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
A head nurse of an intensive care unit wants to ensure that the staff are performing Basic Life
Support (BLS) based on latest American Heart Association's guidelines.
What will be the head nurse's BEST action?
B
Explanation:
Ensuring that staff perform Basic Life Support (BLS) according to the latest American Heart
Association (AHA) guidelines involves several strategies, but performing regular mock drills is the
best approach.
Reviewing the BLS Policy Periodically: While this is important, it alone does not ensure that staff are
up-to-date or proficient in BLS techniques.
Performing Regular Mocks on BLS in the Unit: Regular mock drills provide hands-on practice and
allow staff to apply the latest guidelines in a simulated environment. This helps in retaining skills and
identifying any gaps in knowledge or performance.
Sending Staff to Renew BLS Certification Every Three Years: Certification renewal is necessary, but
practical skills can degrade over time if not regularly practiced.
Monitoring the Staff Performing BLS During the Actual Scene: This is reactive rather than proactive
and does not provide an opportunity for practice and improvement without the pressure of a real-life
situation.
Reference:
American Heart Association (AHA): Guidelines for CPR and ECC
National Institutes of Health (NIH): Effective Training Strategies in Healthcare
A nursing instructor teaching a group of nursing students about the recommended diet for a patient
with a myocardial infarction.
Which of the following points will be included in the teaching?
A
Explanation:
When teaching nursing students about the recommended diet for a patient with a myocardial
infarction, it's crucial to emphasize a diet low in fat and cholesterol. This helps in reducing the risk of
further cardiovascular complications.
Low Fat and Cholesterol: Foods low in saturated fat and cholesterol are recommended to prevent the
build-up of plaque in the arteries and reduce the risk of another heart attack.
Avoiding Red Meat: High intake of red meat is discouraged because it is often high in saturated fat
and cholesterol.
Dark Chocolate Intake: While some dark chocolate in moderation can have health benefits due to its
antioxidant properties, the emphasis should be on a balanced diet.
Protein and Carbohydrates: Protein is essential for recovery, but the focus should be on lean sources.
Carbohydrates should come from whole grains and other healthy sources rather than simple sugars.
Reference:
American Heart Association (AHA): Dietary Recommendations for Cardiovascular Health
National Institutes of Health (NIH): Heart-Healthy Eating
A nurse is performing a chest physical assessment on a client with asthma.
Which of the following lung sounds the nurse expects to hear?
C
Explanation:
In a chest physical assessment of a client with asthma, the nurse expects to hear wheezes.
Wheezes: These are high-pitched, musical sounds heard during expiration (and sometimes
inspiration) caused by narrowing or obstruction of the airways.
Stridor: This is a high-pitched sound usually heard on inspiration, typically associated with upper
airway obstruction, not asthma.
Crackles: These are popping sounds heard during inspiration, often associated with conditions like
pneumonia or heart failure, not typical for asthma.
Diminished Lung Sounds: This can occur in severe asthma but is less common compared to wheezes.
Reference:
American Thoracic Society: Asthma Diagnosis and Monitoring
National Institute of Allergy and Infectious Diseases (NIAID): Asthma Symptoms and Diagnosis
A nurse is aiming to utilize an evidence based process to improve pain management for patients with
cancer.
The initial step the nurse should start with is:
C
Explanation:
The initial step in an evidence-based process to improve pain management for patients with cancer
is to write an answerable question.
Writing an Answerable Question : This is often done using the PICO (Patient/Problem, Intervention,
Comparison, Outcome) format to clearly define the clinical issue and guide the research.
Selecting the Study Design: This comes after formulating the question and involves choosing an
appropriate methodology to answer it.
Obtaining Ethical Approval: This is essential for conducting research but comes after defining the
question and designing the study.
Formulating Hypothesis Statement: This is part of the research design and planning, following the
creation of an answerable question.
Reference:
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing & Healthcare: A
Guide to Best Practice.
National Institutes of Health (NIH): Evidence-Based Practice Resources
A mother of a newborn is diagnosed with breast cancer, the surgeon recommended to carry out an
emergency operation.
According to Freud's theory, which stage of newborn development is being affected?
A
Explanation:
According to Freud's theory of psychosexual development, the stage affected in a newborn is the oral
stage.
Oral Stage: This stage occurs from birth to about 18 months of age, where the infant's pleasure
centers on the mouth through activities like sucking and biting.
Anal Stage: This stage follows the oral stage, from 18 months to 3 years, focusing on bowel and
bladder control.
Phallic Stage: This occurs from 3 to 6 years, focusing on the genitals and the differences between
males and females.
Latent Stage: This stage occurs from 6 years to puberty, characterized by dormant sexual feelings and
a focus on social and intellectual skills.
Reference:
Freud, S. (1905). Three Essays on the Theory of Sexuality.
National Institutes of Health (NIH): Child Development Theories