Comprehensive NCLEX-RN Practice Exam

#8 latest edition 2024

1. Question

Category: Physiological Integrity

A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university.
He is engaged to be married and is to begin a new job upon graduation. Which
of the following diagnoses would be a priority for this client?

• A. Sexual dysfunction related to radiation therapy

• B. Anticipatory grieving related to terminal illness

• C. Tissue integrity related to prolonged bed rest

Correct Answer: A. Sexual dysfunction related to radiation therapy
Radiation therapy often causes sterility in male clients and would be of primary
importance to this client. The psychosocial needs of the client are important to
address in light of the age and life choices. Hodgkin’s disease, however, has a
good prognosis when diagnosed early. Know the importance of sex to individual,
partner, and patient’s motivation for change. Because lymphomas often affect the
relatively young who are in their productive years, these people may be affected
more by these problems and may be less knowledgeable about the possibilities
of change.
• Option B: Grieving may not be an appropriate diagnosis since the
client would be experiencing new milestones in his life despite his
condition. Let the patient describe the problem in own words.
Provides a more accurate picture of patient experience with which to
develop a plan of care.
• Option C: Option B is not applicable since the client is not on bed
rest. Encourage the patient to share thoughts and concerns with his
partner and to clarify values and impact of condition on relationship.
Helps the couple begin to deal with issues that can strengthen or
weaken the relationship.
• Option D: Fatigue may occur during chemotherapy, but it is not the
priority diagnosis. Identify pre-existing and current stress factors that
 may be affecting the relationship. The patient may be concerned
about other issues, such as job, financial, and illness-related
problems.

2. Question

Category: Physiological Integrity

A client has autoimmune thrombocytopenic purpura. To determine the client’s
response to treatment, the nurse would monitor:

• A. Platelet count

• B. White blood cell count

• C. Potassium levels

• D. Partial prothrombin time (PTT)

Correct Answer: A. Platelet count
Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet
counts, making answer A the correct answer. The laboratory tests will show low
platelet count, usually <40×10^9/L for over three months. Blood film shows large
platelets and tiny platelet fragments. Bone marrow examination shows an
increased number of megakaryocytes.
• Option B: Often associated with the CBC is a differential, which
refers to the relative amounts of white blood cell types (i.e.,
neutrophil, lymphocyte, eosinophil, etc.) as a percentage of the total
number of WBCs. Of note, if a subtype of white blood cells seems to
be elevated based on the differential, the actual value of the type of
white blood cells should be calculated by multiplying the percentage
listed on the differential by the total number of white blood cells.
• Option C: Potassium disorders are related to cardiac arrhythmias.
Hypokalemia occurs when serum potassium levels under 3.6
mmol/L—weakness, fatigue, and muscle twitching present in
hypokalemia. Hyperkalemia occurs when the serum potassium levels
above 5.5 mmol/L, which can result in arrhythmias. Muscle cramps,
muscle weakness, rhabdomyolysis, myoglobinuria are presenting
signs and symptoms in hyperkalemia.
 • Option D: Patients with a propensity for bleeding should undergo
testing to determine the presence of a clotting disorder. For patients
with deficiencies or defects of the intrinsic clotting cascade, the PTT
will be elevated. Normal PTT values can vary between laboratories
but 25 to 35 seconds is considered normal.
3. Question

Category: Physiological Integrity

The home health nurse is visiting a client with autoimmune thrombocytopenic
purpura (ATP). The client’s platelet count currently is 80, it will be most important
to teach the client and family about:

• A. Bleeding precautions

• B. Prevention of falls

• C. Oxygen therapy

• D. Conservation of energy
Correct Answer: A. Bleeding precautions
The normal platelet count is 120,000–400, Bleeding occurs in clients with low
platelets. The priority is to prevent and minimize bleeding. Review laboratory
results for coagulation status as appropriate: platelet count, prothrombin
time/international normalized ratio (PT/INR), activated partial thromboplastin
time (aPTT), fibrinogen, bleeding time, fibrin degradation products, vitamin K,
activated coagulation time (ACT); and educate the at-risk patient and caregivers
about precautionary measures to prevent tissue trauma or disruption of the
normal clotting mechanisms.
• Option B: Thoroughly conform patient to surroundings; put call light
within reach and teach how to call for assistance; respond to call
light immediately; avoid use of restraints; obtain a physician’s order
if restraints are needed; and eliminate or drop all possible hazards in
the room such as razors, medications, and matches.
• Option C: Option C is important, but platelets do not carry oxygen.
Wash hands and teach patient and SO to wash hands before contact
with patients and between procedures with the patient; encourage
fluid intake of 2,000 to 3,000 mL of water per day, unless
contraindicated.
 • Option D: Option D is of lesser priority and is incorrect in this
instance. Recommend the use of soft-bristled toothbrushes and
stool softeners to protect mucous membranes; and if infection
occurs, teach the patient to take antibiotics as prescribed; instruct
the patient to take the full course of antibiotics even if symptoms
improve or disappear.
4. Question

Category: Physiological Integrity

A client with a pituitary tumor has had transsphenoidal hypophysectomy. Which
of the following interventions would be appropriate for this client?

• A. Place the client in Trendelenburg position for postural drainage

• B. Encourage coughing and deep breathing every 2 hours

• C. Elevate the head of the bed 30°

• D. Encourage the Valsalva maneuver for bowel movements

Correct Answer: C. Elevate the head of the bed 30°
Elevating the head of the bed 30° avoids pressure on the sella turcica and
alleviates headaches. A, B, and D are incorrect. In the immediate postoperative
period, patients are monitored in an intensive care unit with monitoring for
neurological deterioration, epistaxis, visual dysfunction, diabetes insipidus (DI),
and hypotension secondary to acute hypocortisolism.
• Option A: Placing the patient in Trendelenburg will increase the
intracranial pressure. The most common complications are CSF leak,
sinusitis, and meningitis. CSF leaks, occurring in 6 in every 100 cases,
is usually prevented by a multilayer closure at the end of surgery. In
the occurrence of a leak in the postoperative period, the patient is
advised bed rest, and a lumbar drain is placed. If the leak does not
improve in 24 hours, exploration and closure of the defect are to be
done.
• Option B: Coughing and deep breathing causes increase in
intracranial pressure. Worsening of vision as a result of bleeding or
manipulation and arterial hemorrhage are other immediate
complications. A detailed study of preoperative imaging is essential
to avoid catastrophes like optic nerve and carotid artery injury.
 • Option D: Valsalva maneuver increases the intracranial pressure. The
first follow up visit is 1 week after the procedure, where
postoperative day 7 serum sodium levels are reviewed to rule out
occult hyponatremia. Serial nasal endoscopies are done for
debridement and to assess healing. The frequency of follow-up visits
is determined by nasal crusting and maintenance of nasal hygiene
with irrigation. Routine early postoperative imaging is not done in
most patients.

5. Question

Category: Physiological Integrity

The client with a history of diabetes insipidus is admitted with polyuria,
polydipsia, and mental confusion. The priority intervention for this client is:

• A. Measure the urinary output

• B. Check the vital signs

• C. Encourage increased fluid intake

• D. Weigh the client

Correct Answer: B. Check the vital signs
A large amount of fluid loss can cause fluid and electrolyte imbalance that should
be corrected. The loss of electrolytes would be reflected in the vital signs.
Monitor for signs of hypovolemic shock (e.g., tachycardia, tachypnea,
hypotension). Frequent assessment can detect changes early for rapid
intervention. Polyuria causes decreased circulatory blood volume.
• Option A: Measuring the urinary output is important, but the stem
already says that the client has polyuria. Monitor intake and output.
Report urine volume greater than 200 mL for each of 2 consecutive
hours or 500 mL in a 2-hour period. With DI, the patient voids large
urine volumes independent of the fluid intake. Urine output ranges
from 2 to 3 L/day with renal DI to greater than 10 L/day with central
DI.
• Option C: Encouraging fluid intake will not correct the problem.
Allow the patient to drink water at will. Patients with intact thirst
mechanisms may maintain fluid balance by drinking huge quantities
 of water to compensate for the amount they urinate. Patients prefer
cold or ice water.
• Option D: Weighing the client is not necessary at this time. Monitor
serum and urine osmolality. Urine osmolality will be decreased and
serum osmolality will increase. Monitor urine-specific gravity. This
may be 1.005 or less.
6. Question

A client with hemophilia has a nosebleed. Which nursing action

is most appropriate to control the bleeding?

• A. Place the client in a sitting position with the head hyperextended

• B. Pack the nares tightly with gauze to apply pressure to the source of
bleeding

• C. Pinch the soft lower part of the nose for a minimum of 5 minutes

• D. Apply ice packs to the forehead and back of the neck

Correct Answer: C. Pinch the soft lower part of the nose for a minimum of 5
minutes
The client should be positioned upright and leaning forward, to prevent
aspiration of blood. Usual sites of external bleeding may include the bleeding in
the mouth from a cut, bite, or from cutting or losing a tooth; nosebleeds for no
obvious reasons; heavy bleeding from a minor cut, or bleeding from a cut that
resumes after stopping for a short time. Hemophiliacs do not bleed faster or
more frequently. Instead, they bleed longer due to a deficiency of clotting factor.
Clients are often aware of bleeding before clinical manifestation. Bleeding can be
life-threatening to these clients.
• Option A: Direct pressure to the nose stops the bleeding. Apply
manual or mechanical pressure if active bleeding is noted. If
spontaneous or traumatic bleeding is evident, monitor vital signs.
• Option B: If a pack is necessary, the nares are loosely packed.
Controlling bleeding is a nursing priority. Nasal packing should be
avoided, because the subsequent removal of the packing may
precipitate further bleeding.
 • Option D: Ice packs should be applied directly to the nose as well.
Assess for any signs of bruising and bleeding (note the extent of
bleeding). Assess for prolonged bleeding after minor injuries.
7. Question

Category: Physiological Integrity

A client has had a unilateral adrenalectomy to remove a tumor. To prevent
complications, the most important measurement in the immediate postoperative
period for the nurse to take is:

• A. Blood pressure

• B. Temperature

• C. Output

• D. Specific gravity
Correct Answer: A. Blood pressure
Blood pressure is the best indicator of cardiovascular collapse in the client who
has had an adrenal gland removed. The remaining gland might have been
suppressed due to the tumor activity. Primary adrenal insufficiency occurs after
bilateral adrenalectomy. Signs and symptoms are volume depletion, hypotension,
hyponatremia, hyperkalemia, fever, abdominal pain. Patients are managed by
replacement therapy based on glucocorticoids (hydrocortisone or cortisone),
mineralocorticoids (fludrocortisone) in cases of confirmed corticoids or
aldosterone deficiency, respectively.
• Option B: Temperature would be an indicator of infection. Patients
in the adrenal crisis typically present with profoundly impaired well-
being, hypotension, nausea and vomiting, and fever responding well
to parenteral hydrocortisone administration. Infections are the major
precipitating causes of adrenal crisis.
• Option C: Decreased output would be a clinical manifestation but
would take longer to occur than blood pressure changes. The
clinician must be able to work-up and manage patients with adrenal
masses, both functional and non-functional, to treat these patients
with minimal morbidity. When planning for adrenalectomy,
considerations of hormonal changes and preoperative preparation
 for these changes is as important and demands as much of the
surgeon’s attention as the technical aspects of the case.
• Option D: Specific gravity changes occur with other disorders.
Adrenalectomy has been shown to have a relatively low risk of
postoperative complications, with an overall rate of 3.6%. Improved
patient outcomes and decreased hospital costs have been
demonstrated when adrenalectomy is performed by a high-volume
adrenal surgeon (>/=6 adrenalectomies/year).

8. Question

Category: Physiological Integrity

A client with Addison’s disease has been admitted with a history of nausea and
vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-
Medrol). Which of the following interventions would the nurse implement?

• A. Daily weights

• B. Intake/output measurements

• C. Sodium and potassium levels monitored

• D. Glucometer readings as ordered

Correct Answer: D. Glucometer readings as ordered
IV glucocorticoids raise the glucose levels and often require coverage with
insulin. Cortisone and prednisone replace cortisol deficits, which will promote
sodium reabsorption. Fludrocortisone is a mineralocorticoid for patients who
require aldosterone replacement to promote sodium and water replacement.
Acute adrenal insufficiency is a medical emergency requiring immediate fluid and
corticosteroid administration. If treated for adrenal crisis, the patient requires IV
hydrocortisone initially; usually by the second day, administration can be
converted to an oral form of replacement.
• Option A: Daily weights are unnecessary. Monitor trends in weight.
This provides documentation of weight loss trends. Weight loss is a
common manifestation of adrenal insufficiency.
• Option B: Intake/output measurements are not necessary at this
time. Assess vital signs, especially noting BP and HR for orthostatic
 changes. A BP drop of more than 15 mm Hg when changing from
supine to sitting position, with a concurrent elevation of 15 beats per
min in HR, indicates reduced circulating fluids.
• Option C: Sodium and potassium levels would be monitored when
the client is receiving mineralocorticoids. Abnormal laboratory
findings include hyperkalemia (related to aldosterone deficiency and
decreased renal perfusion), hyponatremia (related to decreased
aldosterone and impaired free water clearance), and increase in
blood urea nitrogen (related to decreased glomerular filtration from).

9. Question

Category: Physiological Integrity

A client had a total thyroidectomy yesterday. The client is complaining of tingling
around the mouth and in the fingers and toes. What would the nurse’s next
action be?

• A. Obtain a crash cart

• B. Check the calcium level

• C. Assess the dressing for drainage

• D. Assess the blood pressure for hypertension

Correct Answer: B. Check the calcium level
The parathyroid glands are responsible for calcium production and can be
damaged during a thyroidectomy. The tingling is due to low calcium levels.
Evaluate reflexes periodically. Observe for neuromuscular irritability: twitching,
numbness, paresthesias, positive Chvostek’s and Trousseau’s signs, seizure
activity.
• Option A: The crash cart would be needed in respiratory distress but
would not be the next action to take. Hypocalcemia with tetany
(usually transient) may occur 1–7 days postoperatively and indicates
hypoparathyroidism, which can occur as a result of inadvertent
trauma to or partial-to-total removal of the parathyroid gland(s)
during surgery.
 • Option C: The drainage would occur in hemorrhage. Check dressing
frequently, especially the posterior portion. If bleeding occurs, the
anterior dressing may appear dry because blood pools dependently.
• Option D: Hypertension occurs in a thyroid storm. Monitor vital
signs noting elevated temperature, tachycardia, arrhythmias,
respiratory distress, cyanosis. Manipulation of the gland during
subtotal thyroidectomy may result in increased hormone release,
causing thyroid storm.
10. Question

Category: Physiological Integrity

A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a
weight gain of 30 pounds in 4 months, and the client is wearing two sweaters.
The client is diagnosed with hypothyroidism. Which of the following nursing
diagnoses is of highest priority?

• A. Impaired physical mobility related to decreased endurance

• B. Hypothermia r/t decreased metabolic rate

• C. Disturbed thought processes r/t interstitial edema

• D. Decreased cardiac output r/t bradycardia

Correct Answer: D. Decreased cardiac output r/t bradycardia
The decrease in pulse can affect the cardiac output and lead to shock, which
would take precedence over the other choices. Protect against coldness. Provide
extra layers of clothing or extra blankets. Discourage and avoid the use of
external heat sources. Monitor patient’s body temperature.
• Option A: Impaired physical mobility is not applicable to a client
with hypothyroidism. Promote rest. Space activities to promote rest
and exercise as tolerated. Assess the client’s ability to perform
activities of daily living (ADLs). The client may experience fatigue
with minimal exertion due to a slow metabolic rate. This symptom
hinder the client’s ability to perform daily activities (e.g., self-care,
eating)
• Option B: Hypothermia is correct but not a priority. Teach the
expected benefits and possible side effects. The client should report
 symptoms such as chest pain/palpitations; these happen due to the
increased metabolic and oxygen consumption.
• Option C: Disturbed thought processes is not a related diagnosis.
Assess the client’s appetite. Clients with hypothyroidism have
decreased appetite. This opposite relationship between weight gain
and decreased appetite is a manifestation found in hypothyroidism.
11. Question

Category: Physiological Integrity

The client is having an arteriogram. During the procedure, the client tells the
nurse, “I’m feeling really hot.” Which response would be best?

• A. "You are having an allergic reaction. I will get an order for Benadryl."

• B. "That feeling of warmth is normal when the dye is injected."

• C. "That feeling of warmth indicates that the clots in the coronary

vessels are dissolving."

• D. "I will tell your doctor and let him explain to you the reason for the
hot feeling that you are experiencing."
Correct Answer: Answer: B. “That feeling of warmth is normal when the dye
is injected.”
It is normal for the client to have a warm sensation when dye is injected. The
client may have some discomfort from a needle stick. He/she may feel symptoms
such as flushing in the face or other parts of the body when the dye is injected.
The exact symptoms will depend on the part of the body being examined.
• Option A: An area of the groin or the artery in the wrist or hand will
be cleaned for the procedure. The client will be given a mild sedative
and pain medication to keep them comfortable throughout the
procedure. The Radiologist will numb the insertion site and a very
small tube called a catheter will be inserted into the vessel. A rapid
sequence of X-rays is taken when the dye is injected into the vessel.
Each time the contrast is injected, the client may experience a
sensation of warmth.
• Option C: Warmth does not indicate that clots are dissolving. If the
angiogram reveals a narrowed vessel, a balloon angioplasty or stent
placement may be performed at the same time. When the procedure
 is completed, the catheter will be removed, and pressure will be held
on the entry site for 10-20 minutes to stop any bleeding. The client
may have a compression device applied to stop the bleeding from
the angiogram site. This device may stay in place for 1-1 ½ hours.
• Option D: This statement indicates that the nurse believes that the
hot feeling is abnormal, so it is incorrect. Once the angiogram is
completed the client may be on bedrest for 4-6 hours or until he has
recovered from sedation. The client will be allowed to eat and will be
encouraged to drink fluids to flush the contrast dye from the system.
During this time, the catheter insertion site will be watched closely,
and blood pressure and pulse will be monitored.

12. Question

Category: Physiological Integrity

The nurse is observing several healthcare workers providing care. Which action by
the healthcare worker indicates a need for further teaching?

• A. The nursing assistant wears gloves while giving the client a bath.

• B. The nurse wears goggles while drawing blood from the client.

• C. The doctor washes his hands before examining the client.

• D. The nurse wears gloves to take the client’s vital signs.

Correct Answer: D. The nurse wears gloves to take the client’s vital signs.
It is not necessary to wear gloves to take the vital signs of the client. If the client
has an active infection with methicillin-resistant Staphylococcus aureus, gloves
should be worn. Wash hands or perform hand hygiene before having contact
with the patient. Also impart these duties to the patient and their significant
others. Know the instances when to perform hand hygiene or “5 moments for
hand hygiene”.
• Option A: Wear personal protective equipment (PPE) properly. Wear
gloves when providing direct care; perform hand hygiene after
properly disposing of gloves. Initiate specific precautions for
suspected agents as determined by CDC protocol.
 • Option B: Use masks, goggles, face shields to protect the mucous
membranes of your eyes, mouth, and nose during procedures and in
direct-care activities (e.g., suctioning secretions) that may generate
splashes or sprays of blood, body fluids, secretions, and excretions.
• Option C: The health care workers indicate knowledge of infection
control by their actions. Friction and running water effectively
remove microorganisms from hands. Washing between procedures
reduces the risk of transmitting pathogens from one area of the
body to another. Wash hands with antiseptic soap and water for at
least 15 seconds followed by an alcohol-based hand rub. If hands
were not in contact with anyone or anything in the room, use an
alcohol-based hand rub and rub until dry. Plain soap is good at
reducing bacterial counts but antimicrobial soap is better, and
alcohol-based hand rubs are the best.
13. Question

Category: Physiological Integrity

The client is having electroconvulsive therapy for treatment of severe depression.
Which of the following indicates that the client’s ECT has been effective?

• A. The client loses consciousness.

• B. The client vomits.

• C. The client’s ECG indicates tachycardia.

• D. The client has a grand mal seizure.

Correct Answer: D. The client has a grand mal seizure.
During ECT, the client will have a grand mal seizure. This indicates completion of
electroconvulsive therapy. Seizure threshold is established via trial and error via
incrementally higher doses of current during the primary treatment session.
Following initial dose calculation, the dose at subsequent ECT sessions for
bilateral ECT is 1.5 to 2 times seizure threshold, and for right unilateral is six times
the seizure threshold. During the course of ECT treatment, the seizure threshold
commonly increases as the patient develops tolerance.
• Option A: Once the patient is rendered unconscious, administration
of a muscle relaxant follows, along with bag valve mask ventilation
with 100 percent oxygen. A nerve stimulator is utilized to determine
 the adequacy of muscle relaxation along with the clinical assessment
of plantar reflexes and fasciculations in the calves and left foot.
• Option B: Physiologically, during the tonic phase of the seizure, a
15- to 20-second parasympathetic discharge occurs, which can lead
to bradyarrhythmias including premature atrial and ventricular
contractions, atrioventricular block, and asystole. Patients with sub
convulsive seizures are at higher risk for asystole.
• Option C: Paradoxically, patients with heart block or underlying
arrhythmias are less likely to develop asystole. The clonic phase of
the seizure correlates with a catecholamine surge that causes
tachycardia and hypertension, which lasts temporally with seizure
duration. Hypertension and tachycardia resolve within 10 to 20
minutes of the seizure, although some patients exhibit persistent
hypertension that requires medical intervention.
14. Question

Category: Physiological Integrity

The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen
for assessment of pinworms, the nurse should teach the mother to:

• A. Examine the perianal area with a flashlight 2 or 3 hours after the

child is asleep

• B. Scrape the skin with a piece of cardboard and bring it to the clinic

• C. Obtain a stool specimen in the afternoon

• D. Bring a hair sample to the clinic for evaluation

Correct Answer: A. Examine the perianal area with a flashlight 2 or 3 hours
after the child is asleep
Infection with pinworms begins when the eggs are ingested or inhaled. The eggs
hatch in the upper intestine and mature in 2–8 weeks. The females then mate and
migrate out the anus, where they lay up to 17,000 eggs. This causes intense
itching. The mother should be told to use a flashlight to examine the rectal area
about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will
allow the eggs to adhere to the tape. The specimen should then be brought in to
be evaluated.
 • Option B: Pinworms do not burrow under the skin, therefore
scraping the skin for examination would not reveal pinworms.
Enterobius can be diagnosed through a cellophane tape test or
pinworm paddle test where an adhesive tape-like material is applied
to the perianal area and then examined under a microscope.
• Option C: Pinworms are not usually detected in stools. Stool
examination is not helpful in the diagnosis of E. vermicularis as they
are only occasionally excreted in the stool usually. Sometimes
analysis of the stool specimen is recommended to rule out other
causes.
• Option D: Taking a hair sample is inappropriate because pinworms
do not live in hair. The examination might reveal characteristic ova
which are 50 by 30 microns in size and have a flattened surface on
one side or may reveal the worms. Female worms are around 8 to 13
mm long while male worms are 2 to 5 mm long. The examination is
usually done in the early morning for higher diagnostic yield.
15. Question

Category: Physiological Integrity

The nurse is teaching the mother regarding treatment for enterobiasis. Which
instruction should be given regarding the medication?

• A. Treatment is not recommended for children less than 10 years of

age.

• B. The entire family should be treated.

• C. Medication therapy will continue for 1 year.

• D. Intravenous antibiotic therapy will be ordered.

Correct Answer: B. The entire family should be treated.
Enterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth
(pyrantel pamoate). The entire family should be treated to ensure that no eggs
remain. Because a single treatment is usually sufficient, there is usually good
compliance. The family should then be tested again in 2 weeks to ensure that no
eggs remain. Enterobiasis can cause recurrent reinfection, so treating the entire
household, whether symptomatic or not is recommended to prevent a
recurrence.
 • Option A: Enterobiasis usually occurs in children under 10 years of
age. The male-to-female infection frequency is 2 to 1. However, a
female predominance of infection is seen in those between the ages
of 5 and 14 years. It most commonly affects children younger than
18 years of age. It is also commonly seen in adults who take care of
children and institutionalized children.
• Option C: The medications used for the treatment of pinworm are
either mebendazole, pyrantel pamoate, or albendazole. Any of these
drugs are given in one dose initially, and then another single dose of
the same drug two weeks later.
• Option D: Oral antibiotics are the most recommended form of
treatment for enterobiasis. Young pinworms tend to be resistant to
treatment and hence two doses of medication, two weeks apart are
recommended. At the same time, all members of the infected child
must be treated. If a large number of children are infected in a class,
everyone should be treated twice at 2-week intervals. Follow-up is
vital to ensure that a cure has been obtained.
16. Question

Category: Safe and Effective Care Environment

The registered nurse is making assignments for the day. Which client should be
assigned to the pregnant nurse?

• A. The client receiving linear accelerator radiation therapy for lung

cancer

• B. The client with a radium implant for cervical cancer

• C. The client who has just been administered soluble brachytherapy for
thyroid cancer

• D. The client who returned from placement of iridium seeds for

prostate cancer
Correct Answer: A. The client receiving linear accelerator radiation therapy
for lung cancer
The pregnant nurse should not be assigned to any client with radioactivity
present. The client receiving linear accelerator therapy travels to the radium
department for therapy. The radiation stays in the department, so the client is not
radioactive. These clients are radioactive in very small doses, especially upon
returning from the procedures. For approximately 72 hours, the clients should
dispose of urine and feces in special containers and use plastic spoons and forks.
• Option B: When brachytherapy is used to treat cervical cancer, the
radioactive substance is usually put inside a special hollow
applicator. This applicator is called an intracavitary implant because
it is placed inside the vagina, or through the vagina and cervix into
the uterus, or both.
• Option C: Brachytherapy is a type of internal radiation. It uses a
radioactive material called a radioactive isotope. The material is
placed right into the tumor or very close to it or in the area where
the tumor was removed.
• Option D: Radioactive seed implants are a form of radiation therapy
for prostate cancer. Permanent radioactive seed implants are a form
of radiation therapy for prostate cancer. The terms “brachytherapy”
or “internal radiation therapy” might also be used to describe this
procedure. During the procedure, radioactive (iodine-125 or I-125)
seeds are implanted into the prostate gland using ultrasound
guidance.
17. Question

Category: Safe and Effective Care Environment

The nurse is planning room assignments for the day. Which client should be
assigned to a private room if only one is available?

• A. The client with Cushing’s disease

• B. The client with diabetes

• C. The client with acromegaly

• D. The client with myxedema

Correct Answer: A. The client with Cushing’s disease
The client with Cushing’s disease has adrenocortical hypersecretion. This increase
in the level of cortisone causes the client to be immunosuppressed. High cortisol
levels also cause immune disruptions; this hormone leads to a decrease in
lymphocyte levels and increases the neutrophils. It causes detachment of the
marginating pool of neutrophils in the bloodstream and increases the circulating
neutrophil levels although there is no increased production of the neutrophils.
• Option B: The client with diabetes poses no risk to other clients.
Hyperglycemia alone can impair pancreatic beta-cell function and
contributes to impaired insulin secretion. Consequently, there is a
vicious cycle of hyperglycemia leading to the impaired metabolic
state. Blood glucose levels above 180 mg/dL are often considered
hyperglycemic in this context, though because of the variety of
mechanisms, there is no clear cutoff point.
• Option C: The client has an increase in growth hormone and poses
no risk to himself or others. The common effect of the abnormal rise
in growth hormone is the production of IGF-1 from the liver. The
effect of IGF-1 on body tissues results in the multisystemic
manifestation of acromegaly. IGF-1 also known as somatomedin C, is
encoded by the IGF-1 gene on chromosome 12q23.2.
• Option D: The client has hypothyroidism or myxedema and poses
no risk to others or himself. Thyroid hormone influences virtually all
cells in the body by activating or repressing a variety of genes after
binding to thyroid hormone receptors. Ninety percent of the
intracellular thyroid hormone that binds to and influences cellular
function is T3, which has been converted from T4 by the removal of
an iodide ion.
18. Question

Category: Safe and Effective Care Environment

The nurse caring for a client in the neonatal intensive care unit administers adult-
strength Digitalis to the 3-pound infant. As a result of her actions, the baby
suffers permanent heart and brain damage. The nurse can be charged with:

• A. Negligence

• B. Tort

• C. Assault

• D. Malpractice
Correct Answer: D. Malpractice
The nurse could be charged with malpractice, which is failing to perform, or
performing an act that causes harm to the client. Giving the infant an overdose
falls into this category. In the United States, a patient may allege medical
malpractice against a clinician, which is typically defined by the failure the provide
the degree of care another clinician in the same position with the same
credentials would have performed that resulted in injury to the patient.
• Option A: Negligence is failing to perform care for the client. a tort
is a wrongful act committed. Negligence, in law, the failure to meet a
standard of behaviour established to protect society against
unreasonable risk. Negligence is the cornerstone of tort liability and
a key factor in most personal injury and property-damage trials.
• Option B: A tort is a wrongful act committed on the client or their
belongings. A tort is a civil wrong that causes harm to another
person by violating a protected right. A civil wrong is an act or
omission that is intentional, accidental, or negligent, other than a
breach of contract. The specific rights protected give rise to the
unique “elements” of each tort. Tort requires the presence of four
elements that are the essential facts required to prove a civil wrong.
• Option C: Assault is a violent physical or verbal attack. Assault is the
intentional act of making someone fear that you will cause them
harm. You do not have to actually harm them to commit assault.
Threatening them verbally or pretending to hit them are both
examples of assault that can occur in a nursing home.
19. Question

Category: Safe and Effective Care Environment

Which assignment should not be performed by the licensed practical nurse?

• A. Inserting a Foley catheter

• B. Discontinuing a nasogastric tube

• C. Obtaining a sputum specimen

• D. Starting a blood transfusion

Correct Answer: D. Starting a blood transfusion
The licensed practical nurse should not be assigned to begin a blood transfusion.
An LPN works under the supervision of doctors and RNs, performing duties such
as taking vital signs, collecting samples, administering medication, ensuring
patient comfort, and reporting the status of their patients to the nurses.
• Option A: Most LPNs work in healthcare facilities, including
hospitals, doctors’ offices, and nursing homes. Their duties generally
include providing routine care, observing patients’ health, assisting
doctors and registered nurses, and communicating with patients and
their families.
• Option B: An LPN can insert NG tube for Levin suction or gavage
feedings; give meds through NG and PEG tubes, and discontinue NG
tubes. In general, LPN’s provide patient care in a variety of settings
within a variety of clinical specializations. Insert and care for patients
that need nasogastric tubes. Give feedings through a nasogastric or
gastrostomy tube.
• Option C: The licensed practical nurse can collect sputum
specimens. Obtaining a specimen involves collecting tissue or fluids
for laboratory analysis or near-patient testing, and may be a first
step in determining a diagnosis and treatment (Dougherty and Lister,
2015). Specimens must be collected at the right time, using the
correct technique and equipment, and be delivered to the laboratory
in a timely manner (Dougherty and Lister, 2015).
20. Question

Category: Physiological Integrity

The client returns to the unit from surgery with a blood pressure of 90/50, pulse
132, and respirations 30. Which action by the nurse should receive priority?

• A. Continuing to monitor the vital signs

• B. Contacting the physician

• C. Asking the client how he feels

• D. Asking the LPN to continue the post-op care

Correct Answer: B. Contacting the physician
The vital signs are abnormal and should be reported immediately. The early
detection of changes in vital signs typically correlates with faster detection of
changes in the cardiopulmonary status of the patient as well as up-gradation of
the level of service if needed. Patient safety is a fundamental concern in any
healthcare organization, and early detection of any clinical deterioration is of
paramount importance whether the patient is in the emergency department or
on the hospital floor.
• Option A: Continuing to monitor the vital signs can result in
deterioration of the client’s condition. The degree of vital sign
abnormalities may also predict the long-term patient health
outcomes, return emergency room visits, and frequency of
readmission to hospitals, and utilization of healthcare resources.
• Option C: Asking the client how he feels will only provide subjective
data. Selected parameters are more important during various stages
of the recovery period. Initially, respiratory rate and blood pressure
are of greater significance during recovery from anesthesia, as it
reflects hemodynamic stability and level of anesthetic reversal. Later,
after adequate analgesia and pulmonary function has been obtained,
pulse rate correlates better with intravascular volume status.
• Option D: Assigning an unstable client to an LPN is inappropriate.
Much information can be obtained by close monitoring of the vital
signs, including blood pressure, pulse, and respiratory rate. More
importantly, the trend and changes of these measurements more
accurately reflect the patient’s ongoing condition. In the immediate
postoperative period, frequent measurements are usually obtained
by the recovery room staff.
21. Question

Category: Safe and Effective Care Environment

Which nurse should be assigned to care for the postpartum client with
preeclampsia?

• A. The RN with 2 weeks of experience in postpartum

• B. The RN with 3 years of experience in labor and delivery

• C. The RN with 10 years of experience in surgery

• D. The RN with 1 year of experience in the neonatal intensive care unit

Correct Answer: B. The RN with 3 years of experience in labor and delivery
The nurse with 3 years of experience in labor and delivery knows the most about
possible complications involving preeclampsia. Registered nurses need to know
their rights and responsibilities when considering a patient assignment. The
nurse-patient assignment process is also often a manual process in which the
charge nurse must sort through multiple decision criteria in a limited amount of
time.
• Option A: The nurse is a new staff to the unit hence lacking the
experience needed. Most nurse-patient assignment models have
focused on balancing patient acuity measures. This focus on patient
acuity concentrates workload measures on direct patient care
activities. While this is very important for the care of the patient, it
does not necessarily take into account all of the activities comprising
a nurse’s workload.
• Option C: The nurse with experience in surgery does not have the
same experience in labor and delivery. Balancing workload among
nurses on a hospital unit is important for the satisfaction and safety
of nurses and patients. To balance nurse workloads, direct patient
care activities, indirect patient care activities, and non-patient care
activities that occur throughout a shift must be considered.
• Option D: This nurse lacks sufficient experience with a postpartum
client. Limitations in experience and knowledge may not require
refusal of the assignment, but rather an agreement regarding
supervision or a modification of the assignment to ensure patient
safety. If no accommodation for limitations is considered, the nurse
has an obligation to refuse an assignment for which she or he lacks
education or experience.
22. Question

Category: Safe and Effective Care Environment

Which information should be reported to the state Board of Nursing?

• A. The facility fails to provide literature in both Spanish and English.

• B. The narcotic count has been incorrect on the unit for the past 3
days.

• C. The client fails to receive an itemized account of his bills and

services received during his hospital stay.

• D. The nursing assistant assigned to the client with hepatitis fails to

feed the client and give the bath.
Correct Answer: B. The narcotic count has been incorrect on the unit for the
past 3 days.
General advice from the Department of Health is that stocks of controlled drugs
should be kept to the minimum required to meet the clinical needs of patients.
They should be stored securely in a locked cabinet or safe to prevent
unauthorised access, with the keys held in a safe place.
• Option A: The Joint Commission conducts inspections with two
main objectives: To evaluate the healthcare organization using TJC
performance measures and standards. To educate and guide the
organization’s staff in “good practices” to help improve the
organization’s performance.
• Option C: The Joint Commission on Accreditation of Hospitals will
probably be interested in the problem in answer A. The Joint
Commission offers many benefits to their members. They help
members organize and strengthen their patient improvement
programs and safety efforts. They raise health care consumer and
community confidence in the quality of the organization’s care,
services and treatment. This provides a competitive edge in the
healthcare industry and a proven framework for organizational
management. The Joint Commission helps to reduce risk
management, liability insurance, and employee turnover costs.
• Option D: The failure of the nursing assistant to care for the client
with hepatitis might result in termination but is not of interest to the
Joint Commission. The Joint Commission monitors and advocates for
legislation that promotes better patient safety. When it comes to
state legislation, The Joint Commission collaborates with patient
safety authorities and state regulatory bodies to minimize unrealistic
expectations and reform outdated rules. They push state regulatory
bodies to rely more on private accreditation instead of mandatory
state licensure inspections.
23. Question

Category: Safe and Effective Care Environment

The nurse is suspected of charting medication administration that he did not
give. After talking to the nurse, the charge nurse should:

• A. Call the Board of Nursing

 • B. File a formal reprimand

• C. Terminate the nurse

• D. Charge the nurse with a tort

Correct Answer: B. File a formal reprimand
The next action after discussing the problem with the nurse is to document the
incident by filing a formal reprimand. As a rule of thumb, nurses should avoid
making assumptions when they notice gaps or missing information in a patient’s
treatment documentation. Healthcare professionals have exceedingly demanding
schedules, but it’s always better to take the time and double-check the details
than to make assumptions and be wrong.
• Option A: If the behavior continues, the nurse should be reported to
the Board of Nursing. Understanding these realities can add hours to
the day, so the practical approach is to be strategic with efforts. Look
for efficiency, work with colleagues, and use best judgment and
ingenuity to find ways to get everything done while still doing it
right. It’s not easy, but it’s also not impossible.
• Option C: If the behavior continues or if harm has resulted to the
client, the nurse may be terminated, but these are not the first
actions requested in the stem. Details save lives, and consistently
getting them right is what makes people feel safe when they go to
the doctor. Moreover, it’s also what keeps nurses from having to
defend their actions in a courtroom someday.
• Option D: A tort is a wrongful act to the client or his belongings and
is not indicated in this instance. A tort is a civil wrong that causes
harm to another person by violating a protected right. A civil wrong
is an act or omission that is intentional, accidental, or negligent,
other than a breach of contract. The specific rights protected give
rise to the unique “elements” of each tort. Tort requires the presence
of four elements that are the essential facts required to prove a civil
wrong.
24. Question

Category: Safe and Effective Care Environment

The home health nurse is planning for the day’s visits. Which client should be
seen first?
 • A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG
tube

• B. The 5-month-old discharged 1 week ago with pneumonia who is

being treated with amoxicillin liquid suspension

• C. The 50-year-old with MRSA being treated with Vancomycin via a

PICC line

• D. The 30-year-old with an exacerbation of multiple sclerosis being

treated with cortisone via a centrally placed venous catheter
Correct Answer: Answer: D. The 30-year-old with an exacerbation of
multiple sclerosis being treated with cortisone via a centrally placed venous
catheter
The client at highest risk for complications is the client with multiple sclerosis
who is being treated with cortisone via the central line. Multiple sclerosis is a
complex disease process. In addition to sensory and visual changes, weakness,
coordination problems, or spasticity can present. Other complaints relating to
overall health include bladder and bowel dysfunction, depression, cognitive
impairment, fatigue, sexual dysfunction, sleep disturbances, and vertigo. The
others are more stable.
• Option A: This client is more stable and can be seen later. Although
PEG is a relatively safe procedure, acute and chronic complications
have been reported, including early mortality. Pih et al conducted a
single-center study aimed at determining risk factors associated with
complications and 30-day mortality after pull-type (n = 139) and
introducer-type (n = 262) PEG.
• Option B: The client is already discharged and has discharge
medications given. Prognosis of pneumonia depends on many
factors including age, comorbidities, and hospital setting (inpatient
or outpatient). Generally, the prognosis is promising in otherwise
healthy patients. Patients older than 60 years or younger than 4
years of age have relatively poorer prognosis than young adults.
• Option C: MRSA is Methicillin-Resistant Staphylococcus Aureus.
Vancomycin is the drug of choice and is given at scheduled times to
maintain blood levels of the drug. Intravenous vancomycin is the
drug of choice for most MRSA infections seen in hospitalized
patients. It can be used both as empiric and definitive therapy as
 most MRSA infections are susceptible to vancomycin. There are
sporadic cases of vancomycin-resistant MRSA. The dosage depends
upon the type and severity of the infection.
25. Question

Category: Safe and Effective Care Environment

The emergency room is flooded with clients injured in a tornado. Which clients
can be assigned to share a room in the emergency department during the
disaster?

• A. A schizophrenic client having visual and auditory hallucinations and

the client with ulcerative colitis

• B. The client who is 6 months pregnant with abdominal pain and the
client with facial lacerations and a broken arm

• C. A child whose pupils are fixed and dilated and his parents, and a
client with a frontal head injury

• D. The client who arrives with a large puncture wound to the abdomen
and the client with chest pain
Correct Answer: B. The client who is 6 months pregnant with abdominal
pain and the client with facial lacerations and a broken arm
The pregnant client and the client with a broken arm and facial lacerations are
the best choices for placing in the same room. Cohorting of patients according to
the presence or absence of specific pathogens coupled with conventional
hygienic precautions can lead to a decrease in incidence and prevalence of
chronic infections with these two species, wherefore patient cohorting is now an
integral component of infection control in patients.
• Option A: Schizophrenia is a brain disorder that probably comprises
multiple etiologies. The hallmark symptom of schizophrenia is
psychosis, such as experiencing auditory hallucinations (voices) and
delusions (fixed false beliefs). Impaired cognition or a disturbance in
information processing is an underappreciated symptom that
interferes with day-to-day life. Hospitalizations are usually brief and
are typically oriented towards crisis management or symptom
stabilization.
 • Option C: The goals of care are for the child and their loved ones are
to be free of complicated grieving and to have access to adequate
resources to allow for the natural grieving process. It is important for
them to verbalize and express their true feelings and seek the help
and support of others. Having privacy from other patients would be
most appropriate.
• Option D: This group of clients needs to be placed in separate
rooms due to the serious nature of their injuries. The client with
chest pain should be placed in a private room to allow him to rest.
Promote expression of feelings and fears. Let the patient/SO know
these are normal reactions. Verbalization of concerns reduces
tension, verifies the level of coping, and facilitates dealing with
feelings. The presence of negative self-talk can increase the level of
anxiety and may contribute to the exacerbation of angina attacks.

26. Question

Category: Physiological Integrity

The nurse is caring for a 6-year-old client admitted with a diagnosis of
conjunctivitis. Before administering eye drops, the nurse should recognize that it
is essential to consider which of the following?

• A. The eye should be cleansed with warm water, removing any exudate,
before instilling the eyedrops.

• B. The child should be allowed to instill his own eye drops.

• C. The mother should be allowed to instill the eyedrops.

• D. If the eye is clear from any redness or edema, the eye drops should
be held.
Correct Answer: A. The eye should be cleansed with warm water, removing
any exudate, before instilling the eyedrops.
Before instilling eye drops, the nurse should cleanse the area with water. Cleanse
the eyelids and lashes with cotton balls or gauze pledgets moistened with normal
saline or water. This prevents debris to be carried into the eye when the
conjunctival sac is exposed.
 • Option B: A 6-year-old child is not developmentally ready to instill
his own eye drops. An ophthalmic assistant, technician, nurse or
physician instills eye drops during a routine eye examination or
during treatment for ocular disease.
• Option C: Although the mother of the child can instill the eye drops,
the area must be cleansed before administration. Use each cotton
ball or pledget for only one stroke, moving from the inner to the
outer canthus of the eye.
• Option D: Although the eye might appear to be clear, the nurse
should instill the eyedrops, as ordered, so answer D is incorrect.
Allow the prescribed number of drops to fall in the lower
conjunctival sac but do not allow to fall onto the cornea. Release the
lower lid after the drops are instilled. Instruct the patient to close
eyes slowly, move the eye and not to squeeze or rub.

27. Question

Category: Health Promotion and Maintenance

The nurse is discussing meal planning with the mother of a 2-year-old toddler.
Which of the following statements, if made by the mother, would require a need
for further instruction?

• A. "It is okay to give my child white grape juice for breakfast."

• B. "My child can have a grilled cheese sandwich for lunch."

• C. "We are going on a camping trip this weekend, and I have bought
hot dogs to grill for his lunch."

• D. "For a snack, my child can have ice cream."

Correct Answer: C. “We are going on a camping trip this weekend, and I
have bought hot dogs to grill for his lunch.”
Remember the ABCs (airway, breathing, circulation) when answering this
question. A hotdog is the size and shape of the child’s trachea and poses a risk of
aspiration. It is important to avoid foods that may cause choking like slippery
foods such as whole grapes; large pieces of meat, poultry, and hot dogs; candy,
and cough drops.
 • Option A: A white grape juice does not pose a risk for aspiration.
The toddler years are full of exploring and discovery. The best thing
you can do is offer your toddler a variety of foods from each food
group with different tastes, textures, and colors.
• Option B: A grilled cheese sandwich would not aspirate a toddler.
Always cut up foods into small pieces and watch your child while he
or she is eating. Offer new foods one at a time, and remember that
children may need to try a new food 10 or more times before they
accept it.
• Option D: Ice cream does not pose a risk of aspiration for a child.
Make food simple, plain, and recognizable. Some kids don’t like food
that is mixed (like a casserole) or food that is touching. Plan regular
meals and snacks and give kids enough time to eat.

28. Question

Category: Physiological Integrity

A 2-year-old toddler is admitted to the hospital. Which of the following nursing
interventions would you expect?

• A. Ask the parent/guardian to leave the room when assessments are

being performed.

• B. Ask the parent/guardian to take the child’s favorite blanket home

because anything from the outside should not be brought into the
hospital.

• C. Ask the parent/guardian to room-in with the child.

• D. If the child is screaming, tell him this is inappropriate behavior.

Correct Answer: C. Ask the parent/guardian to room-in with the child.
The nurse should encourage rooming-in to promote parent-child attachment. It
is okay for the parents to be in the room for assessment of the child. Toddlers
have a strong fear of strangers and they may feel like they are losing control and
autonomy when at the hospital. Explain the procedures to them at the level of
their understanding to further prevent anxiety.
 • Option A: Toddlers are afraid of strangers, so asking the parents to
leave the room would increase the anxiety. The initial assessment of
the interplay of key variables such as anxiety, coping and play can
inform healthcare professionals by serving as a guide in order to
determine a child’s risk for negative psychological outcomes due to
hospitalization, to plan appropriate interventions and to provide
substantial assistance to hospitalized children in the future.
• Option B: Hospitalization for children means leaving their home and
their caregivers and siblings and an interruption of their daily
activities and routines. Moreover, hospital wards are often associated
with staying in a “cold and medical” setting, facing fear of medical
examinations, pain, uncertainty, and loss of control and safeness.
Allowing the child to have items that are familiar to him is allowed
and encouraged.
• Option D: Telling the child that screaming is inappropriate behavior
is not part of the nurse’s responsibilities. Usually, children feel
anxious before encountering medical professionals, as well as
experiencing a hospitalization. Empirical studies suggest that
children express anxiety through regression in behaviors, aggression,
lack of cooperation, withdrawal, and difficulty recovering from
procedures.
29. Question

Category: Health Promotion and Maintenance

Which instruction should be given to the client who is fitted for a behind-the-ear
hearing aid?

• A. Remove the mold and clean every week.

• B. Store the hearing aid in a warm place.

• C. Clean the lint from the hearing aid with a toothpick.

• D. Change the batteries weekly.

Correct Answer: B. Store the hearing aid in a warm place.
The hearing aid should be stored in a warm, dry place. Proper maintenance and
care will extend the life of your hearing aid. Make it a habit to keep hearing aids
away from heat and moisture. Avoid using hairspray or other hair care products
while wearing hearing aids. When it’s exposed to moisture it can cause serious
damage. Although hearing aids are now being made to be water resistant it’s
recommended that they are removed when showering or swimming. If they do
come in contact with water, dry them immediately with a towel. Never attempt to
dry them with a hair drier or other heated device, since the high heat can damage
them.
• Option A: It should be cleaned daily but should not be moldy. Clean
hearing aids as instructed. Earwax and ear drainage can damage a
hearing aid. Turn off hearing aids when they are not in use. Always
take the hearing aids out before having a shower, taking a bath or
going swimming. It’s best to leave the hearing aids out of humid
environments like the bathroom, as moisture can damage the
electronic components in the hearing aid.
• Option C: A toothpick is inappropriate to use to clean the aid; the
toothpick might break off in the hearing aid. A whistling sound can
be caused by a hearing aid that does not fit or work well or is
clogged by earwax or fluid. When cleaning your hearing aids, use a
dry, soft cloth. Hearing aid care products are available through
audiologists and audiometrists. They will also check for ear wax build
up and the general working order of the hearing aid.
• Option D: Changing the batteries weekly is not necessary. Replace
dead batteries immediately. Keep replacement batteries and small
aids away from children and pets. Also when changing out batteries,
remember to clean the battery contacts in the devices. This can be
done by gently wiping them down with a dry cotton swab. If the
battery contacts on the devices are dirty, it can create a poor
connection and lower performance.
30. Question

Category: Physiological Integrity

A priority nursing diagnosis for a child being admitted from surgery following a
tonsillectomy is:

• A. Body image disturbance

• B. Impaired verbal communication

• C. Risk for aspiration

 • D. Pain
Correct Answer: C. Risk for aspiration
Always remember your ABCs (airway, breathing, circulation) when selecting an
answer. Place the child prone or side-lying position. Promotes drainage of blood
and unswallowed saliva from the mouth that can potentially be aspirated.
• Option A: Does not apply for a child who has undergone a
tonsillectomy. Assess for signs and symptoms of inadequate
oxygenation. Early signs of hypoxia include confusion, irritability,
headaches, pallor, tachycardia, and tachypnea.
• Option B: Observe the child for nonverbal indications of pain such
as crying, grimacing, irritability. Provides additional information
about pain. The child may find discomfort in speaking.
• Option D: Although these nursing diagnoses might be appropriate
for this child, risk for aspiration should have the highest priority.
Apply an ice collar on the neck or encourage the child to eat
popsicles. Cold promotes vasoconstriction and decreases swelling
that contributes to pain.