- (Topic 5)
A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:

1. A. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms
2. B. Giving clear liquids too soon
3. C. Allowing the child to come in contact with other children for 3 days
4. D. The possibility of pneumonia as a complication

Correct Answer: A
(A) Aspirin should never be given to children with influenza because of the possibility of causing Reye??s syndrome. Pepto- Bismol is also classified as a salicylate and should be avoided. (B) Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. (C) The disease has a 1–3 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. (D) Although viral pneumonia can be a complication of influenza, this would not be an initial priority.

- (Topic 7)
Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?

1. A. Nifedipine 10 mg SL for B/P 140/90
2. B. Furosemide 20 mg/PO for decreased urine output
3. C. Magnesium salicylate to decrease inflammation
4. D. Nitroglycerin gr 1/150 for chest pain

Correct Answer: A
(A) It is important to maintain a normal to slightly lower pressure to prevent the graft from blowing and excessive pressure to surgical vascular areas. (B, C, D) None of these drugs is related to managing the problem at hand. Also, none of the problems for which these drugs would be indicated is expected with this type of surgery, except if there is a prior history.

- (Topic 5)
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client??s vaginal exam indicates she is 3 cm dilated, 80% effaced, and at _0 station. Based on the vaginal exam, she is in:

1. A. Stage 2, latent phase
2. B. Stage 1, active phase
3. C. Stage 3, transition phase
4. D. Stage 1, latent phase

Correct Answer: D
(A) The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. (B) The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0–3 cm), the active phase (4–7 cm), and the transitional phase (7–10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. (C) The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. (D) The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early orlatent phase (0–3 cm), the active phase (4–7 cm), and the transitional phase (7–10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.

- (Topic 7)
Which of the following lab data is representative of a client with aplastic anemia?

1. A. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million
2. B. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000
3. C. White blood cells 3000, hematocrit 27, red blood cells 2.8 million
4. D. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000

Correct Answer: D
(A, B, C) Although all of the lab data are abnormal and although these values are decreased in aplastic anemia, the disorder is defined by severe deficits in red cell, white cell, and platelet counts. (D) Aplastic anemia is typically defined in terms of abnormalities of red blood cell count, usually <1 million, white cell count <2,000, and thrombocytes <20,000.

- (Topic 6)
A client??s membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?

1. A. Assess quantity of fluid.
2. B. Assess color and odor of fluid.
3. C. Document on fetal monitor strip and chart.
4. D. Assess fetal heart rate (FHR).

Correct Answer: D
(A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well-being, but it does not take priority over assessment of FHR. (B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.