Question 1

A nurse is teaching parents about tricuspid atresia. Which statement indicates that the parents understand this disorder?

Accepted Answer

Answer reason: Tricuspid atresia is a congenital absence/imperforation of the tricuspid valve, which blocks normal blood flow from the right atrium into the right ventricle. As a result, blood must shunt through an atrial septal defect (or patent foramen ovale) to reach the left side, and pulmonary blood flow typically depends on an additional connection (e.g., VSD/PDA) to reach the lungs. This makes “no communication between the right atrium and right ventricle” the defining anatomic/physiologic problem. In contrast, aortic outflow narrowing describes aortic stenosis/coarctation, and pulmonary vein malreturn describes TAPVR rather than tricuspid atresia.

Question 2

A nurse is teaching the parents of a child with acute rheumatic fever about the disorder. Which statement would be the most accurate concerning this condition?

Accepted Answer

Answer reason: Acute rheumatic fever is a post-infectious, immune-mediated inflammatory disease that follows untreated or inadequately treated group A streptococcal pharyngitis. The key concept is molecular mimicry leading to inflammation of the heart, joints, skin, and CNS rather than direct bacterial invasion at the time of symptoms. This makes the history of a recent streptococcal infection central to understanding the condition and prevention via appropriate antibiotic therapy. A common distractor is infective endocarditis, which is a direct infection of the endocardium and typically presents with bacteremia-related findings, not a delayed autoimmune phenomenon.

Question 3

A nurse is teaching the parents of a child with Kawasaki disease. Which statement should the nurse include in her teaching about this disorder?

Accepted Answer

Answer reason:  Kawasaki disease is defined by widespread inflammation of medium-sized arteries with unclear etiology, and parent teaching should emphasize this core pathophysiology and the related risk of coronary artery involvement. This statement accurately captures the nature of the disorder in a way that supports understanding of why close follow-up and cardiac monitoring are needed. Laboratory tests may support inflammation but do not establish the diagnosis, which is primarily clinical. Seasonality is not a reliable defining characteristic for teaching, and although the illness is described in phases, reducing it to only two stages is incomplete and less central than the defining vasculitis concept.

Question 4

The nurse is counseling the parents of a neonate with congenital hypothyroidism. The parents tell the nurse that they are concerned about the severity of the intellectual deficit. The nurse explains that the deficit is related to which factor?

Accepted Answer

Answer reason: The longer hypothyroidism persists before levothyroxine is started, the greater the risk and severity of intellectual impairment. Early detection through newborn screening and prompt treatment markedly improves cognitive outcomes. Factors like hypothermia are clinical manifestations but do not determine long-term neurocognitive prognosis as strongly as delayed therapy. The focus of counseling should therefore emphasize the timing of diagnosis and initiation of treatment.

Question 5

Which statement made to a nurse by the parents of a child with idiopathic growth hormone deficiency would indicate the need for further teaching?

Accepted Answer

Answer reason:  Idiopathic growth hormone deficiency can have congenital or inherited causes, so teaching should include that some cases do have a genetic component. Saying there is no genetic basis reflects an absolute statement that is not accurate and could lead the family to misunderstand risk for siblings or the rationale for further evaluation. In addition, growth hormone deficiency may be due to hypothalamic dysfunction affecting GHRH secretion, which supports that mechanism as plausible. Because pituitary problems can be part of broader hypopituitarism, awareness of possible additional pituitary hormone deficiencies is appropriate and does not indicate misunderstanding.

Question 6

The nurse is assessing a client in the emergency department suspected of being in vaso-occlusive crisis. Which assessment findings would indicate that the client is having a vaso-occlusive crisis?

Accepted Answer

Answer reason: Acute extremity pain and dactylitis (hand-foot syndrome) are classic, direct manifestations of this occlusion, especially in children. Findings like anemia, jaundice, and reticulocytosis more strongly reflect hemolysis rather than an acute vaso-occlusive event. Hypotension with a thready pulse would raise concern for shock and is not the hallmark presentation of uncomplicated vaso-occlusion.

Question 7

The nurse is teaching the parents of a child with Kawasaki disease. What is the most accurate statement by the nurse?

Accepted Answer

Answer reason: Kawasaki disease is an acute systemic vasculitis in young children in which persistent high fever is the hallmark early finding and prompts urgent evaluation and treatment to reduce coronary artery complications. As the illness evolves, mucocutaneous changes occur and desquamation of the hands/feet is a classic associated feature that parents are often taught to watch for. It is not a contagious disease, so isolation for infectivity is not indicated. It is also not afebrile and it most commonly affects children younger than 5 years, making the other statements inaccurate.

Question 8

A previously healthy 70-year-old male client has a serum glucose level of 1,200 mg/dl, a normal serum bicarbonate level, and urine free from acetone. The nurse should suspect which condition?

Accepted Answer

Answer reason: This pattern is classic for HHS, which is more common in older adults and is driven by profound dehydration and hyperosmolarity rather than ketone production. In DKA, metabolic acidosis is expected (low bicarbonate) along with ketonemia/ketonuria. Diabetes insipidus and SIADH are disorders of water balance and do not explain a glucose of 1,200 mg/dL.

Question 9

The client, who is a 15-pack-year cigarette smoker, has painful fingers and toes and is diagnosed with Buerger’s disease (thromboangiitis obliterans). Which measure to prevent disease progression should be the nurse’s initial focus when teaching the client?

Accepted Answer

Answer reason: Eliminating all nicotine/tobacco is the only intervention proven to halt progression and reduce the risk of worsening ischemia, ulceration, and amputation. Teaching should prioritize complete cessation, including avoidance of cigarettes and other nicotine-containing products, because even small amounts can sustain vasoconstriction and inflammation. Measures like avoiding cold can reduce vasospasm and symptom flares but do not stop the underlying tobacco-driven process. Dietary saturated fat reduction targets atherosclerosis risk rather than the primary mechanism in thromboangiitis obliterans.

Question 10

The nurse is reviewing the history and physical of a teenager admitted to a hospital with a diagnosis of ulcerative colitis. Based on this diagnosis, which information should the nurse expect to see on this client’s medical record?

Accepted Answer

Answer reason: This inflammation commonly produces crampy abdominal pain with frequent bloody, mucus-containing diarrhea. Heartburn/regurgitation reflects upper GI reflux disease rather than colitis, and weight gain with hyperglycemia is more consistent with endocrine/metabolic issues or steroid effects rather than baseline presentation. Abdominal distention with hypoactive bowel sounds suggests ileus or obstruction, which is not the typical expected finding for uncomplicated ulcerative colitis.

Question 11

The nurse assesses the client, who was injured in a diving accident 2 hours earlier. The client is breathing independently but has no movement or muscle tone from below the area of injury. A CT scan reveals a fracture of the C4 cervical vertebra. The nurse should plan interventions for which problem?

Accepted Answer

Answer reason: Flaccid paralysis and absent muscle tone occurring within hours of the trauma are classic early findings, even before longer-term patterns (e.g., spasticity) emerge. Independent breathing does not exclude this because the phrenic nerve (C3–C5) may remain functional despite severe deficits below C4. A complete transection cannot be concluded from early flaccidity alone because this same presentation can occur during the shock phase and may partially resolve over time.

Question 12

The nurse is caring for the child with secondary burns over 40% of the body. The child has just been diagnosed with DIC. Which priority nursing problem, based on the most recent condition, should the nurse add to the child's plan of care?

Accepted Answer

Answer reason: In a child with major burns, this new diagnosis signals an immediate, life-threatening deterioration in oxygen delivery at the tissue level, making perfusion the highest-priority nursing problem. Fluid deficits are important in burn care, but the question prioritizes the most recent condition, and DIC shifts the urgent focus to maintaining organ perfusion and detecting shock/organ dysfunction early. Urinary and mobility problems are downstream concerns and do not address the immediate systemic threat posed by DIC.

Question 13

An 18-year-old client who recently had an upper respiratory infection is admitted with suspected rheumatic fever. Which assessment findings confirm this diagnosis?

Accepted Answer

Answer reason: The combination of erythema marginatum and subcutaneous nodules are classic major manifestations, and fever is a common supportive minor manifestation, making this cluster strongly confirmatory. Finger clubbing and a loud S2 more strongly suggest chronic hypoxemia or pulmonary hypertension rather than rheumatic fever. The dyspnea-based options are nonspecific and could reflect many cardiopulmonary conditions without pointing to the hallmark rheumatic fever features.

Question 14

A young, African-American, female client with a history of sickle cell disease is complaining of severe abdominal pain. What is the priority intervention by the nurse?

Accepted Answer

Answer reason: Administering I.V. fluids Severe abdominal pain in sickle cell disease is most consistent with vaso-occlusive crisis, where sickled cells obstruct microcirculation and cause ischemia. Immediate hydration decreases blood viscosity and helps improve microvascular flow, reducing ongoing sickling and tissue hypoxia, making it a priority early intervention. Assessment history is important but does not address the acute physiologic problem driving the pain and risk of organ infarction. NPO status and CT preparation are not first-line and could delay time-sensitive stabilization measures; diagnostic imaging may be considered later if complications are suspected after initial stabilization.

Question 15

A client asks the nurse, “What is the difference between rheumatoid arthritis and osteoarthritis?” What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Osteoarthritis is primarily a degenerative “wear-and-tear” process affecting articular cartilage in specific joints, so findings and symptoms are mainly limited to the involved areas. Rheumatoid arthritis is an autoimmune inflammatory disease with systemic manifestations, reflecting whole-body immune activation rather than isolated joint degeneration. This systemic nature explains features such as fatigue, malaise, and extra-articular involvement that are not typical of osteoarthritis. The alternative claiming osteoarthritis is systemic reverses the core pathophysiology and would mislead patient education about expected symptoms and complications.

Question 16

A 58-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this assessment, the nurse suspects the client may be experiencing?

Accepted Answer

Answer reason: Chronic bronchitis (a COPD phenotype) is characterized by long-term smoking exposure with chronic productive cough and thick sputum from mucus gland hyperplasia and airway inflammation. Cyanotic nail beds reflect chronic hypoxemia, which is more typical of the bronchitic “blue bloater” presentation than emphysema. Peripheral edema suggests cor pulmonale/right-sided heart strain from long-standing pulmonary hypertension secondary to chronic hypoxia, again aligning with chronic bronchitis. ARDS is an acute, rapidly progressive respiratory failure syndrome rather than a chronic smoker’s presentation, and asthma usually has episodic reversible bronchospasm rather than persistent purulent sputum with edema.

Question 17

After a nurse has explained the causes of diabetes insipidus to the parents, which statement made by a parent indicates the need for further teaching?

Accepted Answer

Answer reason:  Diabetes insipidus is most commonly due to deficient ADH production (central) or renal resistance to ADH (nephrogenic), arising from genetic/congenital problems or acquired hypothalamic-pituitary/renal pathology. Prenatal alcohol exposure is not a standard or recognized primary cause of diabetes insipidus, so attributing DI to maternal alcohol use reflects misunderstanding and warrants further teaching. In contrast, intracranial tumors can disrupt ADH synthesis/release and infections like meningitis can damage the hypothalamus/pituitary, making those plausible etiologies. Recognizing accurate causes is important so parents understand the workup (e.g., neurologic evaluation/imaging when indicated) and avoid misplaced guilt.

Question 18

An 18-month-old child is admitted to the hospital for full-thickness burns to the anterior chest. The mother asks the nurse how the burn will heal. What is the best response by the nurse?

Accepted Answer

Answer reason: Full-thickness (third-degree) burns destroy the epidermis and dermis, including skin appendages that provide epithelial cells for regeneration, so they cannot heal effectively by re-epithelialization alone. Without surgical management, these wounds heal slowly by granulation and contraction, leading to significant scarring and functional/cosmetic impairment, especially on the chest. Early excision and skin grafting (or other surgical closure methods) is therefore commonly required to achieve timely wound closure and reduce complications such as infection and excessive contracture. The 10–12 day healing time better fits superficial partial-thickness burns, not full-thickness injuries.

Question 19

The client comes to the emergency department complaining of chest pain. Which comment by the client would indicate to the nurse the client is experiencing angina instead of a myocardial infarction?

Accepted Answer

Answer reason: " Angina is typically triggered by increased myocardial oxygen demand (exertion, stress) in the setting of transient coronary ischemia, whereas myocardial infarction pain is more likely to occur at rest and be more persistent. Exertional onset while mowing is a classic pattern for stable angina because activity raises heart rate and blood pressure, increasing oxygen demand beyond supply. Pain that starts with a deep breath is more consistent with pleuritic/musculoskeletal causes rather than cardiac ischemia. Rest-onset pain would raise concern for unstable angina or infarction rather than straightforward exertional angina.

Question 20

The nurse and a nursing student are caring for a client who is diagnosed with hyperglycemic hyperosmolar state (HHS). The student asks the nurse how HHS differs from diabetic ketoacidosis (DKA). Which is the correct reply by the nurse?

Accepted Answer

Answer reason: HHS is characterized by profound hyperglycemia and hyperosmolality with enough circulating insulin to suppress significant lipolysis and ketone production. Therefore, compared with DKA, ketones are minimal or absent and acidosis is not a prominent feature. Potassium abnormalities can still occur due to osmotic diuresis and insulin therapy, so stating there is no potential for hypokalemia is unsafe. Blood glucose is typically higher and dehydration is typically more severe in HHS, making the other statements incorrect.

Question 21

The client diagnosed with Guillain-Barré syndrome is scheduled to receive plasmapheresis treatments. The client's spouse asks the nurse about the purpose of plasmapheresis. Which explanation is correct?

Accepted Answer

Answer reason: Guillain-Barré syndrome is an acute autoimmune-mediated demyelinating neuropathy in which pathogenic antibodies and other immune factors attack peripheral nerves. Plasmapheresis works by removing the patient’s plasma (which contains these circulating antibodies/immune complexes) and replacing it with a substitute, thereby reducing the immune attack and shortening the disease course. It is not a fluid-removal therapy like dialysis/ultrafiltration, and it does not aim to raise protein levels (plasma proteins may actually be removed). It also does not supply lipoproteins to rebuild myelin; neurologic recovery depends on remyelination/axonal repair after the immune process is dampened.

Question 22

The nurse observes for early signs of ARDS in the client being treated for smoke inhalation. Which early signs indicate the possible onset of ARDS in this client?

Accepted Answer

Answer reason: Diaphoresis reflects physiologic stress and increased work of breathing from hypoxemia. Smoke inhalation is a known precipitating injury that can trigger inflammatory lung damage and rapidly worsening oxygenation. In contrast, respiratory alkalosis and blood-tinged sputum are not the key hallmark of early ARDS, and an elevated PaO2 would argue against evolving ARDS.

Question 23

The child with hemophilia is brought to the clinic due to pain and restricted movement of the left knee after falling. The nurse assesses that the knee is hot, swollen, and tender to touch, and applies an ice pack. Based 011 the child's diagnosis, the nurse is thinking that the child may be experiencing which problem?

Accepted Answer

Answer reason:  Children with hemophilia are at high risk for bleeding into joints after even minor trauma, leading to acute hemarthrosis. The hot, swollen, tender knee with decreased range of motion is classic for blood accumulating in the joint space rather than simple soft-tissue injury. Initial nursing measures such as rest/immobilization and ice align with managing joint bleeding while definitive care focuses on replacing the missing clotting factor. A fracture can cause pain and swelling but does not specifically correlate with the underlying bleeding disorder as strongly as joint hemorrhage does, and DIC would present with systemic bleeding and critical illness rather than an isolated knee effusion.

Question 24

The 5-year-old with periorbital edema, anorexia, decreased urine output, and passage of colacolored urine is brought to the ED by the parent. Which history information reported by the child’s parent is most important to report to the HCP?

Accepted Answer

Answer reason: A recent upper respiratory infection within about 1–3 weeks strongly supports a postinfectious (often poststreptococcal) process and helps direct urgent evaluation (blood pressure, renal function, complement levels, and streptococcal testing). This history increases concern for inflammatory renal injury rather than an isolated benign cause of dark urine. In contrast, minor trauma history does not explain generalized edema and reduced urine output and is less predictive of a glomerular disease pattern.

Question 25

The nurse is teaching a client who has a diagnosis of a stroke versus a transient ischemic attack (TIA). Which statement by the nurse describing to the client the difference between stroke and TIA would be the most accurate?

Accepted Answer

Answer reason: A transient ischemic attack is defined by a brief, reversible neurologic deficit caused by temporary cerebral ischemia without lasting infarction. The key distinguishing teaching point is that symptoms are transient and traditionally resolve within 24 hours (often much sooner), whereas stroke produces persistent deficits due to brain tissue injury. Hemorrhage is not characteristic of a TIA, which is an ischemic event. Persistent motor deficits indicate completed stroke rather than a TIA.

Question 26

A nurse is describing tetralogy of Fallot to a child’s parents. Which statement by the parents demonstrates that the teaching has been effective?

Accepted Answer

Answer reason:  Tetralogy of Fallot is a cyanotic congenital heart defect characterized by right-to-left shunting that can abruptly worsen when pulmonary blood flow decreases. These episodic hypoxic events present as hypercyanotic spells, a hallmark teaching point for families because they drive urgent recognition and management. “Blue tets” is not the standard clinical descriptor used in parent teaching, and frequent respiratory infections are more typical of left-to-right shunt lesions. Decreased/absent lower-extremity pulses points to coarctation of the aorta rather than tetralogy of Fallot.

Question 27

A child is admitted with diabetes insipidus. The nurse asks the parents if they know about this condition. Which statement tells the nurse that the parents understand the condition?

Accepted Answer

Answer reason:  Diabetes insipidus is caused by deficient antidiuretic hormone (ADH) production/release from the posterior pituitary or by renal resistance to ADH, leading to inability to concentrate urine. The key concept parents should understand is that the problem is related to inadequate ADH effect, which clinically presents as polyuria and polydipsia with risk for dehydration and hypernatremia. The statement about the pituitary not working hard enough aligns with inadequate ADH availability in central diabetes insipidus. Thyroid and parathyroid dysfunction do not explain the hallmark water-balance findings of diabetes insipidus, and a pituitary “working overtime” implies excess hormone rather than deficiency.

Question 28

A parent is inquiring about their child who tested positive for sickle cell trait. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason:  Sickle cell trait indicates heterozygosity for the hemoglobin S gene, which generally results in carrier status rather than sickle cell disease. Most individuals with trait do not have chronic hemolytic anemia or vaso-occlusive crises seen in sickle cell anemia, though rare complications can occur under extreme physiologic stress. Stating the child has sickle cell anemia is inaccurate and increases unnecessary anxiety. It is also incorrect to say the child will pass the disease to any offspring, because transmission depends on the other parent’s genotype and inheritance probabilities.

Question 29

A nurse is discussing childhood cancer with the parents of a child in an oncology unit. Which statement by the nurse would be the most accurate?

Accepted Answer

Answer reason:  Childhood malignancies most commonly arise from hematopoietic tissues, with leukemia being the most frequent pediatric cancer, originating in the bone marrow. Therefore, describing the bone marrow as the most common site aligns with epidemiology of pediatric cancers. The statement that all childhood cancers have high mortality is inaccurate because many have high cure rates with modern therapy. Older age at leukemia diagnosis is generally associated with worse outcomes than the typical peak age group, and prognosis is strongly influenced by treatment strategies and risk-adapted therapy.

Question 30

The client is diagnosed with Meniere disease. Which statement by the client supports that the client needs more teaching concerning the management for this disease?

Accepted Answer

Answer reason:  Management of Meniere disease is primarily conservative and symptom-focused, aiming to reduce endolymphatic fluid pressure and control vertigo. Stating that surgery is the only cure reflects misunderstanding because diet modification (notably sodium restriction), trigger control, and medications are typically first-line, with procedures reserved for refractory cases. Surgical or ablative options can carry risk to hearing, but they are not universally required and are not framed as the only effective management. Appropriate self-care during vertigo includes stopping activity and lying down to prevent falls, aligning with safety-focused symptom management.

Question 31

The client diagnosed with peripheral vascular disease is overweight, has smoked two packs of cigarettes a day for 20 years, and sits behind a desk all day. Which statement by the client refers to the strongest factor in the development of atherosclerotic lesions?

Accepted Answer

Answer reason:  Cigarette smoking is a major, high-impact modifiable risk factor that directly injures vascular endothelium, promotes inflammation, increases platelet adhesion, and accelerates atherosclerotic plaque formation. In peripheral arterial disease, tobacco exposure is especially strongly associated with disease development and progression, making cessation the most powerful single intervention among the listed behaviors. Weight loss, increased activity, and higher fiber intake help overall cardiovascular risk, but their effect is generally less immediate and less potent than stopping long-term heavy smoking. The client’s statement identifies recognition of the highest-priority contributor to atherosclerotic lesions in this scenario.

Question 32

Which statement made by a client with a chlamydial infection indicates an understanding of the potential complications?

Accepted Answer

Answer reason:  Untreated chlamydia can ascend from the cervix/urethra to the upper reproductive tract and cause pelvic inflammatory disease (PID). PID increases risk for tubal scarring, infertility, ectopic pregnancy, and chronic pelvic pain, so prompt treatment and partner management are key to preventing long-term complications. This statement correctly links treatment to preventing pelvic spread and future fertility problems. By contrast, chlamydia is not primarily associated with congenital malformations, and “destroying my kidneys” is not a typical complication pathway of uncomplicated chlamydial infection.

Question 33

The nurse completes discharge teaching for the client after a small bowel resection for Crohn’s disease. The nurse determines that more education is needed when overbearing which statement made by the client to the client’s spouse?

Accepted Answer

Answer reason:  Crohn’s disease is a chronic, relapsing inflammatory condition and surgery is not curative because inflammation can recur in other segments of the GI tract. After a small bowel resection, clients still remain at risk for future strictures, fistulas, and recurrent disease that may require additional medical therapy or further surgical intervention. The other statements reflect appropriate discharge considerations: monitoring weight to detect malnutrition/dehydration, corticosteroids may be used for flares, and vitamin/mineral supplementation can be needed due to malabsorption after small bowel disease/resection. The incorrect belief that surgery ends the disease indicates a significant gap in understanding and warrants further teaching.

Question 34

The nurse is taking a hospital admission history for the 40-year—old client. The nurse is concerned about possible acute pancreatitis when the client makes which statement?

Accepted Answer

Answer reason: " Acute pancreatitis classically presents with sudden, severe epigastric or left upper quadrant pain that radiates to the back due to pancreatic inflammation and retroperitoneal irritation. This pain pattern is a key history clue that should prompt urgent evaluation and pancreatic enzyme testing. The lower abdominal pain migrating to the right lower quadrant is more consistent with appendicitis, and loose bloody stools with cramping suggests an inflammatory or infectious colitis. Forceful vomiting with only mild upper abdominal pain is less characteristic for pancreatitis and may indicate another GI disorder such as gastroenteritis or esophageal irritation/tear risk.

Question 35

The nurse assesses that the client with partial- thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?

Accepted Answer

Answer reason: This capillary leak produces generalized edema and apparent weight gain, especially within the first 24–48 hours after a large TBSA burn. Although IV fluids are required for resuscitation, the primary physiologic driver of early, diffuse edema is loss of oncotic pressure and transcapillary fluid movement rather than simple overinfusion. Hemoconcentration (rising hemoglobin/hematocrit) can occur from intravascular volume loss and does not explain the tissue edema itself.

Question 36

A 78-year-old client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with I.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103.7° F (39.47° C), a cough producing yellow sputum, and pleuritic chest pain. The nurse suspects this client may have developed?

Accepted Answer

Answer reason: High fever, productive cough with yellow sputum, and pleuritic chest pain are classic findings of an acute bacterial lower respiratory infection involving the lung parenchyma. Older adults can also present with altered mental status as an early or prominent sign of infection due to decreased physiologic reserve. ARDS would more strongly feature severe hypoxemia and respiratory failure rather than purulent sputum, and MI chest pain is typically pressure-like and not pleuritic with infectious sputum. TB is usually more subacute/chronic with night sweats, weight loss, and often hemoptysis rather than sudden high fever with yellow sputum.

Question 37

A client is admitted to the hospital with shortness of breath. The physician orders a stat hemoglobin and hematocrit level to be drawn. The client is questioning why he needs to have blood drawn when he is having trouble breathing. What is the best response by the nurse?

Accepted Answer

Answer reason: " Hemoglobin is the primary protein that binds and transports oxygen in the blood, so oxygen delivery depends not only on ventilation but also on adequate hemoglobin concentration. When hemoglobin is low (anemia), arterial oxygen saturation can be normal yet total oxygen content is reduced, contributing to dyspnea and fatigue. Drawing hemoglobin/hematocrit helps distinguish impaired oxygen transport from purely respiratory causes and guides treatment (e.g., addressing anemia or bleeding). The statement that hemoglobin has no effect is physiologically incorrect, and low hemoglobin cannot increase oxygen-carrying capacity.

Question 38

A nurse is teaching parents about therapeutic management of their neonate diagnosed with congenital hypothyroidism. Which response by a parent would indicate the need for further teaching?

Accepted Answer

Answer reason:  Congenital hypothyroidism reflects inadequate thyroid hormone production present at birth, and untreated deficiency in infancy can cause irreversible neurodevelopmental harm. Management requires prompt initiation of levothyroxine and ongoing monitoring of thyroid function to maintain normal hormone levels during growth and brain development. Many infants require long-term, often lifelong, replacement; even when a trial off therapy is considered later to assess for transient disease, it is not assumed that maturation will eliminate the need for medication. The statement implies spontaneous resolution without follow-up or therapy, which is unsafe and indicates misunderstanding of the condition and its management.

Question 39

Which neonate is at high risk for developing neonatal chronic lung disease (bronchopulmonary dysplasia)?

Accepted Answer

Answer reason: A 28-week infant on high-pressure ventilation has the highest likelihood of needing sustained respiratory support, making chronic lung injury much more likely. Later-gestation infants receiving minimal or intermittent oxygen are less exposed to the key injurious factors and typically have more mature lung architecture. RSV treatment in a post-term neonate can be severe but is not the classic risk profile for developing neonatal chronic lung disease compared with very preterm ventilated infants.

Question 40

The nurse is caring for a client admitted to the emergency department with weakness, thirst, and an inability to concentrate. Laboratory results show a serum glucose of 712 mg/dl, urine negative for ketones, and minimal electrolyte imbalance. For which diabetic complication should the client be evaluated?

Accepted Answer

Answer reason: HHS typically presents with very high serum glucose (often >600 mg/dL) and neurologic changes from profound dehydration and hyperosmolarity, matching the client’s weakness, thirst, and impaired concentration. Minimal electrolyte imbalance and lack of ketonuria make DKA less likely, since DKA is characterized by ketosis and metabolic acidosis with more prominent electrolyte derangements. The priority evaluation is for hyperosmolarity and dehydration-related complications (e.g., altered mental status, renal hypoperfusion) consistent with HHS.

Question 41

The clinic nurse completed teaching with the adolescent who recently started treatment for PUD caused by Helicobacter pylori (H. pylori). Which statement made by the client indicates the need for further teaching?

Accepted Answer

Answer reason: “Other members of my family could have H. pylori; our well should be checked for contamination.” H. pylori is primarily transmitted person-to-person via fecal–oral or oral–oral routes, so teaching should focus on hygiene and completing eradication therapy rather than attributing infection to a contaminated well. While household contacts can be infected, routine environmental water testing is not a standard or helpful next step for managing this condition. This statement reflects a misunderstanding of typical transmission and prevention strategies. By contrast, avoiding caffeine that worsens dyspepsia and recognizing the urea breath test as a diagnostic method are consistent with appropriate education.

Question 42

After receiving multiple mosquito bites and experiencing flu-like symptoms, the adolescent consults the school nurse and asks whether West Nile virus is a concern and whether an HCP appointment is necessary. Which statement should be the basis for the nurse’s response?

Accepted Answer

Answer reason: West Nile infection has a wide clinical spectrum, with many patients having no symptoms or only a self-limited febrile, flu-like illness, while a smaller subset develop neuroinvasive disease such as meningitis/encephalitis that can be severe or fatal. This statement appropriately frames risk and supports advising medical evaluation if worsening symptoms or neurologic signs develop. There is no routinely recommended curative antiviral therapy for uncomplicated West Nile; care is primarily supportive, making the antiviral claim inaccurate. Illness does not inevitably worsen progressively in all cases, and repellents reduce bites rather than neutralizing virus after inoculation.

Question 43

The parent of the child recently diagnosed with acute poststreptococcal glomerulonephritis (APSGN) is concerned about the usual prognosis. The new nurse instructs the parent on the prognosis of APS GN. Which statement did the new nurse make in error?

Accepted Answer

Answer reason:  APSGN in children generally has an excellent prognosis because the renal inflammation is typically self-limited after the postinfectious immune response resolves. Most pediatric patients recover fully with supportive management, though transient hematuria/proteinuria can persist for weeks to months. Severe complications (e.g., hypertensive encephalopathy, pulmonary edema, acute kidney injury) are possible but uncommon, making mortality rare in typical cases. While a small minority may develop persistent renal abnormalities or chronic kidney disease, stating that all children progress to chronic disease is inaccurate and overly alarming.

Question 44

The HCP has discussed a carotid endarterectomy with the client who has experienced two transient ischemic attacks (TIAs). The client tells the nurse, “I really don’t understand why I need this procedure, and I don’t want to have it.” Which scientific rationale would support the nurse’s response?

Accepted Answer

Answer reason: Carotid endarterectomy is used to reduce future stroke risk in symptomatic carotid stenosis by removing the obstructing plaque at the lesion, improving cerebral perfusion and decreasing embolic events. A history of TIAs indicates clinically significant, unstable carotid atherosclerotic disease where intervention can be beneficial in appropriate stenosis ranges. It cannot guarantee prevention of cerebrovascular accident, because strokes can still occur from other vascular territories, cardiac emboli, or perioperative complications. The procedure targets focal plaque causing narrowing; it does not remove all plaque throughout both carotid arteries nor does it restore arterial wall elasticity.

Question 45

The nurse is caring for a client in the emergency department (ED) who is experiencing chest pain. The physician suspects that the client has suffered a myocardial infarction. If the client has had a myocardial infarction, when should the nurse anticipate an initial rise in the cardiac-specific enzymes troponin and CK-MB?

Accepted Answer

Answer reason: Cardiac biomarker release follows myocyte injury and takes time to appear in measurable amounts in the bloodstream. Troponin and CK-MB typically begin to rise within several hours after an MI, making an early detectable increase expected around this timeframe. Waiting two days is too late for the initial rise, because both markers elevate much earlier after injury. Drawing blood immediately on ED arrival may be too soon to show elevation if symptom onset was recent, so repeat testing is often needed to capture the rise.

Question 46

The parents of a child with sickle cell anemia are being taught pain control measures for their child. Which measure is most important to teach the parents to prevent the onset of vaso-occlusive pain?

Accepted Answer

Answer reason: Vaso-occlusive pain in sickle cell disease is triggered when sickled cells obstruct microcirculation, and dehydration increases blood viscosity and promotes sickling. Maintaining good hydration helps keep blood less viscous and supports tissue perfusion, reducing the likelihood of a pain crisis. Cold application causes vasoconstriction and can worsen ischemia, so routine ice packs are inappropriate as prevention. Routine scheduled acetaminophen does not prevent vaso-occlusion and the listed dose is not individualized for pediatric weight and safety. Increasing exercise can increase oxygen demand and fluid loss, which may precipitate a crisis if not carefully managed.

Question 47

The nurse is planning care for a 67-year-old client who recently had abdominal aortic aneurysm repair surgery. The client has developed disseminated intravascular coagulation (DIC). The nurse is aware that the client has an increased risk for what?

Accepted Answer

Answer reason: After major vascular surgery, activation of coagulation can worsen this process, making thrombotic complications a key concern in addition to bleeding. Reduced cerebral microcirculatory flow can manifest as altered mental status, focal deficits, or decreased level of consciousness, reflecting compromised brain oxygen delivery. Other options are less directly tied to the defining pathophysiology of DIC, where perfusion failure from microvascular thrombosis is a central risk.

Question 48

A six year old boy is admitted to the hospital in diabetic Ketoacidosis. Which manifestations should the nurse expect to observe?

Accepted Answer

Answer reason: Dehydration commonly presents with dry mucous membranes and poor skin turgor, while acidosis and delayed gastric emptying contribute to nausea and vomiting. In contrast, pallor, sweating, trembling, and seizures are more characteristic of hypoglycemia or severe neuroglycopenia rather than DKA. Visual changes and hunger can occur with hyperglycemia, but they are not the classic acute presentation pattern compared with dehydration plus GI symptoms in DKA.

Question 49

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?

Accepted Answer

Answer reason: An irregular rhythm indicates an arrhythmia, a clinically important complication requiring prompt evaluation and management. The other findings are within expected/normal ranges in many adults and do not specifically signal a complication of catecholamine excess. The priority concern with this disorder is unstable cardiovascular status rather than mild variations in renal labs or normal coagulation values.

Question 50

A client with peptic ulcers admits to the hospital for a suspected perforation. While assessing the client, the nurse expects which most common symptom of this complication?

Accepted Answer

Answer reason: The hallmark initial and most common presentation is sudden, intense epigastric/abdominal pain that rapidly becomes generalized. Guarding and a rigid “board-like” abdomen can develop as peritonitis progresses, but it is a later associated sign rather than the most common first symptom. Stool positive for blood indicates gastrointestinal bleeding (a different ulcer complication) rather than perforation.

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