#2
1. Question
Category: Reduction of Risk Potential
A 28-year-old male has been found wandering around in a confusing
pattern. The male is sweaty and pale. Which of the following tests is most
likely to be performed first?
o A. Blood sugar check
o B. CT scan
o C. Blood cultures
o D. Arterial blood gases
Correct Answer: A. Blood sugar check
With a history of diabetes, the first response should be to check blood
sugar levels.
• Option B: Performing a CT scan at this stage of assessment is
unnecessary. A computerized tomography (CT) scan combines
a series of X-ray images taken from different angles around
the body and uses computer processing to create cross-
sectional images (slices) of the bones, blood vessels, and soft
tissues inside the body. CT scan images provide more detailed
information than plain X-rays do.
• Option C: A blood culture test helps the doctor figure out if
the client has a kind of infection that is in the bloodstream and
can affect the entire body. Doctors call this a systemic
infection. The test checks a sample of the blood for bacteria or
yeast that might be causing the infection.
• Option D: An arterial blood gas (ABG) test measures oxygen
and carbon dioxide levels in the blood. It also measures the
, body’s acid-base (pH) level, which is usually in balance when
healthy.
2. 2. Question
Category: Health Promotion and Maintenance
A mother is inquiring about her child’s ability to potty train. Which of the
following factors is the most important aspect of toilet training?
o A. The age of the child
o B. The child's ability to understand instruction
o C. The overall mental and physical abilities of the child
o D. Frequent attempts with positive reinforcement
Correct
Correct Answer: C. The overall mental and physical abilities of the
child.
Age is not the greatest factor in potty training. The overall mental and
physical abilities of the child are the most important factor.
• Option A: Readiness for toilet training varies with every age of
the child.
• Option B: A child who can follow simple instructions may start
toilet training. However, it is not considered the most
important factor.
• Option D: Positive reinforcement is a great tool for toilet
training, yet, it may not be the most important one.
3. 3. Question
Category: Safety and Infection Control
A parent calls the pediatric clinic and is frantic about the bottle of cleaning
fluid her child drank for 20 minutes. Which of the following is
the most important instruction the nurse can give the parent?
o A. This too shall pass
o B. Take the child immediately to the ER
o C. Contact the Poison Control Center quickly
o D. Give the child syrup of ipecac
, Correct Answer: C. Contact the Poison Control Center quickly.
The poison control center will have an exact plan of action for this child.
• Option A: Ingestion of a chemical is an emergency and should
not be delayed.
• Option B: Taking the client to the ER may be correct, however,
they will still have to contact the Poison Control Center.
• Option D: It should not be given to someone who swallowed
chemicals that cause burns on contact or medicines that can
cause seizures very quickly. It can be dangerous to people with
some types of medical problems. When such poisoning
victims got Ipecac anyway, they developed serious
complications or even died.
4. 4. Question
Category: Pharmacological and Parenteral Therapies
A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which
of the following target areas is the most appropriate?
o A. Gluteus maximus
o B. Gluteus minimus
o C. Vastus lateralis
o D. Vastus medialis
Correct Answer: C. Vastus lateralis
Medications are injected into the bulkiest part of the vastus lateralis thigh
muscle, which is the junction of the upper and middle thirds of this muscle.
• Option A: Intramuscular injections given at the dorsogluteal
and ventrogluteal sites are intended for the gluteus maximus
and gluteus medius muscles, respectively. However, little
research has confirmed the reliability of these sites for the
presence and thickness of the target and other muscles, and
subcutaneous fat.
• Option B: Never give an IM injection in the gluteal muscles to
avoid the risk of sciatica nerve damage.
• Option D: The vastus medialis muscle is a part of the
quadriceps muscle group, located on the front of the thigh.
5. 5. Question