QUESTIONS AND ANSWERS UPDATED
2023/2024)
1. 1. Question
The nurse is providing discharge teaching for the client withleukemia. The client should be told to avoid:
o A. Using oil- orcream-based soaps
o B. Flossing between the teeth
o C. The intake of salt
o D. Using an electric razor
Correct Answer: B. Flossing between the teeth
The client who is immune-suppressed and has bone marrow suppression should
be taught not to floss his teeth because platelets are decreased.
Option A: Oil or cream-based soap is allowed for leukemia patients
because these will prevent dry skin, which predisposes to skin injury.
Option C: A healthy amount of salt in the patient’s food is allowed.
Option D: The use of an electric razor is recommended because it
reduces the risk of injury to the skin that can cause bleeding.
• 2. Question
The nurse is changing the ties of the client with a tracheostomy.The safest method of changing the tracheostomy ties is
to:
o A. Apply the new tie before removing the old one.
o B. Have a helper present.
, o C. Hold the tracheostomy with the nondominant handwhile removing the old tie.
o D. Ask the doctor to suture the tracheostomy in place.
Correct Answer: A. Apply the new tie before removing the old one.
Leaving the old ties in place while securing the clean ties prevents inadvertent
dislodging of the tracheostomy tube.
Option B: Having a helper is good, but the helper might not prevent
the client from coughing out the tracheotomy.
Option C: Hold the tracheostomy with the nondominant hand while
removing the old tie is not the best way to prevent the client from
coughing out the tracheotomy.
Option D: Asking the doctor to suture the tracheostomy in place is
unnecessary.
• 3. Question
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse
shouldgive priority to:
o A. Turning the client to the left side
o B. Milking the tube to ensure patency
o C. Slowing the intravenous infusion
o D. Notifying the physician
Correct Answer: D. Notifying the physician
The output of 300 mL is indicative of hemorrhage and should be reported
immediately.
Option A: Turning the client to the left side does nothing to help the
client.
Options B and C: Milking the tube is done only with an order and will
not help in this situation, and slowing the intravenous infusion is not an
appropriate action.
, • 4. Question
The infant is admitted to the unit with tetralogy of fallot. Thenurse would anticipate an order for which medication?
o A. Digoxin
o B. Epinephrine
o C. Aminophylline
o D. Atropine
Correct Answer: A. Digoxin
The infant with Tetralogy of Fallot involves four heart defects: A large ventricular
septal defect (VSD), Pulmonary stenosis, Right ventricular hypertrophy and, An
overriding aorta. He will be treated with digoxin to slow and strengthen the
heart.
Option B: One of the side effects of epinephrine is the pounding, fast,
or irregular heartbeat, which is detrimental to a patient with Tetralogy
of Fallot.
Option C: Increased or rapid heart rate is an adverse effect of
aminophylline and should be avoided for a patient with Tetralogy of
Fallot.
Option D: Atropine prevents or abolishes bradycardia.
• 5. Question
The nurse is educating the lady’s club in a self-breast exam. Thenurse is aware that most malignant breast masses
occur in the Tail of Spence.
On the diagram below, select where the Tail of Spence is.
, o A
o B
o C
o D
Correct Answer: A.
The Tail of Spence is located in the upper outer quadrant of the
breast.
o Option B: Option B is the areola, a dark area of skin
surrounding the nipple.
• 6. Question
The toddler is admitted with a cardiac anomaly. The nurse isaware that the infant with a ventricular septal defect will:
o A. Tire easily
o B. Grow normally
o C. Need more calories
o D. Be more susceptible to viral infections