A patient with a history angina pectoris brought by to the Emergency Department complaining of
severe chest pain. The patient informs the nurse that he did not take nitroglycerine tablet.
Which of the following assessment findings must concern the nurses MOST before administering
nitroglycerine?
D
Explanation:
Patient History: The patient has angina pectoris, which means they have episodes of chest pain due
to reduced blood flow to the heart muscle. Nitroglycerin is a common medication used to relieve this
pain by dilating blood vessels.
Nitroglycerin Mechanism: Nitroglycerin works by relaxing and widening blood vessels, which
decreases the workload on the heart and increases blood flow to the heart muscle. This process
typically lowers blood pressure.
Assessment Concerns:
Heart rate of 90 bpm: This is within the normal range and does not typically contraindicate the use of
nitroglycerin.
Blood sugar of 12 mmol/L: Elevated blood sugar is concerning but not directly affected by
nitroglycerin administration.
Blood pressure of 190/110 mmHg: This is high and nitroglycerin can help reduce it. High blood
pressure is often treated with nitroglycerin.
Blood pressure of 80/60 mmHg: This is hypotension (low blood pressure). Since nitroglycerin lowers
blood pressure further, administering it to a patient with already low blood pressure can lead to
severe hypotension, which is life-threatening.
Conclusion: The most concerning finding is the low blood pressure (80/60 mmHg) because
administering nitroglycerin in this situation can further lower the blood pressure to dangerous levels.
Reference: NCLEX-RN review guides, pharmacology textbooks, clinical guidelines on the
management of angina pectoris and nitroglycerin use.
A circulating nurse is caring for a patient who is undergoing to laparotomy under a general
anesthesia in the Operating Room.
What is the PRIORITY nursing diagnosis the circulating nurse would include in the care plan?
C
Explanation:
Role of Circulating Nurse: The circulating nurse manages the overall environment of the operating
room, ensuring safety and coordination among the surgical team. They are responsible for
maintaining patient safety, including correct positioning.
Prioritizing Safety:
Risk for anxiety: While relevant, managing anxiety is typically addressed preoperatively and
postoperatively, not the immediate intraoperative period.
Risk for bleeding: While bleeding is a concern, it is primarily monitored and managed by the surgical
team.
Risk for injury related to positioning: During surgery, improper positioning can lead to nerve damage,
pressure sores, and musculoskeletal injuries. The circulating nurse must ensure that the patient is
correctly positioned to avoid these injuries.
Risk for infection: Preventing infection is crucial, but the sterile field and surgical techniques
primarily address this risk.
Conclusion: The highest priority for the circulating nurse is to ensure the patient is correctly
positioned to prevent any injury related to positioning, as this is a direct and immediate
responsibility during the surgical procedure.
Reference: Surgical nursing textbooks, NCLEX-RN review guides, AORN (Association of periOperative
Registered Nurses) guidelines.
A nurse is providing health education and instructions to a woman who has been diagnosed with
mastitis.
Which of the following statements if made by the woman indicates a need for further teaching?
A
Explanation:
Understanding Mastitis: Mastitis is an infection of the breast tissue that results in breast pain,
swelling, warmth, and redness. It often occurs in breastfeeding women.
Appropriate Management:
Continue Breastfeeding: It is generally recommended to continue breastfeeding or pumping to
relieve milk stasis and prevent further complications.
Analgesia: Pain relief medications (analgesia) can help manage discomfort associated with mastitis.
Antibiotics: Antibiotics are often prescribed, and improvement is typically seen within 24-48 hours.
Warm Compression: Applying warm compresses before breastfeeding can help alleviate pain and
improve milk flow.
Incorrect Belief: The statement "I need to stop breastfeeding until this condition resolves" indicates a
misunderstanding. Stopping breastfeeding can worsen the condition due to milk stasis and increased
engorgement.
Conclusion: The statement indicates a need for further teaching as continuing breastfeeding is crucial
for managing and resolving mastitis.
Reference: Maternal and child nursing textbooks, NCLEX-RN review guides, clinical guidelines on
breastfeeding and mastitis management.
A nurse is preparing to collect a throat culture for a middle-aged male patient.
The nurse is aware that the swabbing should be collected from:
D
Explanation:
Purpose of Throat Culture: A throat culture is performed to detect the presence of pathogens (like
bacteria) that cause infections such as strep throat.
Correct Technique:
Uvula and Soft Palate: These are not the primary sites for collecting throat cultures.
Any site of Oral Cavity Mucosa: This is too broad and non-specific.
Tongue and Buccal Mucosa: These sites are not typically infected in throat infections and do not
provide accurate culture results.
Oropharynx and Tonsillar Region: The mucosa of the oropharynx and tonsillar region is the most
common site of infection in throat infections, making it the appropriate site for swabbing.
Procedure: The nurse should gently swab the oropharynx and tonsillar area, avoiding the tongue and
other parts of the oral cavity to avoid contamination and ensure accurate results.
Conclusion: The correct site for collecting a throat culture is the mucosa of the oropharynx and
tonsillar region, ensuring the detection of the causative pathogens.
Reference: Clinical nursing skills textbooks, NCLEX-RN review guides, guidelines for throat culture
collection.
The aim of outcome research in nursing is to:
C
Explanation:
Outcome research in nursing focuses on understanding the results of health care practices and
interventions. It aims to evaluate how effective these practices are in improving patient outcomes.
This type of research is crucial for ensuring that the care provided is evidence-based and leads to the
best possible health results for patients.
For example, if a new wound care protocol is introduced, outcome research would measure whether
patients heal faster or have fewer infections compared to the previous method. This helps in
determining the effectiveness of the new protocol.
Reference:
Polit, D. F., & Beck, C. T. (2017). Nursing Research: Generating and Assessing Evidence for Nursing
Practice. Wolters Kluwer Health.
A nurse is caring for an adult client with cancer who is complaining of acute pain.
The MOST appropriate pain assessment would be:
A
Explanation:
The most appropriate way to assess pain is by asking the client to rate their pain. Pain is a subjective
experience, meaning only the person experiencing it can accurately describe its intensity and quality.
This is often done using a numerical scale (0-10) where the patient rates their pain, with 0 being no
pain and 10 being the worst pain imaginable.
Nonverbal cues and the nurse's impression can provide additional information, but they are not as
reliable as the patient's self-report. Pain relief after interventions helps evaluate the effectiveness of
the pain management but does not assess the initial pain level.
Reference:
McCaffery, M., & Pasero, C. (1999). Pain: Clinical Manual. Mosby.
A client with schizophrenia is placed on chlorpromazine 50 mg PO bid, and Benztropine 2 mg PO bid
PRN.
Which of the following nursing assessment findings would indicate a need to administer
Benztropine?
D
Explanation:
Chlorpromazine is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), such
as muscle spasms and tremors. Benztropine is an anticholinergic medication often prescribed to
manage these side effects.
If a client on chlorpromazine develops muscle spasms and tremors, it indicates EPS, and
administering Benztropine would help alleviate these symptoms. The other options, such as severe
agitation, sore throat, or suicidal thoughts, are not directly related to the need for Benztropine.
Reference:
Stahl, S. M. (2013). Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical
Applications. Cambridge University Press.
A nurse is visiting an Asian family and found that both parents have cardiac problems. The nurse is
aware of Asian genetic predisposition to cardiovascular diseases.
The nurse assessment falls below which of the following cultural assessment category?
A
Explanation:
When assessing the health of a family, considering their genetic predispositions to certain conditions
falls under the category of bio-cultural factors. These factors include genetic traits, physical
characteristics, and biological variations that can influence health. In this case, the nurse's awareness
of the genetic predisposition of Asian individuals to cardiovascular diseases helps in understanding
the family's health risks.
Reference:
Spector, R. E. (2017). Cultural Diversity in Health and Illness. Pearson.
A woman presents to the clinic with signs and symptoms of menopause. The doctor advised to start
hormonal replacement therapy. The woman enquired about the adverse effects of this therapy.
Which of the following is an adverse effects of the hormonal replacement therapy?
C
Explanation:
Hormone replacement therapy (HRT) can have several adverse effects. One significant risk associated
with HRT, especially if estrogen is given without progesterone to women with an intact uterus, is the
increased risk of endometrial cancer. Estrogen stimulates the lining of the uterus, and without the
balancing effect of progesterone, this can lead to endometrial hyperplasia and potentially cancer.
Other risks include breast cancer, blood clots, and stroke, but endometrial cancer is a specific
concern with unopposed estrogen therapy.
Reference:
Goodman, N. F., et al. (2011). American Association of Clinical Endocrinologists medical guidelines
for clinical practice for the diagnosis and treatment of menopause. Endocrine Practice, 17(6), 1-25.
A nurse understands that patient with blood transfusion reaction is at risk to develop which of the
following types of jaundice?
C
Explanation:
A blood transfusion reaction can lead to hemolytic jaundice. This type of jaundice occurs when there
is an excessive breakdown of red blood cells, leading to an increase in bilirubin production.
Hemolytic reactions during a blood transfusion cause the destruction of the transfused red blood
cells, releasing large amounts of hemoglobin into the bloodstream, which is then converted to
bilirubin, resulting in jaundice.
Reference:
American Association of Blood Banks (AABB). (2017). Technical Manual, 19th Edition. AABB Press.
A nurse is caring for a patient who is admitted into the surgical ward and was diagnosed with
perforated appendix and is shifted to operation room for appendectomy.
The nurse understands that this procedure is classified as:
B
Explanation:
A perforated appendix is a medical emergency requiring immediate surgical intervention to prevent
complications such as peritonitis and sepsis. Therefore, an appendectomy in this context is classified
as an emergent procedure. Emergent surgeries are those that need to be performed without delay to
preserve the patient's life or health.
Reference:
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of
Medical-Surgical Nursing. Lippincott Williams & Wilkins.
Which of the following is an appropriate role of the parents in the teenage-stage of family
developmental tasks?
C
Explanation:
During the teenage stage of family development, parents play a crucial role in helping their
adolescents balance freedom with responsibility. This includes setting appropriate boundaries,
providing guidance, and encouraging independence while ensuring that teenagers understand and
meet their responsibilities. It is a critical period where parental support and oversight help teens
develop into responsible adults.
Reference:
Hockenberry, M. J., & Wilson, D. (2018). Wong's Nursing Care of Infants and Children. Elsevier.
A nurse is caring for a patient with bacterial meningitis who develops high-grade fever and nasal
discharge.
Which of the following is the FIRST nursing intervention for this patient?
D
Explanation:
The first nursing intervention for a patient with bacterial meningitis who develops a high-grade fever
and nasal discharge is to follow infection precautions. This is crucial to prevent the spread of the
infection to others. Bacterial meningitis is highly contagious, and infection control measures such as
isolation and wearing protective gear should be implemented immediately upon diagnosis and
continued for at least 24 hours after starting antibiotic treatment.
Reference:
Centers for Disease Control and Prevention (CDC). (2018). Bacterial Meningitis. Retrieved from CDC
website.
A nurse must be aware that keeping an aggressive patient in a seclusion or restraint requires an order
from the doctor.
The renewal of such order for a patient aged 19 years old must be done:
C
Explanation:
When a patient aged 19 years old is placed in seclusion or restraint, the renewal of the order must be
done every 4 hours. This requirement is based on the guidelines provided by the Joint Commission
and the Centers for Medicare & Medicaid Services (CMS), which regulate the use of seclusion and
restraints in healthcare settings.
Initial Order: The use of seclusion or restraint must be ordered by a licensed independent
practitioner (LIP), such as a physician.
Time Limits: For adults aged 18 and older, the order must be renewed every 4 hours.
Renewal Process: This renewal must involve an assessment of the patient's condition and the need
for continued seclusion or restraint.
Documentation: The rationale for using seclusion or restraint and the patient's response to the
intervention must be documented thoroughly in the patient's medical record.
Reference:
The Joint Commission: Standards for Behavioral Health Care
Centers for Medicare & Medicaid Services (CMS): Conditions of Participation for Hospitals, 42 CFR
482.13(e)
The unit in-charge is following up an incident report for a patient who fell down from the bed to be
written by the nurse.
Which of the following actions if done by the nurse needs to be corrected?
D
Explanation:
When an incident such as a patient fall occurs, specific protocols must be followed to ensure proper
documentation and quality improvement processes.
Writing the Incident Report Immediately: The nurse should document the incident as soon as
possible to ensure accurate details are captured.
Investigating the Root Cause of the Incident: This is essential to prevent future occurrences and
improve patient safety. It involves a thorough analysis of the factors that led to the incident.
Writing the Incident Report by the Assigned Nurse: The nurse who witnessed or discovered the
incident is typically responsible for documenting it, ensuring first-hand accuracy.
Documenting the Incident Report in Patient's Record: This is incorrect. Incident reports are meant for
internal use to track and analyze incidents and should not be included in the patient’s medical
record. Including it in the patient's record can potentially compromise confidentiality and affect the
patient’s care.
Reference:
The Joint Commission: Sentinel Event Policy and Procedures
National Patient Safety Foundation: Guidelines for Incident Reporting