, 1. Which individual is at greatest risk for developing hypertension?
● Ⓐ . 45-year-old African-American attorney
● Ⓑ . 60-year-old Asian-American shop owner
● Ⓒ . 40-year-old Caucasian nurse
● Ⓓ . 55-year-old Hispanic teacher
Question Tag: hypertension
Question Category: Physiological Integrity, Reduction of Risk Potential
Correct Answer: A: 45-year-old African American attorney
● Option A: African-Americans develop high blood pressure at younger ages than other
groups in the US. Researchers have uncovered that African-Americans respond
differently to hypertensive drugs than other groups of people. They are also found out
to be more sensitive to salt, which increases the risk of developing hypertension.
● Option B: The incidence of hypertension in Asian-Americans does not appear to be
significantly higher than the general population, according to limited US data.
● Option C: The racial disparity in hypertension and hypertension-related outcomes has
been recognized for decades with African-Americans with greater risks than
Caucasians.
● Option D: Hypertension prevalence rates in Hispanics may vary by gender and
country of origin. Hispanic Americans overall have relatively low levels of
hypertension, despite elevated levels of diabetes and obesity.
2. A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45
minutes ago is rushed to the emergency department. Which of these orders should the
nurse do first?
● Ⓐ . Gastric lavage
● Ⓑ . Administer acetylcysteine (Mucomyst) orally
● Ⓒ . Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open
● Ⓓ . Have the patient drink activated charcoal mixed with water
Question Tag: acetaminophen
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Correct Answer: A. Gastric lavage
● Option A: Acetaminophen overdose is extremely toxic to the liver causing
hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting, abdominal
pain, and diarrhea. If not treated immediately, hepatic necrosis occurs and may lead to
death. Removing as much of the drug as possible is the first step in treatment for
acetaminophen overdose, this is best done through gastric lavage. Gastric lavage
(irrigation) and aspiration consist of flushing the stomach with fluids and then aspirating
the fluid back out. This procedure is done in life-threatening cases such as
acetaminophen toxicity and only if less than one (1) hour has occurred after ingestion.
, ● Option B: The oral formulation of acetylcysteine is the drug of choice for the treatment
of acetaminophen overdose but should be done after GI decontamination with activated
charcoal. Liver damage is minimized by giving acetylcysteine (Mucomyst), the antidote
for acetaminophen. Acetylcysteine reduces injury by substituting for depleted
glutathione in the reaction that converts the toxic metabolite of acetaminophen to its
nontoxic form. When given within 8 hours of acetaminophen toxicity, acetylcysteine is
effective in preventing severe liver injury. It is administered orally or intravenously.
● Option C: Intermittent IV infusion with Dextrose 5% may be considered for
late-presenting or chronic ingestion.
● Option D: Oral activated charcoal (AC) avidly adsorbs acetaminophen and may be
administered if the patient presents within 1 hour after ingesting a potentially toxic
dose. Charcoal should not be administered immediately before or with antidotes since it
can effectively adsorb it and neutralize the benefits.
3. Which complication of cardiac catheterization should the nurse monitor for in the
initial 24 hours after the procedure?
● Ⓐ . Angina at rest
● Ⓑ . Thrombus formation
● Ⓒ . Dizziness
● Ⓓ . Falling blood pressure
Question Tag: cardiac catheterization
Question Category: Safe and Effective Care Environment, Management of Care
Correct Answer: B. Thrombus formation
A thrombus formation may prevent blood from flowing normally through the circulatory system,
which may become an embolism, and block the flow of blood towards major organs in the body.
● Option A: The reported incidence of myocardial infarction with angina at rest is less
than 0.1%, and is mostly influenced by patient-related factors like the extent and
severity of underlying cardiovascular-related diseases and technique-related factors.
● Options C & D: A falling BP and dizziness occur along with hemorrhage of the
insertion site which is associated with the first 12 hours after the procedure.
4. A client is admitted to the emergency room with renal calculi and is complaining of
moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees
Fahrenheit. The priority nursing goal for this client is:
● Ⓐ . Maintain fluid and electrolyte balance
● Ⓑ . Control nausea
● Ⓒ . Manage pain
● Ⓓ . Prevent urinary tract infection
Question Tag: renal calculi, flank pain
Question Category: Physiological Integrity, Basic Care and Comfort
, Correct Answer: C. Manage pain
Managing pain is always a priority because it ultimately improves the quality of life. The
cornerstone of ureteral colic management is analgesia, which can be achieved most expediently
with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs).
● Option A: IV hydration in the setting of acute renal colic is controversial. Whereas
some authorities believe that IV fluids hasten the passage of the stone through the
urogenital system, others express concern that additional hydrostatic pressure
exacerbates the pain of renal colic.
● Option B: Because nausea and vomiting frequently accompany acute renal colic,
antiemetics often play a role in renal colic therapy. Several antiemetics have a sedating
effect that is often helpful.
● Option D: Overuse of the more effective antibiotic agents leaves only highly resistant
bacteria, but failure to adequately treat a UTI complicated by an obstructing calculus
can result in potentially life-threatening urosepsis and pyonephrosis.
5. What would the nurse expect to see while assessing the growth of children during their
school age years?
● Ⓐ . Decreasing amounts of body fat and muscle mass
● Ⓑ . Little change in body appearance from year to year
● Ⓒ . Progressive height increase of 4 inches each year
● Ⓓ . Yearly weight gain of about 5.5 pounds per year
Question Tag: growth, school age
Question Category: Health Promotion and Maintenance
Correct Answer: D. Yearly weight gain of about 5.5 pounds per year
School age children gain about 5.5 pounds each year and increase about 2 inches in height.
Between ages 2 to 10 years, a child will grow at a steady pace.
● Option A: Decreasing amounts of body fat and muscle mass are common in toddlers.
● Option B: A decrease in the change in body appearance occurs among young adults.
● Option C: Growth spurts are common in school-age children, as are periods of slow
growth.
6. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg.
The client states “My blood pressure is usually much lower.” The nurse should tell the
client to:
● Ⓐ . Go get a blood pressure check within the next 15 minutes
● Ⓑ . Check blood pressure again in two (2) months
● Ⓒ . See the healthcare provider immediately
● Ⓓ . Visit the health care provider within one (1) week for a BP check
● Ⓐ . 45-year-old African-American attorney
● Ⓑ . 60-year-old Asian-American shop owner
● Ⓒ . 40-year-old Caucasian nurse
● Ⓓ . 55-year-old Hispanic teacher
Question Tag: hypertension
Question Category: Physiological Integrity, Reduction of Risk Potential
Correct Answer: A: 45-year-old African American attorney
● Option A: African-Americans develop high blood pressure at younger ages than other
groups in the US. Researchers have uncovered that African-Americans respond
differently to hypertensive drugs than other groups of people. They are also found out
to be more sensitive to salt, which increases the risk of developing hypertension.
● Option B: The incidence of hypertension in Asian-Americans does not appear to be
significantly higher than the general population, according to limited US data.
● Option C: The racial disparity in hypertension and hypertension-related outcomes has
been recognized for decades with African-Americans with greater risks than
Caucasians.
● Option D: Hypertension prevalence rates in Hispanics may vary by gender and
country of origin. Hispanic Americans overall have relatively low levels of
hypertension, despite elevated levels of diabetes and obesity.
2. A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45
minutes ago is rushed to the emergency department. Which of these orders should the
nurse do first?
● Ⓐ . Gastric lavage
● Ⓑ . Administer acetylcysteine (Mucomyst) orally
● Ⓒ . Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open
● Ⓓ . Have the patient drink activated charcoal mixed with water
Question Tag: acetaminophen
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Correct Answer: A. Gastric lavage
● Option A: Acetaminophen overdose is extremely toxic to the liver causing
hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting, abdominal
pain, and diarrhea. If not treated immediately, hepatic necrosis occurs and may lead to
death. Removing as much of the drug as possible is the first step in treatment for
acetaminophen overdose, this is best done through gastric lavage. Gastric lavage
(irrigation) and aspiration consist of flushing the stomach with fluids and then aspirating
the fluid back out. This procedure is done in life-threatening cases such as
acetaminophen toxicity and only if less than one (1) hour has occurred after ingestion.
, ● Option B: The oral formulation of acetylcysteine is the drug of choice for the treatment
of acetaminophen overdose but should be done after GI decontamination with activated
charcoal. Liver damage is minimized by giving acetylcysteine (Mucomyst), the antidote
for acetaminophen. Acetylcysteine reduces injury by substituting for depleted
glutathione in the reaction that converts the toxic metabolite of acetaminophen to its
nontoxic form. When given within 8 hours of acetaminophen toxicity, acetylcysteine is
effective in preventing severe liver injury. It is administered orally or intravenously.
● Option C: Intermittent IV infusion with Dextrose 5% may be considered for
late-presenting or chronic ingestion.
● Option D: Oral activated charcoal (AC) avidly adsorbs acetaminophen and may be
administered if the patient presents within 1 hour after ingesting a potentially toxic
dose. Charcoal should not be administered immediately before or with antidotes since it
can effectively adsorb it and neutralize the benefits.
3. Which complication of cardiac catheterization should the nurse monitor for in the
initial 24 hours after the procedure?
● Ⓐ . Angina at rest
● Ⓑ . Thrombus formation
● Ⓒ . Dizziness
● Ⓓ . Falling blood pressure
Question Tag: cardiac catheterization
Question Category: Safe and Effective Care Environment, Management of Care
Correct Answer: B. Thrombus formation
A thrombus formation may prevent blood from flowing normally through the circulatory system,
which may become an embolism, and block the flow of blood towards major organs in the body.
● Option A: The reported incidence of myocardial infarction with angina at rest is less
than 0.1%, and is mostly influenced by patient-related factors like the extent and
severity of underlying cardiovascular-related diseases and technique-related factors.
● Options C & D: A falling BP and dizziness occur along with hemorrhage of the
insertion site which is associated with the first 12 hours after the procedure.
4. A client is admitted to the emergency room with renal calculi and is complaining of
moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees
Fahrenheit. The priority nursing goal for this client is:
● Ⓐ . Maintain fluid and electrolyte balance
● Ⓑ . Control nausea
● Ⓒ . Manage pain
● Ⓓ . Prevent urinary tract infection
Question Tag: renal calculi, flank pain
Question Category: Physiological Integrity, Basic Care and Comfort
, Correct Answer: C. Manage pain
Managing pain is always a priority because it ultimately improves the quality of life. The
cornerstone of ureteral colic management is analgesia, which can be achieved most expediently
with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs).
● Option A: IV hydration in the setting of acute renal colic is controversial. Whereas
some authorities believe that IV fluids hasten the passage of the stone through the
urogenital system, others express concern that additional hydrostatic pressure
exacerbates the pain of renal colic.
● Option B: Because nausea and vomiting frequently accompany acute renal colic,
antiemetics often play a role in renal colic therapy. Several antiemetics have a sedating
effect that is often helpful.
● Option D: Overuse of the more effective antibiotic agents leaves only highly resistant
bacteria, but failure to adequately treat a UTI complicated by an obstructing calculus
can result in potentially life-threatening urosepsis and pyonephrosis.
5. What would the nurse expect to see while assessing the growth of children during their
school age years?
● Ⓐ . Decreasing amounts of body fat and muscle mass
● Ⓑ . Little change in body appearance from year to year
● Ⓒ . Progressive height increase of 4 inches each year
● Ⓓ . Yearly weight gain of about 5.5 pounds per year
Question Tag: growth, school age
Question Category: Health Promotion and Maintenance
Correct Answer: D. Yearly weight gain of about 5.5 pounds per year
School age children gain about 5.5 pounds each year and increase about 2 inches in height.
Between ages 2 to 10 years, a child will grow at a steady pace.
● Option A: Decreasing amounts of body fat and muscle mass are common in toddlers.
● Option B: A decrease in the change in body appearance occurs among young adults.
● Option C: Growth spurts are common in school-age children, as are periods of slow
growth.
6. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg.
The client states “My blood pressure is usually much lower.” The nurse should tell the
client to:
● Ⓐ . Go get a blood pressure check within the next 15 minutes
● Ⓑ . Check blood pressure again in two (2) months
● Ⓒ . See the healthcare provider immediately
● Ⓓ . Visit the health care provider within one (1) week for a BP check
