NUR 114 Final Exam Actual Questions And Correct Detailed Answers New Version Graded A+
The nurse analyzes the laboratory results ofa child with hemophilia.The nurse
understands that which result will most likelybe abnormalin thischild?
1.Platelet count
2.Hematocrit level
3.Hemoglobin level
4.Partial thromboplastin time-CORRECT ANSWER-Answer:4
Rationale:Hemophilia refers to a group of bleeding disorders resulting from a deficiency of
specific coagulation proteins. Results oftests that measure platelet function are normal;results of
tests that measure clotting factor function may be abnormal.Abnormal laboratory results in
hemophilia indicate a prolonged partialthromboplastintime.The platelet count,hemoglobin
level,and hematocrit level are normal in hemophilia.
Test-Taking Strategy:Focus on the subject,laboratory tests uused to monitor
hemophilia,and note the strategic words,most likely.Recalling the pathophysiology
associated with this disorder and recalling that it results from a deficiency of specific
coagulation proteins will direct you to the correct option.
The nurse analyzes the laboratory values of a child with leukemia who is receiving
chemotherapy.The nurse notes that the platelet countis 19,500 mm3(19.5x109/L).On the basis ofthis
laboratory result, which intervention would the nurse include in the plan of care?
1.Initiate bleeding precautions.
2.Monitor closely forsigns ofinfection.
3.Monitor the temperature every 4 hours.
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4.Initiate protective isolation precautions.-CORRECT ANSWER-Answer:1
Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the
bone marrow. It affects the bone marrow,causing anemia from decreased erythrocytes, infection from
neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child has a low
platelet count, usually less than 50,000 mm3 (50.0 x 109/L), bleeding precautions need to be initiated because
of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head
injury,using soft toothbrushes, checking urine and stools for blood, and administering stool softeners
toprevent straining with constipation. In addition,suppositories, enemas, and rectal temperatures are
avoided. Options 2, 3, and 4are related to the prevention of infection rather than bleeding.
Test-Taking Strategy: Note that the platelet count is low, and recall that a low platelet count places the child
at risk for bleeding. In addition, note that options 2,3, and 4 are comparable or alike because they relate to
prevention of and monitoring for infection.
The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to
the eyes of a newborn. Which student statement indicates that further teaching is needed about
administration of the eye medication?
1. "I will flush the eyes after instilling the ointment."
2. "I will clean the newborn's eyes before instilling ointment."
3. "I need to administer the eye ointment within 1 hour after delivery."
4. "I will instill the eye ointment into each of the newborn's conjunctival sacs." -CORRECT ANSWER-
Answer:1
OLaaed
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Rationale: Eye prophylaxis protects the newborn against Neisseria gonorrhoeae and Chlamydia trachomatis.
The eyes are not flushed after instillation of the medication because the flush would wash away the
administered medication.Options 2, 3, and 4 are correct statements regarding the procedure for administering
eye medication to the newborn.
Test-Taking Strategy: Note the strategic words, further teaching is needed. These words indicate a negative
event query and ask you to select an option that is an incorrect statement. Eliminate options 3 and 4 first
because they are comparable or alike and relate to instilling the eye medication. From the remaining
options,visualize the effectof each. This will direct you to the correct option.
The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the
respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate?
1.Administer oxygen.
2. Document the findings.
3. Notify the pediatrician.
4.Reassess the respiratory rate in 15 minutes.-CORRECT ANSWER-Answer:2
Rationale:The normal respiratory rate in a 12-month-old infant is 20 to 40breaths per minute.The normal apical
heart rate is 90 to 130 beats per minute,and the average blood pressure is 90/56 mm Hg. The nurse would
document the findings.
TLeied
, 72|Page
Test-Taking Strategy: Focus on the data in the question and note the strategic words,most appropriate.
Recalling the normal vital signs of an infant and noting that the respiratory rate identified in the question is
within the normal range will direct you to the correct option.
The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat
loss by evaporation?
1.Warming the crib pad
2. Closing the doors to the room
3.Drying the infant with a warm blanket
4.Turning on the overhead radiant warmer-CORRECT ANSWER-Answer:3
Rationale: Evaporation of moisture from a wet body dissipates heat along with the moisture.Keeping the
newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation.Hypothermia caused
by conduction occurs when the newborn is on a cold surface,such as a cold pad or mattress,and heat from the
newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing
hypothermia by conduction.Convection occurs as air moves across the newborn's skin from an open door and
heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface
(indirect contact).
Test-Taking Strategy: Note the strategic words, most effective. Recalling that evaporation of moisture
from a wet body dissipates heat along with the moisture will assist in directing you to the correct option.
ZLaied
The nurse analyzes the laboratory results ofa child with hemophilia.The nurse
understands that which result will most likelybe abnormalin thischild?
1.Platelet count
2.Hematocrit level
3.Hemoglobin level
4.Partial thromboplastin time-CORRECT ANSWER-Answer:4
Rationale:Hemophilia refers to a group of bleeding disorders resulting from a deficiency of
specific coagulation proteins. Results oftests that measure platelet function are normal;results of
tests that measure clotting factor function may be abnormal.Abnormal laboratory results in
hemophilia indicate a prolonged partialthromboplastintime.The platelet count,hemoglobin
level,and hematocrit level are normal in hemophilia.
Test-Taking Strategy:Focus on the subject,laboratory tests uused to monitor
hemophilia,and note the strategic words,most likely.Recalling the pathophysiology
associated with this disorder and recalling that it results from a deficiency of specific
coagulation proteins will direct you to the correct option.
The nurse analyzes the laboratory values of a child with leukemia who is receiving
chemotherapy.The nurse notes that the platelet countis 19,500 mm3(19.5x109/L).On the basis ofthis
laboratory result, which intervention would the nurse include in the plan of care?
1.Initiate bleeding precautions.
2.Monitor closely forsigns ofinfection.
3.Monitor the temperature every 4 hours.
, 70|Page
4.Initiate protective isolation precautions.-CORRECT ANSWER-Answer:1
Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the
bone marrow. It affects the bone marrow,causing anemia from decreased erythrocytes, infection from
neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child has a low
platelet count, usually less than 50,000 mm3 (50.0 x 109/L), bleeding precautions need to be initiated because
of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head
injury,using soft toothbrushes, checking urine and stools for blood, and administering stool softeners
toprevent straining with constipation. In addition,suppositories, enemas, and rectal temperatures are
avoided. Options 2, 3, and 4are related to the prevention of infection rather than bleeding.
Test-Taking Strategy: Note that the platelet count is low, and recall that a low platelet count places the child
at risk for bleeding. In addition, note that options 2,3, and 4 are comparable or alike because they relate to
prevention of and monitoring for infection.
The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to
the eyes of a newborn. Which student statement indicates that further teaching is needed about
administration of the eye medication?
1. "I will flush the eyes after instilling the ointment."
2. "I will clean the newborn's eyes before instilling ointment."
3. "I need to administer the eye ointment within 1 hour after delivery."
4. "I will instill the eye ointment into each of the newborn's conjunctival sacs." -CORRECT ANSWER-
Answer:1
OLaaed
, 71|Page
Rationale: Eye prophylaxis protects the newborn against Neisseria gonorrhoeae and Chlamydia trachomatis.
The eyes are not flushed after instillation of the medication because the flush would wash away the
administered medication.Options 2, 3, and 4 are correct statements regarding the procedure for administering
eye medication to the newborn.
Test-Taking Strategy: Note the strategic words, further teaching is needed. These words indicate a negative
event query and ask you to select an option that is an incorrect statement. Eliminate options 3 and 4 first
because they are comparable or alike and relate to instilling the eye medication. From the remaining
options,visualize the effectof each. This will direct you to the correct option.
The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the
respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate?
1.Administer oxygen.
2. Document the findings.
3. Notify the pediatrician.
4.Reassess the respiratory rate in 15 minutes.-CORRECT ANSWER-Answer:2
Rationale:The normal respiratory rate in a 12-month-old infant is 20 to 40breaths per minute.The normal apical
heart rate is 90 to 130 beats per minute,and the average blood pressure is 90/56 mm Hg. The nurse would
document the findings.
TLeied
, 72|Page
Test-Taking Strategy: Focus on the data in the question and note the strategic words,most appropriate.
Recalling the normal vital signs of an infant and noting that the respiratory rate identified in the question is
within the normal range will direct you to the correct option.
The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat
loss by evaporation?
1.Warming the crib pad
2. Closing the doors to the room
3.Drying the infant with a warm blanket
4.Turning on the overhead radiant warmer-CORRECT ANSWER-Answer:3
Rationale: Evaporation of moisture from a wet body dissipates heat along with the moisture.Keeping the
newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation.Hypothermia caused
by conduction occurs when the newborn is on a cold surface,such as a cold pad or mattress,and heat from the
newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing
hypothermia by conduction.Convection occurs as air moves across the newborn's skin from an open door and
heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface
(indirect contact).
Test-Taking Strategy: Note the strategic words, most effective. Recalling that evaporation of moisture
from a wet body dissipates heat along with the moisture will assist in directing you to the correct option.
ZLaied
