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