
that can help prevent hip dislocations; these include
removing all tripping hazards from home, moving
around the layout of home furniture so that there are
fewer turns, and installing grab rails around the house.
 75. Question
An elderly client with an abdominal surgery is admitted to the
unit following surgery. In anticipation of complications of
anesthesia and narcotic administration, the nurse should:

o A. Administer oxygen via nasal cannula

o B. Have narcan (naloxone) available

o C. Prepare to administer blood products

o D. Prepare to do cardio resuscitation

Correct Answer: B. Have narcan (naloxone) available

Narcan is the antidote for narcotic overdose. Naloxone is
indicated for the treatment of opioid toxicity, specifically to
reverse respiratory depression from opioid use. It is useful in
accidental or intentional overdose and acute or chronic toxicity.
Common opioid overdoses treated with naloxone include heroin,
fentanyl, carfentanil, hydrocodone, oxycodone, methadone, and
others.
o Option A: If hypoxia occurs, the client should have
oxygen administered by mask, not cannula. The
 incidence of naloxone-induced noncardiogenic
pulmonary edema is estimated to be between 0.2%
and 3.6% of patients who have received naloxone and
are transported to the emergency department.
Symptoms include persistent hypoxia, despite the
resolution of respiratory depression secondary to
acute overdose. Patients may also have a cough
productive of the classic “pink, frothy sputum”
indicative of pulmonary edema.
o Option C: In chronic opioid users, naloxone requires
slow administration to individuals who are dependent
on opioids. All patients who have responded to
naloxone should be continuously monitored for at least
six to 12 hours since some opioids (methadone,
fentanyl, buprenorphine) have a much longer half-life
than naloxone.
o Option D: There is no data to support cardiac
resuscitation in this case. The patient should have vital
signs, including pulse oximetry, monitored until
obtaining a full recovery. Even after reversing
respiratory depression, the patient must be monitored
for at least six to 12 hours because the patient may
have ingested the longer-acting opioids, which will
continue to exert their effects after excretion of the
naloxone. Any patient that requires IV naloxone of
doses more than 5 mg should be admitted.