109 - Nursing Exams Questions & Answers - Svastham Exemplar

Question 5471) 

The nurse notes that a child who has had a serious heart condition since birth does not do the expected activities for that age. The child’s mother says, “I worry constantly about my child. I don’t let the older children or the neighborhood kids play with my child very much. I try to make things as easy for my child as I can.” What is the best interpretation of these data? 

A. The child is physically incapable due to his cardiac defect 

B. The child’s mother is overprotective and allows the child few challenges to develop skills.

C. The child is probably mentally retarded from the effects of continual hypoxia. 

D. The child has regressed due to the effects of hospitalization. 

Answer: B 

Explanation: The child’s mother does not let the child play with others and appears to do everything for the child. She seems to be overprotective. Most children with heart defects are capable of doing most age-appropriate activities. There is no evidence to support that the child is mentally retarded. There are no data to support that the child has regressed. 

Question 5472) 

Ten days after cardiac surgery, an 18-month-old child is recovering well. The child is alert and fairly active and is playing well with the parents. Discharge is planned soon. The nurse notes that the parents are still very reluctant to allow the child to do anything without help. What is the best initial action for the nurse to take? 

A. Reemphasize the need for autonomy in toddlers 

B. Provide opportunities for autonomy when the parents are not present 

C. Reassess the parent’s needs and concerns 

D. Discuss the success of the surgery and how well the child is doing 

Answer: C 

Explanation: Before the nurse can teach the parents, it will be necessary to reassess their needs and concerns. The question asks for the best initial action. Initially, the nurse should assess. Later, the nurse may emphasize the toddler’s need for autonomy. The nurse may provide the child with opportunities to develop autonomy, although it would be better to teach the parents. The nurse may also discuss the success of the surgery and how well the child is doing, but this is not the initial action. 

Question 5473) 

Sodium salicylate is prescribed for a child with rheumatic fever. What should the nurse assess the child for because the child is on this medication? 

A. Tinnitus and nausea 

B. Dermatitis and blurred vision 

C. Unconsciousness and acetone odor of breath 

D. Chills and elevation of temperature 

Answer: A 

Explanation: Tinnitus and nausea are signs of toxicity to salicylate drugs 

Question 5474) 

The nurse makes an initial assessment of a 4-year old child admitted with possible epiglottitis. Which observation is most suggestive of epiglottitis? 

A. Low-grade fever 

B. Retching 

C. Excessive drooling 

D. Substernal retractions 

Answer: C 

Explanation: Excessive drooling is a sign of epiglottitis. A child with epiglottitis is apt to have a high fever. Retching is not typical. Retractions could occur if respiratory distress was great enough, but drooling is the hallmark of epiglottitis. 

Question 5475) 

Which Nursing Action could be life threatening for a child with epiglottitis? 

A. Examining the child’s throat with a tongue blade 

B. Placing the child in a semi-sitting position 

C. Maintaining high humidity 

D. Obtaining a nasopharyngeal culture 

Answer: A 

Explanation: Examining the child’s throat with a tongue blade may cause the epiglottis to become so irritated that it will close off completely and obstruct the airway. The child should be placed in a semi-sitting to upright position. Humidity is not a problem. A nasopharyngeal culture would not cause problems. The nurse should get a throat culture, however.

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Question 5461) 

A 6-year-old child with tetralogy of Fallot is being admitted for surgery. What is most important to teach the child during the preoperative period? 

A. Strict hand washing technique 

B. How to cough and deep breathe 

C. The importance of drinking plenty of fluids 

D. Positions of comfort 

Answer: B 

Explanation: The child will have to learn to cough and deep breathe postoperatively. Studies demonstrate that preoperative teaching makes it easier for the client to perform coughing and deep breathing exercises in the postoperative period. The nurses will do strict hand washing, not the client. Fluids will likely be restricted postoperatively. It is important to teach the client about positions of comfort, but it is more important to teach the child how to deep breathe and cough. 

Question 5462) 

A 6-year-old with tetralogy of Fallot has open heart surgery. The septal defect was closed, and the pulmonic valve was replaced. When the child returns to the unit, he has oxygen, IVs, and closed chest drainage. How should the nurse position the chest drainage system? 

A. Above the level of the bed 

B. At the level of the heart 

C. Below the level of the bed 

D. Alternating above and below the bed every two hours 

Answer: C 

Explanation: Chest bottles are always positioned below bed level to prevent the reflux of material into the chest cavity. 

Question 5463) 

A parent brings a 3-week-old infant to the clinic. The parent states that the baby does not eat very well. She takes 45 cc of formula in 45 minutes and gets “tired and sweaty” when eating. The nurse observes the baby sleeping in the parent’s arms. Her color is pink, and the child is breathing without difficulty. What is the best response for the nurse to make? 

A. “It’s normal for an infant to get tired while feeding. That will go away as the child gets older.” 

B. “It’s normal for an infant to get tired while feeding. You could try feeding the baby smaller amounts of formula more frequently.” 

C. “This could be a sign of a health problem. Does your baby’s skin color change while eating?” 

D. “This could be a sign of a health problem. How does your baby’s behavior compare with your other children when they were that age?” 

Answer: C 

Explanation: Activity intolerance related to feeding is often a key sign of a serious cardiac problem in an infant. Taking only 45 cc of formula in 45 minutes at 3 weeks of age probably indicates difficulty sucking. This is definitely not normal. The fact that the infant’s color is pink at rest does not tell you what happens during exertion, such as with eating. Asking about skin color during feeding is a good first question to ask. Answers 1 and 2 are incorrect because they interpret the infant’s behavior as normal, which it is not. Answer 4 is not correct. It does identify the behavior as abnormal but suggests comparing it to the child’s siblings. This is not the appropriate question to ask to get the most information. 

Question 5464) 

The nurse is explaining cardiac catheterization to the parents of a child. The nurse explains to the parents that information about which of the following can be obtained during cardiac catheterization? 

A. Oxygen levels in the chambers of the heart 

B. Pulmonary vascularization 

C. Presence of abdominal aortic aneurysm 

D. Activity tolerance 

Answer: A 

Explanation: The catheter is passed into the chambers of the heart, and oxygen levels can be measured. The cardiac catheter does not assess pulmonary vascularization. Coronary arteries can be visualized, however. An abdominal aortic aneurysm is diagnosed with an arteriogram, not a cardiac catheterization. A cardiac catheterization gives information about the heart structures but does not give information about activity tolerance. 

Question 5465) 

The nurse is caring for a toddler who is six hours post cardiac catheterization. The nurse is administering antibiotics. The child’s mother asks why the child needs to have antibiotics. The nurse’s response should indicate that antibiotics are given to the client to prevent which type of infection? 

A. Urinary tract infection 

B. Pneumonia 

C. Otitis media 

D. Endocarditis 

Answer: D 

Explanation: During a cardiac catheterization, a catheter is inserted into the heart; therefore, the infection that the client is most at risk for is endocarditis. Urinary tract infection, pneumonia, and otitis media are not related to a client undergoing a cardiac catheterization. 

Question 5466) 

The nurse is caring for a toddler with a cardiac defect who has had several episodes of congestive heart failure in the past few months. Which data would be the most useful to the nurse in assessing the child’s current congestive heart failure? 

A. The degree of clubbing of the child’s fingers and toes 

B. Amount of fluid and food intake 

C. Recent fluctuations in weight 

D. The degree of sacral edema 

Answer: C 

Explanation: Weight is the best indicator of fluid balance. Congestive heart failure causes fluid retention. Sacral edema is positionally dependent. Weight will give a better indication of the child’s status. Clubbing of the fingers and toes is an indication of chronic hypoxemia, not the status of his current congestive heart failure. Fluid and food intake is a general indicator of his status and is not particularly related to his current congestive heart failure. 

Question 5467) 

A child with a cyanotic heart defect has an elevated hematocrit. What is the most likely cause of the elevated hematocrit? 

A. Chronic infection 

B. Recent dehydration 

C. Increased cardiac output 

D. Chronic oxygen deficiency 

Answer: D 

Explanation: The body tries to compensate for chronic oxygen deficiency by making additional red cells to transport oxygen. The additional red cells increase the hematocrit, which is the percentage of blood that is red blood cells. Chronic infection can cause anaemia. Recent dehydration will cause an elevated hematocrit because there is less fluid in the blood. However, there is no indication that the child is dehydrated, and we are told that he has a cyanotic heart defect, which makes him chronically hypoxic. Therefore, answer 4 is better than answer 2. Answer 3, increased cardiac output, is also incorrect. Increased cardiac output does not cause an elevated hematocrit. 

Question 5468) 

The nurse is administering the daily digoxin dose of 0.035 mg to a 10-month-old child. Before administering the dose, the nurse takes the child’s apical pulse, and it is 85. Which of the following interpretations of these data is most accurate? 

A. The child has just awakened, and the heart action is slowest in the morning.

B. This is a normal rate for a 10-month-old child. 

C. The child may be going into heart block due to digoxin toxicity 

D. The child’s potassium level needs to be evaluated. 

Answer: C 

Explanation: A pulse below 100 in a 10-month-old child who is taking digoxin most likely indicates digoxin toxicity. The nurse should withhold the medication and notify the physician. The normal pulse for this age is about 120 or a little more at rest. The pulse rate does not tell us that the child needs to have his/her potassium level checked. If the child is also taking Lasix or another potassium-depleting diuretic, then the potassium should be checked. 

Question 5469) 

The nurse is discussing dietary needs of a child with a serious heart defect. The child is being treated with digoxin and hydrochlorothiazide (Hydrodiuril). The nurse should stress the importance of giving the child which of the following foods? 

A. Cheese and ice cream 

B. Finger foods such as hot dogs 

C. Apricots and bananas 

D. Four glasses of whole milk per day 

Answer: C 

Explanation: The child should be on a sodium-restricted diet with high-potassium foods because he is taking Hydrodiuril, a potassium-depleting diuretic. Apricots and bananas are low in sodium and high in potassium. Cheese and ice cream are high in sodium. Hot dogs are high in sodium. Whole milk is high in sodium. Not only is potassium needed, but excessive sodium should also be avoided because those with severe heart defects are prone to fluid retention. 

Question 5470) 

A child with a cyanotic heart defect has a hypoxic episode. What should the nurse do for the child at this time? 

A. Administer PRN oxygen and position the child in the squat position 

B. Position the child side-lying and give the ordered morphine 

C. Ask the parents to leave and start oxygen 

D. Give oxygen and notify the physician 

Answer: A 

Explanation: The knee-chest or squat position increases intra-abdominal pressure and increases blood flow to the lungs. Oxygen is also indicated because the child is hypoxic. Positioning on the side is not appropriate because it will not improve the blood flow to the lungs. There is no need to ask the parents to leave. In fact, they need to know how to handle these episodes if they are not yet comfortable doing so. Children with cyanotic heart defects have hypoxic episodes fairly regularly. Positioning in the squat position is more important at this time than notifying the physician. 

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Question 5451) 

An 8-year-old child is terminally ill. Considering the child’s age, which statement would you most expect the child to make? 

A. “After I’m dead, will you come visit me?” 

B. “Who will take care of me when I am dead?” 

C. “Will it hurt me when I die?” 

D. “Can you help me do a videotape about dying from leukemia?” 

Answer: C 

Explanation: An 8-year-old is concerned about pain and mutilation. An 8-year-old has an understanding that death is the end of life as we know it and would be unlikely to respond with answers 1 or 2. Answers 1 and 2 are typical of a preschooler. Answer 4 is typical of an adolescent who wants to leave a legacy. 

Question 5452) 

A father has bought his 4 month old daughter to the well-baby clinic. Which statement that he makes is the greatest cause for concern to the nurse? 

A. “She cannot sit up by herself.” 

B. “She does not hold the rattle as well as she did at first.” 

C. “She does not follow objects with her eyes.” 

D. “She spits up after a feeding.” 

Answer: C 

Explanation: A 4-month-old should follow objects with her eyes. A 4-month-old is not likely to be able to sit up by herself. This behavior is seen at 6 months of age. Not being able to hold the rattle as well as she did at first is typical of the time after the loss of the grasp reflex and before pincer movement is established. Most newborn reflexes are gone by about 4 months of age. Spitting up after a feeding is normal 4-month-old behavior. 

Question 5453) 

A 3-year-old child has all of the following abilities. Which did he acquire most recently? 

A. Walking 

B. Throwing a large ball 

C. Riding a tricycle 

D. Stating his name 

Answer: C 

Explanation: Riding a tricycle is 3-year-old behavior. Remember, “three years, three wheels.” Children start to walk at about 1 year of age. Throwing a large ball and stating his name are 2-year-old behaviors. Remember to use developmental trends when determining the most recently acquired behavior—head to tail and simple to complex. Look for a complex lower body behavior. 

Question 5454) 

The mother of a 2-year-old child calls the doctor’s office because her child swallowed “the rest of the bottle of adult aspirin” about a half hour ago. The nurse determines that there were about 15 tablets left in the bottle. What initial assessment findings are consistent with aspirin ingestion? 

A. Bradypnea and pallor 

B. Hyperventilation and hyperpyrexia 

C. Subnormal temperature and bleeding 

D. Melena and bradycardia 

Answer: B 

Explanation: The child will have an elevated body temperature. Contrary to what you might expect, metabolism is increased following aspirin overdose. The child will be hot and flushed. Hyperpyrexia means high temperature. The child will be in metabolic acidosis from the acid load of the aspirin. Compensation for metabolic acidosis is rapid, deep breathing. The first choice is incorrect; the child will be hyperventilating and will be flushed, not pale. The third choice is not correct; the temperature will be high, not low. Bleeding may occur following aspirin ingestion, but not initially. The fourth choice is not correct. Melena is hidden blood in the stool. It will take some time for a gastrointestinal bleed to develop and pass through the stool. Bradycardia will not be present. The child will have tachycardia. 

Question 5455) 

A toddler who has swallowed several adult aspirin is admitted to the emergency room. When admitted, the child is breathing but is difficult to arouse. What is the immediate priority of care? 

A. Administration of syrup of ipecac 

B. Cardiopulmonary resuscitation 

C. Ventilatory support D. Gastric lavage 

Answer: D 

Explanation: Since the child is breathing, there is no need for cardiopulmonary resuscitation (CPR) or ventilatory support. Gastric lavage is usually used rather than inducing emesis. In any event, the child is difficult to arouse, so it would not be safe to induce vomiting. 

Question 5456) 

A 6-month-old child is being seen for a well-baby visit. The child has received all immunizations as recommended so far. What immunizations does the nurse expect to give at this visit? 

A. DTP, MMR, IPV 

B. DTP, hepatitis B, HIB 

C. HIB, IPV, varicella D. MMR, hepatitis B, HIB 

Answer: B 

Explanation: At 6 months of age, the nurse would expect to administer the third DTP, the third hepatitis B, and the third Haemophilus influenzae type B (HIB) immunizations. MMR (measles, mumps, and rubella) is not given until 15 months of age. IPV is given at 2 months and 4 months and then again at 18 months and preschool. Varicella vaccine is given between the ages of 1 year and 12 years. 

Question 5457) 

The mother of a 6-year-old child who has chickenpox asks the nurse when the child can go back to school. What information should be included in the nurse’s response? The child is contagious: 

A. until all signs of the disease are gone 

B. as long as the child has scabs 

C. as long as there are fluid-filled vesicles. 

D. until the rash and fever are gone. 

Answer: C 

Explanation: Chickenpox is contagious as long as there are fluid-filled vesicles. Scabs are not contagious. The child will have scabs for a while. The fever may be down, but if there are fluid-filled vesicles, the child is contagious. 

Question 5458) 

A 2-year-old child is in for an annual examination. Which comment by the mother alerts the nurse to a risk for lead poisoning? 

A. “Why does he eat paint off the window sills?” 

B. “Will his temper tantrums ever stop?” 

C. “I haven’t been able to toilet train him yet.” 

D. “He is such a messy eater.” 

Answer: A 

Explanation: Eating paint is one of the major risk factors for lead poisoning. Temper tantrums are normal in a 2- year-old. Most 2-year-olds are not toilet trained. Most 2-year-olds are messy eaters. 

Question 5459) 

A 6-year-old boy has tetralogy of Fallot. He is being admitted for surgery. The nurse knows that which problem is not associated with tetralogy of Fallot? 

A. Severe atrial septal defect 

B. Pulmonary stenosis 

C. Right ventricular hypertrophy 

D. Overriding aorta 

Answer: A 

Explanation: Atrial septal defect is not associated with tetralogy of Fallot. The four defects are pulmonary stenosis, which causes right ventricular hypertrophy, ventricular septal defect, and overriding aorta. 

Question 5460) 

A 6-year-old child with tetralogy of Fallot is being admitted for surgery. While the nurse is orienting the child to the unit, the child suddenly squats with the arms thrown over the knees and knees drawn up to the chest. What is the best immediate nursing action? 

A. Observe and assist if needed 

B. Place the child in a lying position 

C. Call for help and return the child to the room 

D. Assist the child to a standing position 

Answer: A 

Explanation: The squatting position will help the child with tetralogy of Fallot to have better hemodynamics. It increases intra-abdominal pressure and increases pulmonary blood flow. Placing the child in a lying or standing position will increase his symptoms and be counterproductive. It is not necessary to call for help because this is not an emergency situation. 

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Question 5151) 

The nurse is caring for a client who is very hard of hearing. How should the nurse communicate with this person? 

A. Speak loudly and talk in his better ear 

B. Stand in front of him and speak clearly and distinctly 

C. Yell at him using a high-pitched voice 

D. Write all communication on a note pad or magic slate 

Answer: B 

Explanation: Standing in front of him and speaking clearly and distinctly will allow him to read lips. Speaking loudly is usually not the best approach. Most persons with difficulty hearing hear lowpitched sounds better than highpitched ones; yelling and speaking loudly tend to raise the pitch of the voice. Written communication might become necessary for some persons; however, that would only be a last resort after all other methods of communication have failed. 

Question 5152) 

The day following a stapedectomy, the client tells the nurse that he cannot hear much in the operative ear and thinks the stapedectomy was a failure. What is the best response for the nurse to make? 

A. “There is packing in your ear. You will not hear well for a few days.” 

B. “The doctors have not yet turned on the stapes replacement.” 

C. “You may not have hearing, but you will now be free of pain.” 

D. “You seem upset that you aren’t hearing well.” 

Answer: A 

Explanation: Packing in the ear will reduce sound wave transmission. Hearing will be muffled until the packing is removed. The stapes replacement does not need to be turned on. The purpose of a stapedectomy is to restore some hearing. Otosclerosis, for which the stapedectomy was performed, is not a painful condition. It is more appropriate to give the client the information that he needs regarding hearing rather than to focus on the client’s feelings. 

Question 5153) 

A cataract extraction is performed on a client’s right eye. What is the priority nursing care immediately postoperative? 

A. Assist her to turn, cough, and deep breathe every two hours. 

B. Keep her NPO for four hours. 

C. Assist her in moving her arms and legs in ROM. 

D. Position client on her right side. 

Answer: C 

Explanation: Of these answers, moving arms and legs is the best answer because it will help to prevent thrombophlebitis. The client should not cough because this will increase intraocular pressure. There is no need to keep her NPO. She should not be positioned on the operative side because this will increase intraocular pressure. 

Question 5154) 

A client is admitted to the hospital with a gnawing pain in the mid-epigastric area and black stools for the past week. A diagnosis of chronic duodenal ulcer is made. During the initial nursing assessment, the client makes all of the following statements. Which is most likely related to his admitting diagnosis? 

A. “I am a vegetarian.” 

B. “My mother and grandmother have diabetes.” 

C. “I take aspirin several times a day for tension headaches.” 

D. “I take multivitamin and iron tablets every day.” 

Answer: C 

Explanation: Aspirin is very irritating to the gastric mucosa and is known to cause ulcers. Being a vegetarian does not cause ulcers. Ulcers are not known to be inherited. Multivitamins and iron do not cause ulcers. 

Question 5155) 

An upper GI series is ordered for a client. Which action is essential for the nurse before the test? 

A. Check to see if the client has an allergy to shellfish. 

B. Instruct the client to have nothing to eat after midnight the night before the test. 

C. Encourage the client to drink plenty of liquids before the test. 

D. Be sure the client does not eat fat-containing foods for 18 hours before the test. 

Answer: B 

Explanation: Preparation for an upper GI series is NPO for eight hours. In an upper GI series, the client swallows barium, a radiopaque substance. An iodine dye is not used, so it is not necessary to ask about iodine allergies (shellfish). Fats are restricted before gallbladder x-rays, not for an upper GI series. 

Question 5156) 

The client with a duodenal ulcer is ready for discharge. Which statement made by the client indicates a need for more teaching about his diet? 

A. “It’s a good thing I gave up drinking alcohol last year.” 

B. “I will have to drink lots of milk and cream every day.” 

C. “I will stay away from cola drinks after I am discharged.” 

D. “Eating three nutritious meals and snacks every day is okay.” 

Answer: B 

Explanation: Milk and cream are now known to cause rebound acidity and are not prescribed for ulcer clients. The other choices all indicate good knowledge. He should not drink alcohol or cola. Three meals and snacks will help keep the stomach from staying empty for long periods. 

Question 5157) 

The client, admitted with appendicitis, overhears the physician say that the pain has reached McBurney’s point. She becomes very frightened and asks the nurse to explain what this means. Which is the best response? 

A. “The next time the doctor comes in, we should ask him what he meant by that.” 

B. “I’ve felt that I don’t understand the doctor at times either.” 

C. “That is the term used to indicate that the pain has traveled to the right lower side.” 

D. “McBurney’s point refers to severe pain for which surgery is the only treatment.” 

Answer: C 

Explanation: McBurney’s point is the area in the right lower quadrant where the appendix is. The client asked for information that the nurse should be able to provide. Answer 4 is not correct. McBurney’s point refers to the location of the appendix, not the severity of the pain. 

Question 5158) 

Which blood test results would confirm a diagnosis of appendicitis? 

A. WBC of 13,000 

B. RBC of 4.5 million 

C. Platelet count of 300,000 

D. Positive heterophil antibody test 

Answer: A 

Explanation: An elevated WBC count indicates appendicitis. The RBC and platelet levels given are normal but are not specifically related to appendicitis. A positive heterophil antibody test indicates infectious mononucleosis. 

Question 5159) 

The nurse is admitting a client with the diagnosis of appendicitis to the surgical unit. Which question is it essential to ask? 

A. “When did you last eat?” 

B. “Have you had surgery before?” 

C. “Have you ever had this type of pain before?” 

D. “What do you usually take to relieve your pain?” 

Answer: A 

Explanation: When a person is admitted with possible appendicitis, the nurse should anticipate surgery. It will be important to know when she last ate when considering the type of anesthesia so that the chance of aspiration can be minimized. The other information is “nice to know” but not essential. 

Question 5160) 

The client with appendicitis asks the nurse for a laxative to help relieve her constipation. The nurse explains to her that laxatives are not given to persons with possible appendicitis. What is the primary reason for this? 

A. Laxatives will decrease the spread of infection. 

B. Laxatives are not given prior to any type of surgery. 

C. The client does not have true constipation. She only has pressure. 

D. Laxatives could cause a rupture of the appendix. 

Answer: D 

Explanation: Laxatives cause increased peristalsis, which may cause the appendix to rupture. Answer 2 is not a true statement. Laxatives may well be given prior to gynecological, rectal, and colon surgery. Answer 3 is true but is not the primary reason why laxatives are not given when a person has appendicitis. 

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Question 5131) 

A 27-year-old woman is admitted to the hospital complaining of numbness in both legs, difficulty walking, and double vision of one week in duration. Multiple sclerosis is suspected. Orders include bed rest with bathroom privileges, brain scan, EEG, lumbar puncture, adrenocorticotropic hormone (ACTH) 40 units intramuscularly (IM) bid × 3 days, then 30 units IM bid × 3 days, then 20 units IM bid × 3 days; and passive range of motion (ROM) progressing to active ROM as tolerated. In planning care for this client, which activity is most important to include? 

A. Encouraging her to perform all care activities for herself 

B. Frequent ambulation to retain joint mobility 

C. Scheduling frequent rest periods between physical activity 

D. Feeding the client to reduce energy needs 

Answer: C 

Explanation: She will need rest periods between activities. She may be too weak to perform all self activities. Her orders include bed rest, not ambulating ad lib. Feeding her is not necessary and is likely to cause her to be upset. 

Question 5132) 

The doctor orders a Tensilon test for a woman suspected of having myasthenia gravis. Which statement is true about this test? 

A. A positive result will be evident within one minute of injection of Tensilon if she has myasthenia gravis. 

B. This is of diagnostic value in only 25% of patients with myasthenia gravis. 

C. Administration of Tensilon causes an immediate decrease in muscle strength for about an hour in persons with myasthenia gravis. 

D. Tensilon works by blocking the action of acetylcholine at the myoneural junction. 

Answer: A 

Explanation: Tensilon works almost immediately to cause an increase in muscle strength by increasing the amount of acetylcholine at the myoneural junction. The test is of value in almost all clients suspected of having myasthenia gravis. 

Question 5133) 

When planning care for a woman with myasthenia gravis, the nurse asks her what time of day she feels strongest. The nurse would expect which of the following replies? 

A. “I can wash up and comb my hair before breakfast because I feel best in the morning.” 

B. “I only feel good for about an hour after I take my medication.” 

C. “I feel strongest in the evening, so I would prefer to take a shower before bedtime.” 

D. “I feel best after lunch after I’ve been moving around a little 

Answer: A 

Explanation: Muscle strength is best early in the day. Weakness usually progresses during the day and is at its worst in the evening. 

Question 5134) 

Which of the following would not be included in the nursing care plan for a client with Parkinson’s disease? 

A. Restricting his intake of oral fluids 

B. Range of motion exercises 

C. Allowing him to carry out activities of daily living by himself even though he is very slow 

D. Providing him with diversionary tasks that require motor coordination of hands 

Answer: A 

Explanation: Fluids should be encouraged because he has a tendency to drool and lose fluid. Encouraging the client to perform activities of daily living is desirable. He should be encouraged to move frequently to prevent joint contractures. Activities requiring hand coordination will help him to retain function. 

Question 5135) 

The nurse is caring for a client admitted with Guillain-Barré syndrome. On day three of hospitalization, his muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in his nursing care plan should be to prevent which of the following? 

A. Aspiration pneumonia 

B. Decubitus ulcers 

C. Bladder distention 

D. Hypertensive crisis 

Answer: A 

Explanation: Because he is having difficulty swallowing and talking, he is at high risk for aspiration pneumonia. He is also at risk for decubitus ulcers, but this is of lesser priority than the airway. Bladder distention is a possibility but not as high a priority as the risk of aspiration pneumonia. There is no evidence that he is at risk for hypertensive crisis. 

Question 5136) 

An adult client is admitted for removal of a cataract from her right eye. Which of the following would the client likely have experienced as a result of the cataracts? 

A. Acute eye pain 

B. Redness and constant itching of the right eye 

C. Gradual blurring of vision 

D. Severe headaches and dizziness 

Answer: C 

Explanation: Cataracts are characterized by a gradual blurring of vision. Acute eye pain is characteristic of acute glaucoma or foreign objects in the eye. Redness and itching is more characteristic of an eye infection. Severe headaches and dizziness are not characteristic of cataracts. 

Question 5137) 

A client has had a cataract extraction performed. Which statement would indicate that the client needs more teaching? 

A. “I will take a stool softener daily.” 

B. “I’m going to start doing calisthenic exercises as soon as I get home.” 

C. “I’m going to my daughter’s for a few weeks until I am recovered.” 

D. “I am looking forward to watching television during my recovery period.” 

Answer: B 

Explanation: Bending, stooping, and lifting should be avoided for several weeks following eye surgery. A stool softener is recommended so that the client will not strain at stool. Television and reading are not restricted following cataract extraction. Eye movement is restricted following surgery for detached retina. 

Question 5138) 

A 50-year-old client is admitted with the diagnosis of open-angle glaucoma. Which of the following symptoms would the nurse expect the client to have? 

A. Severe eye pain 

B. Constant blurred vision 

C. Severe headaches, nausea, and vomiting 

D. Severe headaches, nausea, and vomiting 

Answer: D 

Explanation: Chronic glaucoma is characterized by halos around objects. Severe eye pain and severe headaches, nausea, and vomiting are more characteristic of acute glaucoma. Constant blurred vision is characteristic of cataracts. 

Question 5139) 

The nurse is administering eye drops to a client. Which action is correct? 

A. Ask the client to report any blurring of vision and difficulty focusing that occurs after the administration of eye drops. 

B. Apply gentle pressure to the nasolacrimal canal for one to two minutes after instillation to prevent systemic absorption. 

C. Have the client lie down with eyes closed for 45 minutes after giving drops. 

D. Gently pull the lower lid down and place medicine in the center of the eye. 

Answer: B 

Explanation: This action will prevent systemic absorption of eye medication and prevent the nose from running. Blurred vision and difficulty focusing are normal immediately after administering eye drops. There is no need to lie down after eye drops are given. Eye drops should be placed in the conjunctival sac, not the center of the eye. 

Question 5140) 

A 10-year-old boy comes to the school clinic holding his broken pair of glasses. He says that he got hit in the face playing ball and his eye hurts and feels like there’s something in it. What should the nurse do before taking him to the emergency room? 

A. Thoroughly examine his eyes 

B. Put a pressure dressing on his right eye. 

C. Cover both eyes lightly with gauze 

D. Flush his right eye with water for 20 minutes 

Answer: C 

Explanation: Covering both eyes lightly with gauze prevents tracking by the affected eye, which would occur if the unaffected eye was not covered. Examining the eyes should be done only in the emergency room by a physician. A pressure dressing would further damage the eye if broken glass is in the eye. Flushing is appropriate for chemical spills in the eye.

69 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

Question 5111) 

An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. He is also receiving pyridoxine (vitamin B6). Why is this medication prescribed for him? 

A. Pyridoxine is bacteriostatic against Mycobacterium tuberculosis. 

B. To enhance his general nutritional status 

C. To prevent side effects of INH 

D. Pyridoxine acts to increase the effects of streptomycin. 

Answer: C 

Explanation: Pyridoxine (vitamin B6) prevents the development of peripheral neuritis toxicity of INH. 

Question 5112) 

The wife of a client with active tuberculosis has a positive skin test for tuberculosis. She is to be started on prophylactic drug therapy. What drug is the drug of choice for prophylaxis of tuberculosis? 

A. Streptomycin 

B. Para-aminosalicylic (PAS) acid 

C. Isoniazid (INH) 

D. Ethambutol (Myambutol) 

Answer: C 

Explanation: INH is the drug of choice for chemoprophylaxis. All of the other drugs listed can be used in the treatment of tuberculosis. 

Question 5113) A farmer who has had a cough for several months has noticed a lack of energy lately. He is being tested for histoplasmosis. Which factor reported by the client would be most related to the diagnosis of histoplasmosis? 

A. He drinks raw milk. 

B. He cleans chicken houses 

C. He handles fertilizer frequently. 

D. He stepped on a rusty nail recently 

Answer: B 

Explanation: Histoplasma capsulatum is a fungus that grows in chicken and pigeon manure. Drinking raw milk might cause “milk fever.” Handling fertilizer could cause “white lung,” a COPD illness. Stepping on a nail might cause tetanus 

Question 5114) 

The nurse is caring for a client who is admitted with histoplasmosis. What drug is most likely to be prescribed for this client? 

A. Penicillin 

B. Chloromycetin 

C. Streptomycin 

D. Amphotericin B 

Answer: D 

Explanation: Amphotericin B is the drug of choice to treat histoplasmosis. 

Question 5115) An adult is to have a thoracentesis performed. What should the nurse do while preparing the client for this procedure? 

A. Keep him NPO for eight hours 

B. Prepare him to go to the operating room 

C. Explain the procedure to him 

D. Administer anticholinergic and analgesic as ordered 

Answer: C 

Explanation: The nurse should explain the procedure to the client and obtain a permit if one has not already been signed. Thoracentesis is usually done at the bedside. NPO is not necessary. Anticholinergics and analgesics are not ordered. 

Question 5116) The nurse is planning care for a client who has COPD. Which statement is the client most likely to say about activity tolerance? 

A. “The most difficult time of the day for me is the first hour after waking up in the morning.” 

B. “I feel best in the morning after a good night’s sleep. 

C. “I seem to have more energy after eating a big meal.” 

D. “I don’t know why, but I get my ‘second wind’ at night and don’t want to go to bed.” 

Answer: A 

Explanation: Morning is a difficult time for persons with COPD because secretions have accumulated during the night. They have to do a great deal of hacking and coughing to clear their air passages in the morning. The client with COPD is apt to be short of breath after a big meal because he is an abdominal breather. Most clients with COPD do not get a “second wind” at night. They need a lot of rest. 

Question 5117) 

The nurse is caring for a woman who is admitted with pneumonia. On admission, the client is anxious and short of breath but able to respond to questions. One hour later, the client becomes more dyspneic and less responsive, answering only yes and no questions. What is the best action for the nurse to take at this time? 

A. Stimulate the client until client responds 

B. Increase the oxygen from the ordered 6 L to 10 L. 

C. Assess the client again in 15 minutes 

D. Notify the charge nurse of the change in the client’s mental status. 

Answer: A 

Explanation: The change in the client’s status is significant and indicates hypoxia. The charge nurse or physician must be notified quickly. Stimulating a severely hypoxic client is not appropriate. Increasing the oxygen from 6 L to 10 L is not likely to change the client’s status. The licensed practical nurse (LPN) should notify the charge nurse now, not in 15 minutes. 

Question 5118) 

A client’s PPD test is positive, and a chest x-ray is negative. What is the best interpretation of these data? 

A. The client’s resistance to tuberculosis is low. 

B. The client has been exposed to the organism but has not developed the disease. 

C. The client has tuberculosis, but it is not serious. 

D. The client has active tuberculosis 

Answer: B 

Explanation: A positive PPD test indicates antibodies against tuberculosis. A positive PPD test and a negative x-ray indicate that the client has been exposed to tuberculosis but has not developed the disease. These findings do not give information regarding the client’s resistance. The negative x-ray indicates that the client does not have active tuberculosis. 

Question 5119) 

An adult with tuberculosis has started taking rifampin (Rimactane). Which side effect is the client most likely to experience when taking this drug?

A. Reddish-orange color of urine, sputum, and saliva 

B. Erythema and urticaria 

C. Tinnitus and deafness 

D. Peripheral neuritis 

Answer: A 

Explanation: Rimactane (rifampin) causes body secretions to turn reddish-orange. Erythema and urticaria are not likely to be seen. Tinnitus and deafness are side effects of streptomycin. Peripheral neuritis is a side effect of isoniazid (INH). 

Question 5120) 

Which laboratory tests should the client receive before prophylactic drug therapy for tuberculosis is started? 

A. Serum creatinine and blood urea nitrogen (BUN) 

B. Aspartate aminotransferase (AST; SGOT) and alanine aminotransferase (ALT; SGPT) 

C. Complete blood count (CBC) and hematocrit 

D. White blood cell (WBC) count and urinalysis 

Answer: B 

Explanation: AST (SGOT) and ALT (SGPT) are liver function tests. INH can cause liver toxicity. Serum creatinine and BUN are renal function tests and would test for toxicity to streptomycin or kanamycin. CBC and hematocrit might be indicated if bleeding or bone marrow depression were major expected toxicities. WBC and urinalysis might be indicted for urinary tract infections. 

68 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5101) 

During the preoperative period, which nursing action will be of greatest priority for a person who is to have a laryngectomy? 

A. Establish a means of communication. 

B. Prepare the bowel by administering enemas until clear. 

C. Teach the client to use an artificial larynx 

D. Demonstrate the technique for suctioning a laryngectomy tube. 

Answer: A 

Explanation: Establishing a means of communication is the highest priority. Teaching the client to use an artificial larynx is a postoperative task. Because the laryngectomy tube will be temporary, the client will not need to learn to suction. That is a nursing function. 

Question 5102) 

A 62-year-old man is admitted with emphysema and acute upper respiratory infection. Oxygen is ordered at 2 L/min. The reason for low-flow oxygen is to: 

A. prevent excessive drying of secretions 

B. facilitate oxygen diffusion of the blood 

C. prevent depression of the respiratory drive. 

D. compensate for increased airway resistance 

Answer: C 

Explanation: The stimulus to breathe in a person with COPD is a low oxygen level rather than a carbon dioxide level, as in normal persons. If high-flow oxygen were given, the oxygen level would increase, and the respiratory drive would cease. 

Question 5103) 

An adult is admitted with chronic obstructive pulmonary disease (COPD). The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of which of the following? 

A. Pneumothorax 

B. Cor pulmonale 

C. Cardiogenic shock 

D. Left-sided heart failure 

Answer: B 

Explanation: Distended neck veins and peripheral edema are signs of right-sided heart failure or cor pulmonale— heart failure due to pulmonary causes. 

Question 5104) 

A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client’s temperature is 102°F., respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to: 

A. promote thoracic expansion. 

B. prevent the development of atelectasis 

C. decrease metabolic needs. 

D. prevent infection of others. 

Answer: C 

Explanation: Bed rest will reduce metabolic needs in this client who has pneumonia and is having difficulty meeting oxygenation needs. Semiupright position, not bed rest, will promote thoracic expansion. Isolation prevents infection of others. Deep breathing will help to prevent the development of atelectasis. 

Question 5105) 

An adult is to have a tracheostomy performed. What is the nursing priority? 

A. Shave the neck 

B. Establish a means of communication 

C. Insert a Foley catheter 

D. Start an IV 

Answer: B 

Explanation: The nursing priority is to establish a means of communication because she will not be able to speak after the tracheostomy is performed. 

Question 5106) 

Which nursing action is essential during tracheal suctioning? 

A. Using a lubricant such as petroleum jelly 

B. Administering 100% oxygen before and after suctioning 

C. Making sure the suction catheter is open or on during insertion 

D. Assisting the client to assume a supine position during suctioning 

Answer: B 

Explanation: One hundred percent oxygen is given before and after suctioning to help prevent hypoxia. Petroleumbased lubricants are not water-soluble and should never be used near an airway. Saline is used as a lubricant. The suction catheter is off during insertion to avoid traumatizing the tissues. The client should be in a semi-sitting position during suctioning. Supine predisposes to aspiration. 

Question 5107) 

An adult has a chest drainage system. Several hours after the chest tube was inserted, the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling? 

A. The client’s lungs have re-expanded. 

B. There is an obstruction in the tubing coming from the client. 

C. There is a mechanical problem in the pump 

D. Air is leaking into the drainage apparatus. 

Answer: B 

Explanation: Cessation of bubbling in the water seal bottle means either an obstruction in the tubing or reexpansion of the lung. This is the night of insertion of the tube. It takes at least 24 hours and often two to three days for the lung to reexpand. 

Question 5108) 

An adult has a chest drainage system. The client’s wife reports to the nurse that her husband is restless. The nurse enters the room just in time to see him pull out his chest tube. The most appropriate initial action for the nurse to take is to: 

A. go get petrolatum gauze and apply over the wound. 

B. place her/his hand firmly over the wound. 

C. apply a sterile 4 × 4 dressing. 

D. reinsert the chest tube. 

Answer: B 

Explanation: The nurse’s primary goal has to be to stop air from entering the thoracic cavity and causing the lung to collapse again. Placing a hand firmly over the wound will accomplish this. Answer 1 is wrong, because the nurse should not leave the client. Petrolatum gauze would be ideal, but the nurse should not leave the client. Answer 3 is wrong because a sterile 4 × 4 dressing allows air to enter the thoracic cavity. The nurse should not reinsert the chest tube 

Question 5109) 

An adult had a negative purified protein derivative (PPD) test when he was first employed two years ago. A year later, the client had a positive PPD test and a negative chest xray. This indicated that at that time the client: 

A. was less susceptible to a tuberculosis infection than the year before. 

B. had acquired some degree of passive immunity to tuberculosis. 

C. had fought the Mycobacterium tuberculosis but had not developed active tuberculosis. 

D. was harboring a mild tuberculosis infection in an organ other than the lung. 

Answer: C 

Explanation: A positive PPD test indicates that the client has come in contact with the organism and fought it. A negative chest x-ray indicates that the client won the fight and does not at that time have active tuberculosis. 

Question 5110) 

An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. Which of the following symptoms would suggest a toxic effect of INH? 

A. Paroxysmal tachycardia 

B. Erythema multiforme 

C. Peripheral neuritis 

D. Tinnitus and deafness 

Answer: C 

Explanation: Peripheral neuritis is a toxic effect of INH. Tinnitus and deafness are side effects of streptomycin.

67 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5091) 

The nurse knows that infectious mononucleosis is caused by which of the following? 

A. Cytomegalovirus 

B. Beta-hemolytic Streptococcus 

C. Epstein-Barr virus 

D. Herpes simplex virus I 

Answer: C 

Explanation: The Epstein-Barr virus is the causative organism for infectious mononucleosis. 

Question 5092) 

A child who has leukemia is to have a bone marrow biopsy performed. How will the child be positioned for this procedure? 

A. On his side with the top knee flexed 

B. Prone 

C. Modified Trendelenburg position 

D. On his back with his head elevated 30 degrees 

Answer: A 

Explanation: The iliac crest is the site usually used for a bone marrow biopsy. 

Question 5093) 

A child is being evaluated for possible leukemia. Which assessment finding is most likely to be present? 

A. Numerous bruises on the child’s body 

B. Ruddy complexion 

C. Diarrhea and vomiting

D. Chest pain 

Answer: A 

Explanation: The child with leukemia has a large number of immature white blood cells and not enough red blood cells and platelets. He is likely to have numerous bruises because of the low platelet count. He is likely to have a pale, not ruddy, complexion because he is deficient in red blood cells. Diarrhea and vomiting are possible if he had an intestinal virus, but bruises are much more common. Chest pain is unlikely. 

Question 5094) 

An adult client is to have a sputum for culture. When is the best time for the nurse to collect the specimen? 

A. In the morning right after he awakens 

B. Immediately after breakfast 

C. Two hours after eating 

D. Shortly before he retires for the evening 

Answer: A 

Explanation: The sputum has collected during the night. It is most concentrated early in the morning. 

Question 5095) 

A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse? A. Hemoptysis B. Respirations of 28 C. Pulse of 80 D. Temperature of 99°F Answer: A Explanation: Hemoptysis is the only abnormal finding. All of the others are within normal range for someone who has undergone an invasive procedure. Question 5096) An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for: 

A. 7 A.M.; 11 A.M.; 4 P.M.; 10 P.M. 

B. 10 A.M.; 2 P.M.; 6 P.M.; 10 P.M. 

C. 6 A.M.; 12 noon; 6 P.M.; 12 midnight 

D. 6 A.M.; 10 A.M.; 2 P.M.; 6 P.M. 

Answer: A 

Explanation: Postural drainage should be scheduled before or between meals and close to bedtime. 

Question 5097) 

An adult man has a tracheostomy tube in place. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy?

A. Use a sterile tube each time and suction for 30 seconds 

B. Use sterile technique and turn the suction off as the catheter is introduced 

C. Use clean technique and suction for 10 seconds 

D. Discard the catheter at the end of every shift 

Answer: B 

Explanation: Suctioning should be done under sterile technique for no more than 10 seconds. The suction should be off as the tube is inserted and applied intermittently as it is withdrawn. 

Question 5098) 

During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take? 

A. Release the suction by opening the vent 

B. Continue suctioning to remove the obstruction 

C. Increase the pressure 

D. Suction deeper 

Answer: A 

Explanation: Suction should not be applied as the suction tube is inserted, because this will cause the suction tube to appear to attach to the tracheal wall and create a pulling sensation. 

Question 5099) 

A client comes to the clinic with a bloody nose. Which instruction is most appropriate? 

A. “Sit up with your head tilted forward. Grasp the soft part of your nose firmly between your thumb and forefinger.” 

B. “Lay down and tilt your head backward. Grasp the end of your nose between your fingers.” 

C. “Sit up and lean backwards. Put pressure on the side of your nose with your hand.” 

D. “Lie down with your head lower than your feet. Grasp as much of your nose as possible between your fingers.” 

Answer: A 

Explanation: This position will help to stop bleeding without causing aspiration of any blood dripping down the back of the throat. 

Question 5100) 

A client is admitted with a diagnosis of cancer of the larynx. Which statement made by the client is most likely related to the cause of his illness? 

A. “I have always enjoyed hot Mexican-style food.” 

B. “I have smoked three packs of cigarettes a day for the last 40 years.” 

C. “I used to work in a factory that burned coal.” 

D. “I sang in the church choir every Sunday until my voice got hoarse last year.” 

Answer: B 

Explanation: Cigarette smoking is the greatest risk factor for development of laryngeal cancer. 

66 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5081) 

Which of the following assessment findings should alert the nurse that the elderly client should be evaluated for pernicious anemia? 

A. Clubbing of the nails 

B. Bloody stools 

C. Beefy-red tongue 

D. Enlarged lymph nodes 

Answer: C 

Explanation: Early in the course of pernicious anemia, the tongue becomes beefy red and painful. Later, the tongue atrophies and becomes smooth. Nail clubbing is associated with respiratory and cardiac disorders. Numbness and tingling of the hands and feet are more common with pernicious anemia. Mild diarrhea is associated with pernicious anemia, whereas bloody stools usually are not. Colorectal bleeding is likely to lead to iron deficiency anemia. Enlarged lymph nodes are associated with leukemia, not anemia. 

Question 5082) 

An elderly client who is being treated for pernicious anemia needs to be monitored periodically for which of the following conditions? 

A. Lactose intolerance 

B. Stomach cancer 

C. Dementia 

D. Hearing loss 

Answer: B 

Explanation: The incidence of stomach cancer is increased in clients with deficiency of gastric acid. Intrinsic factor is in gastric acid. Treatment of pernicious anemia corrects the deficiency of vitamin B12 but does not alter the gastric acid production, so the client remains at risk for stomach cancer. Both lactose intolerance and hearing loss occur more commonly with aging, as does pernicious anemia. The presence of pernicious anemia does not alter the risk for either lactose intolerance or hearing loss, however. Dementia does occur in the late stages of untreated pernicious anemia, but for a client who is receiving treatment, there is no increased risk of dementia. 

Question 5083) 

Which of the following would be the best lunch for a client with folic acid deficiency anemia? 

A. Bologna sandwich and vegetable soup 

B. Grilled cheese sandwich and tomato soup 

C. Coleslaw and cream of mushroom soup 

D. Spinach salad and bean soup 

Answer: D 

Explanation: Leafy green vegetables and dried beans are good sources of folic acid. Nuts and citrus fruits are other good sources. The other options do not contain foods high in folic acid. 

Question 5084) 

The nurse administers iron using the Z track technique. What is the primary reason for administering iron via Z track? 

A. To prevent adverse reactions 

B. To prevent staining of the skin 

C. To improve the absorption rate 

D. To increase the speed of onset of action 

Answer: B 

Explanation: Iron is black and stains the skin. The Z track method of pulling the skin to one side before injecting the medications prevents staining of the skin. It also reduces pain from the medication. It does not prevent adverse reactions, improve the absorption rate, or increase the speed of onset of action 

Question 5085) 

The nurse is caring for a client who is thought to have pernicious anemia. What signs and symptoms would the nurse expect in this person? 

A. Easy bruising 

B. Beefy-red tongue 

C. Fine red rash on the extremities 

D. Pruritus 

Answer: B 

Explanation: A beefy-red tongue is characteristic of pernicious anemia. Easy bruising would be seen in a clotting disorder such as hemophilia, in leukemia, or in bone marrow depression. Pruritus is characteristic of Hodgkin’s disease. Pernicious anemia does not present a fine, red rash on the extremities. 

Question 5086) 

A 1-year-old is admitted to the hospital with sickle cell anemia in crisis. Upon admission, which therapy will assume priority? 

A. Fluid administration 

B. Exchange transfusion 

C. Anticoagulant 

D. IM administration of iron and folic acid 

Answer: A 

Explanation: Dehydration causes sickling. Sickling causes clumping and pain. The first priority of care upon admission should be the administration of fluids. Exchange transfusion, if done, is not the first priority. Anticoagulants are not the first priority. Iron and folic acid may be given but are not the first priority. They will not help stop the sickling. Folic acid and iron are necessary to make red blood cells. 

Question 5087) 

A toddler is diagnosed with sickle cell anemia. Her mother is four months pregnant with her second child. The mother asks if there is any chance the new baby will have sickle cell anemia. She says that neither she nor her husband has sickle cell anemia. What is the best response for the nurse to make? 

A. “No. Sickle cell anemia is not inherited.” 

B. “Yes. The new baby will also have sickle cell anemia.” 

C. “There is a 25% chance that each child you have will have the disease.” 

D. “Because neither of you has the disease, another child will not have it. You should ask your physician.” 

Answer: C 

Explanation: Sickle cell anemia is a recessive gene that is transmitted, giving a 25% chance that each child will have the disease. To have a child with the disease, both parents must be carriers for the disease even though neither one has the disease. 

Question 5088) 

The child with haemophilia is admitted to the hospital with a swollen knee joint. He is complaining of severe pain. What is the priority of nursing care for this child upon admission? 

A. Maintain joint function 

B. Use a bed cradle 

C. Administer aspirin as needed for pain 

D. Encourage fluids 

Answer: B 

Explanation: Hemarthrosis (bleeding into a joint) is very painful. A bed cradle will keep the bed covers off of his sore joint. Moving a bleeding joint will increase bleeding and should not be done. Aspirin is an anticoagulant and contraindicated for a hemophiliac. Fluid administration is not the priority nursing action. 

Question 5089) 

The nurse is caring for a child who has hemophilia. He is admitted with a bleeding episode. Which of the following should the nurse expect will be given to stop the bleeding? 

A. Heparin 

B. Cryoprecipitate 

C. Packed cells 

D. Whole blood 

Answer: B 

Explanation: Cryoprecipitate is frozen clotting factor and replaces the factors that the child is missing. Heparin is an anticoagulant and contraindicated for this child. Packed cells might be given after a severe hemorrhage but do not contain any clotting factors.Whole blood does not contains clotting factors. 

Question 5090) 

A 19-year-old college student reports to the health service with a sore throat, malaise, and fever of four days in duration. Examination shows cervical lymphadenopathy and splenomegaly. Temperature is 103°F. Blood is positive for heterophil antibody agglutination test. Which condition does the nurse expect this student to have? 

A. Streptococcal sore throat 

B. Infectious mononucleosis 

C. Rubella 

D. Influenza 

Answer: B 

Explanation: The findings are characteristic of infectious mononucleosis. The heterophil antibody agglutination test is diagnostic for mononucleosis. A throat culture would identify a streptococcal sore throat. Rubella (German measles) typically has a rash. The fever and sore throat are not typical of rubella. Influenza might have similar symptoms but would not have a positive heterophil agglutination test.

65 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5071) 

A 5-year-old boy is admitted because he bled profusely when he lost his first baby tooth. After a workup, he is diagnosed as having classic hemophilia. His mother asks the nurse if his two younger sisters will also develop hemophilia. What is the best answer for the nurse to give? 

A. “They will not develop the disease.” 

B. “Statistically, one of them is likely to develop the disease.” 

C. “They are not likely to get the disease, but they may be carriers.” 

D. “If it doesn’t show up by the time they start school, they are unlikely to develop the condition.” 

Answer: 

C Explanation: Hemophilia is carried on the X chromosome and causes disease when it appears in combination with the Y chromosome in the male. Answer 1 is a true statement, but it is not complete and, therefore, not the best answer. 

Question 5072) 

The nurse has been teaching the parents of a child with hemophilia about the care he will need. Which statement by the parents indicates a need for more instruction? 

A. “If my child needs something for pain or a fever, I will give him acetaminophen instead of aspirin.” 

B. “I will take my child to the dentist for regular checkups.” 

C. “I will keep my child in the house most of the time.” 

D. “My son’s Medic Alert Bracelet arrived.” 

Answer: C 

Explanation: Parents of children with hemophilia tend to overprotect them. A goal is to have the child lead as normal a life as possible. Answer 1 is correct. He should not receive aspirin because it is an anticoagulant. Answer 2 indicates good knowledge. Prophylactic dental care is important so he will not need dental work or extractions. Answer 4 indicates good knowledge. He should always wear a Medic Alert Bracelet in case he is injured. 

Question 5073) 

A college student who is diagnosed as having infectious mononucleosis asks how the disease is spread. The nurse’s response is based on the knowledge that the usual mode of transmission is through 

A. skin. 

B. genital contact. 

C. contaminated water 

D. intimate oral contact 

Answer: D 

Explanation: The virus is spread through intimate oral contact. It is called the “kissing disease.” It can also be spread by sharing eating and drinking utensils and by coughing and sneezing. 

Question 5074) 

A young man who has infectious mononucleosis asks what the treatment is for his condition. What is the best response for the nurse to make? 

A. “You will receive large doses of antibiotics for the next 10 days.” 

B. “Rest and good nutrition are the best things you can do.” 

C. “You will be given an antiviral agent that will help to control the symptoms.” 

D. “You will probably be given steroid medications for several months.” 

Answer: B 

Explanation: Rest and good nutrition are the hallmarks of treatment for mononucleosis. Recovery may take several months. Because it is caused by a virus, antibiotics are not indicated. He would receive antibiotics only if he develops a secondary infection. There are no effective antiviral agents for this condition. Steroids are not indicated. 

Question 5075) 

An 8-year-old boy is admitted to the unit with a diagnosis of acute lymphocytic leukemia. During a routine physical exam, numerous ecchymotic areas were noted on his body. The parent reported that the child has been more tired than usual lately. The parent says that the child has had a cold for the last several weeks and asks if this is related to the leukemia. The nurse’s response is based on the knowledge that: 

A. leukemia causes a decrease in the number of normal white blood cells in the body. 

B. a chronic infection such as the child has had makes a child more likely to develop leukemia. 

C. the virus responsible for colds is thought to cause leukemia. 

D. having an infection prior to the onset of leukemia is merely a coincidence. 

Answer: A 

Explanation: Leukemia causes a decrease in normal white blood cells. White blood cells are the infection fighting cells. Infections occur because of the decrease in white blood cells due to leukemia. Infections do not cause leukemia. 

Question 5076) 

A child with leukemia bruises easily. This is most likely due to which of the following? 

A. Decreased fibrinogen levels 

B. Excessive clotting elsewhere in the body 

C. Decreased platelets 

D. Decreased erythrocytes 

Answer: C 

Explanation: n leukemia, there is bone marrow failure. In addition to producing abnormal, immature white blood cells, the bone marrow fails and does not produce stem cells from which red blood cells and platelets develop. 

Question 5077) 

A child who is being treated for leukemia develops stomatitis. Which of the following nursing care measures is essential? 

A. Using dental floss to clean the teeth 

B. Frequent cleaning of the mouth with an astringent mouthwash 

C. Use of an overbed cradle 

D. Swabbing the mouth with moistened cotton swabs 

Answer: D 

Explanation: Stomatitis (mouth inflammation) is a frequent complication of chemotherapy for leukemia. He has a tendency to bleed because of his decreased platelets. Dental floss might cause bleeding. An astringent mouthwash is too strong for his tender mouth. An overbed cradle does not relate to stomatitis. Moistened cotton swabs are a gentle means of cleaning the mouth. 

Question 5078) 

When planning care for a client who is HIV positive, the nurse should do what? 

A. Teach persons coming in contact with the client to wear a gown and mask at all times 

B. Teach persons to wear gloves when handling any of the client’s body fluids 

C. Restrict visitors to immediate family 

D. Encourage the client to stay away from other persons as much as possible 

Answer: B 

Explanation: Standard precautions are indicated. Answer 1 is not correct. It is not necessary to wear a gown and mask unless there is a risk of exposure to body fluids. Answer 3 is not correct. There is no reason to limit visitors. Answer 4 is not correct. The client is HIV positive. There is no indication that the client is immunocompromised and at an increased risk of infection from others. The client will not transmit the disease unless there is contact with body fluids. 

Question 5079) 

Which action should the nurse expect to perform after a client has a bone marrow biopsy taken from the iliac crest? 

A. Apply pressure to the site for one minute 

B. Administer a narcotic analgesic 

C. Apply an adhesive bandage to the site 

D. Place the client in a recumbent position 

Answer: D 

Explanation: The client should lie in bed in a recumbent position on top of a pressure dressing that has been applied to the site. Hemorrhage poses a slight risk after this procedure. Pressure should be applied to the site for several minutes. A pressure dressing should then be applied for one hour to reduce the chances of bleeding or hemorrhage. An analgesic may be ordered and administered prior to the procedure. Use of deep breathing and relaxation techniques may also be helpful. There is seldom any pain after the biopsy, although the site may ache for a few days. 

Question 5080) 

Which of the following would be the most appropriate snack for a client who has iron deficiency anemia? 

A. Half of a grapefruit 

B. A carrot raisin salad 

C. A cup of yogurt 

D. Apple slices and cheese 

Answer: B 

Explanation: Carrots and raisins are both high in iron. Red meats and spinach are other good iron sources. Citrus fruits such as grapefruit are high in folic acid, vitamin C, and potassium, but not iron. Dairy products such as yogurt and cottage cheese provide calcium but no iron. Apples are not good sources of iron.