REVALIDA EXAM 200 ITEMS..ANSWER WITH RATIONALE 1. A.

The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safetyof the fetus and necessitate discontinuing the drug. 2. B. It is of paramount importance to prevent the client from hurting himself or herself or others. 3. B. After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding. 4. A. Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes. 5. B. The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator. 6. C. The most frequent cause of noncompliance to the treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the clients ability to read for extended periods and making participation in games with fast-moving objects impossible. 7. B. This stops the sucking of air through the tube and prevents the entry of contaminants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube. 8. D. Because umbilical cords insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth. 9. B. It is important to externalize the anger away from self. 10. D. Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infants muscle tone would be poor and the infant would not be able to achieve this milestone. 11. D. Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospitals policy regarding telephone orders. Failure to followhospital policy could be considered negligence. In this case, the nurse was new and did not know the hospitals policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless a) no one else is available and b) it is an emergency situation. 12. C. The nurse is obligated to inform the nurse manager about changes in the condition of the client, which may change the decision made by the nurse manager. 13. A. Perinatal risk factors for the development of Down syndrome include advanced maternal age, especially with the first pregnancy. 14. B. Assignments should be based on scope of practice and expertise. 15. B. The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the childs serum potassium level should be carefully monitored. 16. A. The responsible for an accurate informed consent is the physician. An exception to this answer would be a life-threatening emergency, but there are no data to support another response. 17. D. Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded.

18. B. Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again. 19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate holding the medication and notifying the physician. 20. B. This option is least threatening. 21. D. In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant container. 22. A. Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding. 23. B. This is the proper use of anger. 24. C. There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations and continually monitor progress overtime. 25. A. Phenytoin should be infused or injected into larger veins to avoid the discoloration know as purple glove syndrome; infusing into a smaller vein is not appropriate. 26. C. Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH. 27. D. Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the clients only remaining lung. 28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia. 29. D. The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents. 30. C. It describes a democratic process in which all members have input in the clients care. 31. A. Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland. 32. B. In case management, the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty. 33. A. Smoke inhalation affects gas exchange. 34. C. Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result. 35. B. This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning). 36. D. Taking the mothers pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia. 37. A. Antihistamines cause pupil dilation and should be avoided with glaucoma.

38. A. This suggests that the level of consciousness is decreasing. 39. D. An advance directive is a form of informed consent, and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse, are enforced. 40. C. Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive. 41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn. 42. D. The priority for this client is being able to establish an airway. 43. A. Signs of placental separation include a change in the shape of the uterus from ovoid to globular. 44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding. 45. D. Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and deepbreathing exercises should be planned to maximize the analgesic effects. 46. B. Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage. 47. D. After surgery for a ruptured appendix, the client should be placed in a semi-Fowlers position to promote drainage and to prevent possible complications. 48. C. Directing and evaluation of staff is a major responsibility of a nursing manager. 49. A. The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac. 50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to recognized and evaluate because it is not apparent. 51. C. Erythema toxicum is the normal, nonpathological macular newborn rash. 52. D. The family needs to understand what brain death is before talking about organ donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed. 53. A. Bending from the waist in pregnancy tends to make backache worse. 54. B. Support and limit setting decrease anxiety and provide external control. 55. C. The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful and excoriated. 56. B. It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur from sperm deposited before ovulation. 57. C. An advocate role encourage freedom of choice, includes speaking out for the client, and supports the clients best interests.

58. A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to ones sexual partner. 59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy. 60. D. Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may in greater pathology in a woman with potential breast carcinoma. 61. B. The registered nurse cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraint requires further assessment to determine if there are additional causes for the behavior. 62. C. The client with chest pain may be having a myocardial infarction, and immediate assessment and intervention is a priority. 63. B. Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours. 64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant. 65. A. Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated. 66. C. Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the client noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance. Client should be in a well-ventilated room, without air recirculation, to prevent air contamination. 67. A. It is best to establish baseline information first. 68. B. Listening is probably the most effective response of the four choices. 69. A. Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose). 70. C. A high fever accompanied by a body rash could indicate that the child has a communicable disease and would have exposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection. 71. A. Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may indicate premature rupture of the membrane. 72. D. Gentle aspiration of mucus helps maintain a patent airway, required for effective gas exchange. 73. A. Somatoform disorders provide a way of coping with conflicts. 74. C. Immunization should never be mixed together in a syringe, thus necessitating three separate injections in three sites. Note: some manufacturers make a premixed combination of immunization that is safe and effective. 75. A. Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees. 76. A. Syrup of ipecac is not administered when the ingested substances is corrosive in nature. Toilet

bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested substance burned the esophagus going down, it will burn the esophagus coming back up when the child begins to vomit after administration of syrup of ipecac. 77. B. Inability to open eyelids on operative side is seen with cranial nerve III damage. 78. A. Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the first priority. 79. C. The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment, as well as legal obligation to provide adequate supervision. 80. D. Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi. 81. A. Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will experience a longer time to get pregnant. 82. B. Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance test. 83. A. Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings. 84. C. The behavior should be stopped. The first is to remind the staff that confidentiality maybe violated. 85. C. With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. The clients good side should be closest to the bed to facilitate the transfer. 86. D. Legos are small plastic building blocks that could easily slip under the childs cast and lead to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are some other narrow or small items that could easily slip under the childs cast and lead to a break in skin integrity and infection. 87. D. Oxytocin (Pitocin) is used to maintain uterine tone. 88. B. The submission of reports about incidents that expose clients to harm does not remove the obligation to report ongoing behavior as long as the risk to the client continues. 89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of tetracycline. In this case, the child is being given this medication four times a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses.) 90. C. An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors. 91. A. Personality disorders stem from a weak superego, implying a lack of adequate controls. 92. C. The basal body temperature is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 C to 36.3C during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature may be seen, after ovulation in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 C. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred. 93. A. This choice implies concern for client care and self-improvement. 94. C. The first trimester is the period of organogenesis, that is, cell differentiation into the various organs, tissues, and structures. 95. C. This response does not contradict the clients perception, is honest, and shows empathy.

96. D. Tension on round ligament occurs because of the erect human posture and pressure exerted by the growing fetus. 97. D. The Good Samaritan Law does not impose a duty to stop at the scene of an emergency outside of the scope of employment, therefore nurses who do not stop are not liable for suit. 98. C. Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia, she will most probably have bathroom privileges. 99. B. A normal respiratory rate for a newborn is 30-40 breaths per minute. 100. D. The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal (often unsuspected on a surgical unit.) 101. D. Move the person to a safer place. * The old woman is in the middle of a train railway. It is very unsafe to immobilize here legs and remain still at the middle of a railway considering that a train might come anytime while waiting for an ambulance. Safety is the utmost importance at this point. If letter D is not among the choices and the situation is a little less dangerous, the answer will be A. Remember that in all cases of emergencies, removing the victim from the scene to a much safer place is a priority. 102. D. Shortened, Adducted and Externally Rotated. * SADDER should be your keyword. A hip fracture will produce a SHORTENED, ADDUCTED AND EXTERNALLY ROTATED extremity. Treatment will evolve in casting the leg and putting it in a EXTENSION, NEUTRALLY POSITIONED and SLIGHT INTERNAL ROTATION. In Hip prosthesis, The nurse should maintain the clients leg in FLEXION, EXTERNAL ROTATION and ABDUCTION to prevent the dislocation of the prosthesis from the acetabulum. Take note of the difference because I mistakenly answered the LATTER in casting a hip fracture thinking that it is similar to a the leg positioning in hip dislocation. Just imagine a patient with a cast that has his leg in ABDUCTION, EXTERNAL ROTATION AND FLEXION. It will cause flexion contractures. 103. B. Inflammation * After a trauma, Inflammation will start almost instantly. Infection occurse 24-48 hours after bone fracture and not immediately. Thrombophlebitis occurs within 4 to 7 days of hospitalization after prolonged immobilization. There is no evidence that the client has a degenerative disease and degenerative diseases will manifest in variety of ways and not after a trauma. 104. A. Hypothyroidism * B,C,D all contributes to bone deminiralization except HYPOTHYROIDISM. Hyperthyroidism will contribute to bone deminiralization as well as Hyperparathyroidism due to the increase in PTH, It will cause the movement of calcium from the bone to the blood causing HYPERCALCEMIA. ESRD will cause increase in PHOPHSATE due to its poor excretion. The amount of phosphate is inversely proportional to the amount of calcium. Cushing disease promotes bone demineralization as well as medications like diuretics and anti convulsants. 105. A. Tachycardia and Hypotension * hemorrhage results in severing of the vascular supply of the bone of the femur and the pelvis due to the fracture leading to bleeding causing the s/s of tachycardia and hypotension.

106. B. On his left hand, because of reciprocal motion. * Reciprocal motion is a very important aspect of rehabilitation. Mr. Rojas has a weakness on his right leg. If a human moves his right leg, the left arm will accompany the movement of the right leg. That is what you call RECIPROCAL MOTION which is innate, natural and required to maintain balance. Mr. Rojas has weakness in his RIGHT LEG. If we put the cane on his right arm, The client will then be left UNSUPPORTED when he use his stronger leg [LEFT LEG] and stand with his weaker leg [RIGHT LEG] due to the fact that the opposite arm must accompany the movement of the opposite leg [RIGHT ARM]. In a more easier term, Always put the cane on the opposite of the weaker side. A is not correct because the client is NOT hemiplegic and will never be correct to reason out why the cane must always be at the opposite of the weaker side, it will always be due to reciprocal motion. 107. c. 6 Inches at the lateral side of the foot. * Remove option A, the client will kick off the cane if it was in the front of the foot. Remove option D because that is too far and will cause the cane to poorly support the client because the side, not the tip, is touching the ground. At 3 inches, imagine how short it is and will cause a very poor supporting base. The correct answer is anywhere from 6 to 10 inches for both crutches and cane. 108. A. Moves the cane when the right leg is moved. * If the right side of the brain is affected, weakness will always be CONTRALATERAL and therefore, Mr. Rojas will have weakness on his left side. Earlier I told you that cane is held on the opposite side of the weaker side, which in this situation, will be on the RIGHT. Imagine if the client moves his RIGHT LEG together witht the RIGHT CANE, it already violated the LAW OF RECIPROCAL MOTION. Moving the right leg will require Mr. Rojas to move his left arm and not the cane, which is on his right. 109. A. PPD * PPD stands for purified protein derivative. It is used to check for TB exposure. All clients who had BCG need not perform this test because they will always be + . 110. C. ID * A Wheal is created intradermally and then it is marked and timed. reading will be done within 2 to 3 days. 111. D. 10 mm Induration * 10 mm Induration [ redness ] is considered positive for individuals with competitive immune response. Wheals are not measured, they will not anymore enlarge. A 5 mm induration is considered positive for patients with AIDS or immunocompromised. 112. B. 48 hours * Clients are asked to comeback within 2 to 3 days for the reading. 113. A. Call the Physician * The nurse has no authority order the radiology department for a chest x ray evaluation nor order for a sputum exam. The client need not be isolated because Mantoux test do not determine the activeness of the disease.

114. D. Almost all Filipinos will test positive for Mantoux Test * almost all filipinos tests positive for mantoux test due to the fact that BCG are required and TB exposure in the country is fullminant. All individuals vaccinated with BCG will test POSITIVE for mantoux test all their lives. 115. A. I * Category I patients are those with a newly diagnosed TB whose sputum culture are positive. II are for those who have relapses while III are those with negative sputum culture but positive chest x ray, or PTB Minimal. 116. C. 4 months * Clients in category I will have 2 months INTENSIVE and 4 months maintenance treatment. 117. C. Ethambutol * Drugs given in the maintenance phase includes Rifampicin and Isoniazid. Ethambutol is given on the intensive phase along with rifampicin and isoniazid. Pyridoxine is given during Isoniazid treatment to prevent peripheral neuritis in contrast in treatment of parkinson's with levodopa, Pyridoxine or VB6 is restricted. 118. A. 6-12 months after * According to the department of health, the most hazardous period for development of clinical disease is during the first 6 to 12 months. 119. B. National Tuberculosis Control Program * National tuberculosis control program is the name of the program of the DOH to control and eradicate TB in the country. DOTS refers to the STRATEGY used by the department in treating TB patients. EPI is not a program for TB control although BCG is one of the vaccine given in this program. 120. A. 23 Year old athlete with diabetes insipidus * Nutrition, Long term immunosupression and drug abuse are all factors that affects the resistance of an individual in acquiring communicable diseases. Other factors includes extremes of ages, poor environmental sanitation, poverty and poor living conditions. Diabetes insipidus does not, in anyway alter a persons immune response. 121. B. Secondary * National board exam loves asking about level of prevention. Mastery with the primary, secondary and tertiary levels of prevention is a must. All diagnostic, case finding and treatment belongs to the secondary level of prevention. 122. B. Participate with the nurse in his daily ostomy care * Actual participation conveys positive acceptance and adjustment to the altered body image. Although looking at the ostomy site also conveys acceptance and adjustment, Participating with the nurse to his daily ostomy care is the BEST adaptation a client can make during the first few days after colostomy creation.

123. A. Plain NSS / Normal Saline * The colon is not sterile, nor the stomach. Tap water is used in enema irrigation and not NSS. Although some clients would prefer a distilled, mineral or filtered water, NSS is not always necessary. KY Jelly is used as the lubricant for the irrigation tube and is inserted 3-4 inches into the colostomy pointing towards the RIGHT. Irrigation sleeve is use to direct the flow of the irrigated solution out of the stomach and into the bedpan or toilet. 124. B. 3-4 inches * Remember 3-4 inches. They are both used in the rectal tube and colostomy irrigation tube insertion. 1 to 2 inches is too short and may spill out the irrigant out of the stoma. Starting from 6 inches, it would be too long already and may perforate the bowel. 125. B. 12 inches C. 18 inches * If you will answer in the CGFNS and NCLEX, C will be the correct answer. According to BRUNNER AND SUDDARTHS and Saunders, The height of the colostomy irrigation bag should be hanging above the clients shoulder at around 18 inches. According to MOSBY, 12 inches should be the maximum height. According to Lippinncots, 18 inches is the maximum height. According the the board of examiners, 12 inches should be the maximum height and an 18 inches irrigant height would cause rapid flow of the irrigant towards the colostomy. Therefore, answer in the local board should only be at 12 inches. 126. C. Agrees to look at the colostomy * The client made the best initial step in learning to care for his colostomy once he looks at the site. This is the start of the client's acceptance on his altered body image. A,B and D delays learning and shows the client's disintrest regarding colostomy care. 127. A. Stop the irrigation by clamping the tube * Stopping the irrigation will also stop the cramping and pain. During the first few days of irrigation, The client will feel pain and cramping as soon as the irirgant touches the bowel. This will start to lessen once the client got accustomed to colostomy irrigation. Slowing down the irrigation will not stop the pain. Telling the client that it is normal and will subside eventually is not acceptable when a client experiences pain. Pain is all encompasing and always a priority over anything else in most situations. Notifying the physician will not be helpful and unecessary. 128. D. Protruding stoma with swollen appearance * A refers to a retracted stoma, B refers to a stoma that is getting a very poor blood supply. C is a description of stenosis of the stoma. 129. C. Eat beet greens and parsley * Kinchay and Pechay helps lessen the odor of the colostomy. Spinach, broccoli, Cabbage, Cucumbers, Patola or bottle gourd also help lessen the odor BUT are gas formers. Eggs are not recommended because they are known to cause unpleasant odors in patients with colostomy. 130. B. Suspend the irrigant 45 cm above the stoma * 1 inches is equal to 2.54 cm. Convert the cm if you are not familiar. 45 cm is around 17 inches which is ideal for colostomy irrigation. Any value from 12 to 18 is accepted as the colostomy irrigant height.

Tap water is used as an irrigant and is infused at room temperature. 4 cm is a little bit short for the ideal 3-4 inches. If cramping occurs STOP the irrigation and continue when is subsides. 131. A. Brick Red * The stoma should be RED in color. Pale pink are common with anemic or dehydrated patients who lost a lot of blood after an operation. Blue stoma indicated cyanosis or alteration in perfusion. Stomas are not expected to be Gray. 132. D. Suction the client every hour * This is unecessary. Suctioning is done on PRN basis and not every hour. A,B and C are all correct processes of suctioning a tracheostomy. 133. D. Fr. 18 * The height is given and it looks like james is a very tall individual. The maximum height of suction tube is used. fr 12-18 are used for adults while 6-8 are used in children.

134. C. 10-15 mmHg * A is used in pediatric clients. B is for children and C is for adults. 20-25 mmHg is too much for a portable suction unit and is not recommended. 135. C. 100-120 mmHg * A is used in pediatric clients. B is for children and C is for adults. 155-175 mmHg is too much for a wall suction unit and is not recommended. 136. C. Obturator and Kelly clamp * In an emergency like this, The first thing the nurse should do is maintaining the airway patency. With the cannunlas dislodged, The stoma will stenosed and narrows giving james an obstructed airway. The nurse would insert the kelly clamp to open the stoma and lock the clamp in place to maintain it open while she uses an obturator as to prevent further stenosis of the stoma. An obturator is a part of the NGT package included by most manufacturers to guide the physician or nurses in inserting the outer cannula. 137. A. Wilma places 2 fingers between the tie and neck * Wilma should place 2 fingers underneath the tie to ensure that it is not too tight nor too loose. Letter D is the measurement for NGT insertion and is unrelated to tracheostomy. 138. A. James respiratory rate is 18 * an RR of 18 means that James is not tachypneic and has an adequate air exchange. Oxygen saturation should be more than 95%. Frank blood is not expected in the suction tube. A slight tinged of blood in the tube is acceptable and expected. Amount of secretion are not in anyway related in assessing the respiratory condition of a person and so is the amount of blood in the tube. 139. A. 10 seconds * According to our reviewers and lecturers, 10 to 15 seconds is the maximum suction time. But according to almost all foreign books I read, it should only be 10 seconds at max. I prefer following

Saunders,Mosby and Lippinncots when they are all united. 140. D. Pain * There is NO PAIN in open angle glaucoma. A,B,C are all present in both glaucomas including the low pressure glaucoma. Pain is absent because the increase in intra ocular pressure is not initiated abruptly. It is gradual and progressive and will lead to unoticed loss of peripheral vision. Pain is present in acute close angle glaucoma because there is a sudden closure or narrowing of the canal of schlemm. Therefore if you will be ask what s/s is common in both, answer IRREVERSIBLE LOSS OF PERIPHERAL VISION. 141. A. Sudden blockage of the anterior angle by the base of the iris * Sudden blockage of the angle will cause s/s of acute angle closure glaucoma. B and C are all related to open angle glaucoma. D is insignificant, If the client bends or cough, IOP can increase from 8 to as much as 30 mmHg but then return again to normal. 142. B. Measures the Intra Ocular Pressure * Tonometry measures the IOP. Normal range is 8 to 21 mmHg. 143. D. CONES [RETINA] * CONES Are responsible for COLOR VISION and DAY VISION, they are very sensitive to RED LIGHT that is why red lights are use to guide the elderly towards the bathroom when they wake up to urinate. Rods are responsible for night vision. They are sensitive to blue and green lights. 144. D. In the Ciliary Body * AH is produced in the CILIARY BODY. It is filtered by the trabecular meshwork into the canal of schlemm. 145. A. 8-21 mmHg 146. B. Snellens Chart * CN II is the optic nerve. To assess its acuity, Snellen's chart is used. Slit lamp is the one you see in the usual Eye glasses shop where in, you need to look into its binocular-like holes and the optometrist is on the other side to magnify the structures of the eye to assess gross damage and structure. Woods light is a BLUE LIGHT used in dermatology. It is use to mark lesions usually caused skin infection. Gonioscopy is the angle measurement of the eye. 147. A. Contract the Ciliary muscle * When the ciliary muscles contract, pupils constrict and the angle widens causing an increase AH outflow and decrease IOP. Relaxing the ciliary muscle will cause mydriasis or dilation, it is used as a pre op meds for cataract surgery and eye examination to better visualize the structures behind the iris. A and C are the same. Other drugs like betaxolol, Azetazolamide and epinephrine are the drugs used to decrease AH production. 148. B. Reduce production of Aqueous Humor * All the eye drops the ends in OLOL decreases AH production. They are BETA BLOCKERS. Watch out for the S/S of congestive heart failure, bradycardia, hypotension and arrythmias.

149. B. Bending at the waist * Bending at the waist increase IOP and should be avoided by patients with glaucoma. Treatment for glaucoma is usually for life. Patients are given laxatives to avoid stratining at the stool. They should avoid all activities that will lead to sudden IOP increase like bending at the waist. Clients should bend at the knees. 150. A. Reading newsprint * The client had an eye angiography. Eye angiography requires the use MYDRIATICS pre-procedure. It is done by injecting an Intravenous dye and visualizes the flow of the dye throught the fluoroscopy along the vessels of the eye. This is to assess macular degeneration or neovascularizations [ proliferation of new vessels to compensate for continuous rupture and aneurysms of the existing vessels ] Mydratics usually takes 6 hours to a day to wear off. If client uses a mydratic, his pupil wil dilate making it UNABLE to focus on closer objects. Only A necessitates the constriction of the pupil to focus on a near object, which Mr.Batumbakals eye cannot perform at this time. 151. Answer C. When obtaining the history of a patient who may be in labor, the nurses highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illness, allergies, and support persons. 152. Answer B. During the second stage of labor, the nurse should assess the strength, frequency, and duration of contraction every 15 minutes. If maternal or fetal problems are detected, more frequent monitoring is necessary. An interval of 30 to 60 minutes between assessments is too long because of variations in the length and duration of patients labor. 153. Answer A. Blurred vision of other visual disturbance, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for both the patient and fetus. Although hemorrhoids may be a problem during pregnancy, they do not require immediate attention. Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progresses. 154. Answer B. Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Maternal age is not a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history or preterm labor may place the patient at risk for preterm labor, it does not correlate with genetic defects. 155. Answer C. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle is not significant. Breast tenderness and mittelschmerz are not reliable indicators of ovulation. 156. Answer A. An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR. The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. Pushing the control button after every three fetal movements or at the end of fetal movement wouldnt allow accurate comparison of fetal movement and FHR changes. 157. Answer B. Blurred or double vision may indicate hypertension or preeclampsia and should be

reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy. 158. Answer B. Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breast-feeding after surgery is possible. Still, its good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mothers ability to meet all of her babys nutritional needs, and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the clients psychological adaptation to mothering may be dependent on how successfully she breast feeds. 159. Answer B. Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration. 160. Answer B. In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an ectopic pregnancy. 161. Answer C. Fetal station the relationship of the fetal presenting part to the maternal ischial spines is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as 1, 2, or 3. A presenting part below the ischial spines, as +1, +2, or +3. 162. Answer D. Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby whos smacking his lips isnt well attached and can injure the mothers nipples. 163. Answer D. Ultrasound is used between 18 and 40 weeks gestation to identify normal fetal growth and detect fetal anomalies and other problems. Amniocentesis is done during the third trimester to determine fetal lung maturity. Chorionic villi sampling is performed at 8 to 12 weeks gestation to detect genetic disease. Fetoscopy is done at approximately 18 weeks gestation to observe the fetus directly and obtain a skin or blood sample. 164. Answer C. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isnt in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isnt within normal limits. 165. Answer C. During the third trimester, the pregnant client typically perceives the fetus as a separate being. To verify that this has occurred, the nurse should ask whether she has made appropriate changes at home such as obtaining infant supplies and equipment. The type of anesthesia planned doesnt reflect the clients preparation for parenting. The client should have begun prenatal classes earlier in the pregnancy. The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes. 166. Answer B. This question requires an understanding of station as part of the intrapartal assessment process. Based on the clients assessment findings, this client is ready for delivery, which

is the nurses top priority. Placing the client in bed, checking for ruptured membranes, and providing comfort measures could be done, but the priority here is immediate delivery. 167. Answer A. Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the clients position from supine to side-lying may immediately correct the problem. An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the priority is to change the womans position and relieve cord compression. 168. Answer A. Hemorrhage jeopardizes the clients oxygen supply the first priority among human physiologic needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over diagnoses of Risk for infection, Pain, and Urinary retention. 169. Answer A. Lactation is an example of a progressive physiological change that occurs during the postpartum period. 170. Answer B. The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruption placentae. 171. Answer D. For most clients with type 1 diabetes mellitus, nonstress testing is done weekly until 32 weeks gestation and twice a week to assess fetal well-being. 172. Answer A. The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyper stimulated neurologic system by interfering with signal transmission at the neuromascular junction. 173. Answer B. The blastocyst takes approximately 1 week to travel to the uterus for implantation. 174. Answer A. An episiotomy serves several purposes. It shortens the second stage of labor, substitutes a clean surgical incision for a tear, and decreases undue stretching of perineal muscles. An episiotomy helps prevent tearing of the rectum but it does not necessarily relieves pressure on the rectum. Tearing may still occur. 175. Answer D. The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration, and intrauterine growth retardation (IUGR). Therefore, the nurse must notify the physician of the clients cocaine use because this knowledge will influence the care of the client and neonate. The information is used only in relation to the clients care. 176. Answer B. After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 3 months to prevent the possibility of the vaccines toxic effects to the fetus. 177. Answer D. The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. 178. Answer A. In some birth settings, intravenous therapy is not used with low-risk clients. Thus, clients in early labor are encouraged to eat healthy snacks and drink fluid to avoid dehydration. Yogurt, which is an excellent source of calcium and riboflavin, is soft and easily digested. During pregnancy, gastric emptying time is delayed. In most hospital settings, clients are allowed only ice chips or clear liquids. 179. Answer A. When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the clients statement. If the client is not delivering precipitously,

the nurse can calm her and use appropriate breathing techniques. 180. Answer A. Using both hands to assess the fundus is useful for the prevention of uterine inversion. 181. Answer B. The actual access to the subclavian vein is still just under the clavicle, but by tunneling the distal portion of the catheter several inches under the skin the risk of migratory infection is reduces compared to a catheter that enters the subclavian vein directly and is not tunneled. The catheter is tunneled to prevent infection. 182. Answer C. A foreign body in a blood vessel increases the risk of infection. Catheters that come outside the body have an even higher risk of infection. Most infections are caused by skin bacteria. Other infective organisms include yeasts and fungi. Options 1 and 4 are complications of a CVAD but are not the primary problem. Once placed, these lines do not cause pain and discomfort. 183. Answer D. A solution containing heparin is used to reduce catheter clotting and maintain patency. The concentration of heparin used depends on the patients age, comorbidities, and the frequency of catheter access/flushing. Although patients have few complications, the device is not risk free. Patients may develop infection, catheter clots, vascular obstruction, pneumothorax, hemothorax, or mechanical problems (catheter breakage). Strict adherence to protocol enhances the longevity of central access devices. They routinely last weeks to months and sometimes years. The patient will be taught how to perform dressing changes at home. 184. Answer A. Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription. Alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression. Nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkins lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA cross-linkage. Alkylating agents are noncell cycle-specific agents. 185. Answer C. Estrogen antagonists are used to treat estrogen hormone-dependent cancer, such as breast carcinoma. A well-known estrogen antagonist used in breast cancer therapy is tamoxifen (Nolvadex). This drug, in combination with surgery and other chemotherapeutic drugs reduces breast cancer recurrence by 30 percent. Estrogen antagonists can also be administered to prevent breast cancer in women who have a strong family history of the disease. Thyroxine is a natural thyroid hormone. It does not treat thyroid cancer. ACTH is an anterior pituitary hormone, which stimulates the adrenal glands to release glucocorticoids. It does not treat adrenal cancer. Glucagon is a pancreatic alpha cell hormone, which stimulates glycogenolysis and gluconeogenesis. It does not treat pancreatic cancer. 186. Answer D. The time required to clear circulating cells before the effect that chemotherapeutic drugs have on precursor cell maturation in the bone marrow becomes evident. Leukopenia is an abnormally low white blood cell count. Answers A-C pertain to red blood cells. 187. Answer A. Epoetin alfa (Epogen, Procrit) is a recombinant form of endogenous erythropoietin, a hematopoietic growth factor normally produced by the kidney that is used to induce red blood cell production in the bone marrow and reduce the need for blood transfusion. Glucagon is a pancreatic alpha cell hormone, which cause glycogenolysis and gluconeogenesis. Fenofibrate (Tricor) is an antihyperlipidemic agent that lowers plasma triglycerides. Lamotrigine (Lamictal) is an anticonvulsant. 188. Answer A. Prostate tissue is stimulated by androgens and suppressed by estrogens. Androgen antagonists will block testosterone stimulation of prostate carcinoma cells. The types of cancer in options 2-4 are not androgen dependent. 189. Answer A. Chemotherapy often induces vomiting centrally by stimulating the chemoreceptor trigger zone (CTZ) and peripherally by stimulating visceral afferent nerves in the GI tract. Ondansetron (Zofran) is a serotonin antagonist that bocks the effects of serotonin and prevents and treats nausea and vomiting. It is especially useful in single-day highly emetogenic cancer chemotherapy (for example, cisplatin). The agents in options 2-4 are selective serotonin reuptake inhibitors. They increase the available levels of serotonin.

190. Answer C. With intrathecal administration chemotherapy is injected through the theca of the spinal cord and into the subarachnoid space entering into the cerebrospinal fluid surrounding the brain and spinal cord. The methods in options A, B, and D are ineffective because the medication cannot enter the CNS. 191. Answer B. Leucovorin is used to save or "rescue" normal cells from the damaging effects of chemotherapy allowing them to survive while the cancer cells die. Therapy to rapidly reduce the number of cancerous cells is the induction phase. Consolidation therapy seeks to complete or extend the initial remission and often uses a different combination of drugs than that used for induction. Chemotherapy is often administered in intermittent courses called pulse therapy. Pulse therapy allows the bone marrow to recover function before another course of chemotherapy is given. 192. Answer B. Prevent uric acid nephropathy, uric acid lithiasis, and gout during cancer therapy since chemotherapy causes the rapid destruction of cancer cells leading to excessive purine catabolism and uric acid formation. Allopurinol can induce myelosuppression and pancytopenia. Allopurinol does not have this function. 193. Answer B. Medications administered intravesically are instilled into the bladder. Intraventricular administration involves the ventricles of the brain. Intravascular administration involves blood vessels. Intrathecal administration involves the fluid surrounding the brain and spinal cord. 194. Answer C. The overall goal of cancer chemotherapy is to give a dose large enough to be lethal to the cancer cells, but small enough to be tolerable for normal cells. Unfortunately, some normal cells are affected including the bone marrow. Myelosuppression limits the bodys ability to prevent and fight infection, produce platelets for clotting, and manufacture red blood cells for oxygen portage. Even though the effects in options a, b, and d are uncomfortable and distressing to the patient, they do not have the potential for lethal outcomes that myelosuppression has. 195. Answer A. Vomiting (emesis) is initiated by a nucleus of cells located in the medulla called the vomiting center. This center coordinates a complex series of events involving pharyngeal, gastrointestinal, and abdominal wall contractions that lead to expulsion of gastric contents. Catecholamine inhibition does not induce vomiting. Chemotherapy does not induce vomiting from autonomic instability. Chemotherapy, especially oral agents, may have an irritating effect on the gastric mucosa, which could result in afferent messages to the solitary tract nucleus, but these pathways do not project to the vomiting center. 196. Answer A. Myelo comes from the Greek word myelos, which means marrow. Ablation comes from the Latin word ablatio, which means removal. Thus, myeloablative chemotherapeurtic agents destroy the bone marrow. This procedure destroys normal bone marrow as well as the cancerous marrow. The patients bone marrow will be replaced with a bone marrow transplant. Myelocytes ar e not muscle cells Tumors are solid masses typically located in organs. Surgery may be performed to reduce tumor burden and require less chemotherapy afterward. 197. Answer C. Nausea and vomiting (N&V) are common side effects of chemotherapy. Some patients are able to trigger these events prior to actually receiving chemotherapy by anticipating, or expecting, to have these effects. N&V occurring post-chemotherapeutic administration is not an anticipatory event but rather an effect of the drug. N&V occurring during the administration of chemotherapy is an effect of the drug. 198. Answer C. Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect. Less drug is available if bound to protein. Distribution to receptor sites is irrelevant since the drug bound to protein cannot bind with a receptor site. Metabolism would not be increased. The liver will first have to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again. 199. Answer C. Drugs and drug metabolites with molecular weights higher than 300 may be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their halflife and duration of action in the body. Hepatic clearance is the amount of drug eliminated by the liver. Total clearance is the sum of all types of clearance including renal, hepatic, and respiratory.

First-pass effect is the amount of drug absorbed from the GI tract and then metabolized by the liver; thus, reducing the amount of drug making it into circulation. 200. Answer C. Drug B will induce the cytochrome p-450 enzyme system of the liver; thus, increasing the metabolism of Drug A. Therefore, Drug A will be broken down faster and exert decreased therapeutic effects. Drug A will be metabolized faster, thus reducing, not increasing its therapeutic effect. Inducing the cytochrome p-450 system will not increase the adverse effects of Drug B. Drug B induces the cytochrome p-450 system but is not metabolized faster. Thus, the therapeutic effects of Drug B will not be decreased.