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Nursing Board Practice Test Compilation                                                                                   ...
ANSWERS AND RATIONALE – MATERNAL AND CHILD                                              MEDICAL SURGICAL NURSING Part 1 .....
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5.    Benner’s “Proficient” nurse level is different                                                                    fr...
5           b. 5 seconds                                           that the patient smokes and drinks coffee. When        ...
What is the client’s blood pressure?                          to lungs. This can be avoided by:          a. 130/80        ...
7           c. Breathe deeply                                              d. Weber’s test           d. Clear his throat  ...
38.    Where would the nurse tape Eileen’s indwelling              regulation is secreted in the:       catheter in order ...
9            a.   grievance                                                d. It should disclose previous diagnosis,      ...
d. Iron 75 mg/100 ml60.     A participant in the STROKE class asks what is a        risk factor of stroke. Your best respo...
11            c. There is a continuous bubbling in the               waterseal                                    75.     ...
b. Not takes sides, remain neutral and fair          c. Assume that ethical questions are the        85.    Based on the C...
13        gain independence as quickly as possible. Which                include:        of the following nursing actions ...
b. Medicine preparation is correct           c. Position of the client is correct           d. Consent is signed by relati...
15                                                                      D. Follicle stimulating hormoneNURSING PRACTICE II...
requirements of pregnancies related to           15. While talking with Susan, 2 new patients arrived                 lack...
17           B. Five years           C. Twelve months                                    23. Another client named Lilia is...
B. have increased hepatic, renal and                     D. Chronic poverty                gastrointestinal function      ...
19       C. The skin turns yellow and then brown                    release          over the first 48 hours of life      ...
C. The urine dipstick showing glucose in the                urine for 3 days, extreme thirst, increase         51. If a ch...
21           B. Conducting strong health education                  health worker should first:              drives/campai...
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  1. 1. Nursing Board Practice Test Compilation FOUNDATION OF PROFESSIONAL NURSING PRACTICE 188Contents ANSWER KEY - FOUNDATION OF PROFESSIONALNURSING PRACTICE I: FOUNDATION OF NURSING NURSING PRACTICE.................................................. 199PRACTICE .......................................................................... 4 COMMUNITY HEALTH NURSING AND CARE OF THENURSING PRACTICE II ..................................................... 15 MOTHER AND CHILD .................................................... 200NURSING PRACTICE III .................................................... 26 ANSWER KEY: COMMUNITY HEALTH NURSING AND CARE OF THE MOTHER AND CHILD .......................... 211NURSING PRACTICE IV.................................................... 36 Comprehensive Exam 1................................................ 213NURSING PRACTICE V..................................................... 46 CARE OF CLIENTS WITH PHYSIOLOGIC ANDTEST I - Foundation of Professional Nursing Practice .... 56 PSYCHOSOCIAL ALTERATIONS...................................... 222 Answers and Rationale – Foundation of Professional ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC Nursing Practice ......................................................... 66 AND PSYCHOSOCIAL ALTERATIONS ......................... 234TEST II - Community Health Nursing and Care of the Nursing Practice Test V ................................................ 235Mother and Child ........................................................... 74 Nursing Practice Test V ................................................ 245 Answers and Rationale – Community Health Nursing and Care of the Mother and Child ............................. 84 TEST I - Foundation of Professional Nursing Practice .. 255TEST III - Care of Clients with Physiologic and Answers and Rationale – Foundation of ProfessionalPsychosocial Alterations ................................................ 91 Nursing Practice ....................................................... 265 Answers and Rationale – Care of Clients with TEST II - Community Health Nursing and Care of the Physiologic and Psychosocial Alterations ................ 102 Mother and Child ......................................................... 273TEST IV - Care of Clients with Physiologic and Answers and Rationale – Community Health NursingPsychosocial Alterations .............................................. 111 and Care of the Mother and Child ........................... 283 Answers and Rationale – Care of Clients with TEST III - Care of Clients with Physiologic and Physiologic and Psychosocial Alterations ................ 122 Psychosocial Alterations .............................................. 290TEST V - Care of Clients with Physiologic and Psychosocial Answers and Rationale – Care of Clients withAlterations.................................................................... 133 Physiologic and Psychosocial Alterations ................ 301 Answers and Rationale – Care of Clients with TEST IV - Care of Clients with Physiologic and Physiologic and Psychosocial Alterations ................ 144 Psychosocial Alterations .............................................. 310PART III PRACTICE TEST I FOUNDATION OF NURSING . 153 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 321 ANSWERS AND RATIONALE – FOUNDATION OF NURSING .................................................................. 158 TEST V - Care of Clients with Physiologic and Psychosocial Alterations.................................................................... 332PRACTICE TEST II Maternal and Child Health ............... 162 Answers and Rationale – Care of Clients with ANSWERS AND RATIONALE – MATERNAL AND CHILD Physiologic and Psychosocial Alterations ................ 343 HEALTH..................................................................... 167 PART III ......................................................................... 352MEDICAL SURGICAL NURSING ..................................... 173 PRACTICE TEST I FOUNDATION OF NURSING .............. 352 ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING .................................................................. 178 ANSWERS AND RATIONALE – FOUNDATION OF NURSING .................................................................. 357PSYCHIATRIC NURSING ................................................ 180 PRACTICE TEST II Maternal and Child Health ............... 361 ANSWERS AND RATIONALE – PSYCHIATRIC NURSING ................................................................................. 185
  2. 2. ANSWERS AND RATIONALE – MATERNAL AND CHILD MEDICAL SURGICAL NURSING Part 1 ........................... 475 HEALTH..................................................................... 366 ANSWERS and RATIONALES for MEDICAL SURGICALMEDICAL SURGICAL NURSING ..................................... 372 NURSING Part 1 ........................................................ 479 ANSWERS AND RATIONALE – MEDICAL SURGICAL MEDICAL SURGICAL NURSING Part 2 ........................... 481 NURSING .................................................................. 377 MEDICAL SURGICAL NURSING Part 2 ....................... 485PSYCHIATRIC NURSING ................................................ 379 ANSWERS and RATIONALES for MEDICAL SURGICAL ANSWERS AND RATIONALE – PSYCHIATRIC NURSING NURSING Part 2 ........................................................ 489 ................................................................................. 384 MEDICAL SURGICAL NURSING Part 3 ........................... 491FUNDAMENTALS OF NURSING PART 1 ........................ 387 ANSWERS and RATIONALES for MEDICAL SURGICALFUNDAMENTALS OF NURSING PART 2 ........................ 392 NURSING Part 3 ........................................................ 495 ANSWERS and RATIONALES for FUNDAMENTALS OF PSYCHIATRIC NURSING Part 1 ...................................... 497 NURSING PART 2 ...................................................... 397 ANSWERS and RATIONALES for PSYCHIATRIC NURSINGFUNDAMENTALS OF NURSING PART 3 ........................ 401 Part 1 ........................................................................ 502 ANSWERS and RATIONALES for FUNDAMENTALS OF PSYCHIATRIC NURSING Part 2 ...................................... 504 NURSING PART 3 ...................................................... 405 ANSWERS and RATIONALES for PSYCHIATRIC NURSINGMATERNITY NURSING Part 1 ........................................ 409 Part 2 ........................................................................ 509 ANSWERS and RATIONALES for MATERNITY NURSING PSYCHIATRIC NURSING Part 3 ...................................... 512 Part 1 ........................................................................ 418 ANSWERS and RATIONALES for PSYCHIATRIC NURSINGMATERNITY NURSING Part 2 ........................................ 428 Part 3 ........................................................................ 516 Answer for maternity part 2 .................................... 433 PROFESSIONAL ADJUSTMENT ...................................... 519PEDIATRIC NURSING .................................................... 434 LEADERSHIP and MANAGEMENT ................................. 522 ANSWERS and RATIONALES for PEDIATRIC NURSING NURSING RESEARCH Part 1 .......................................... 532 ................................................................................. 439 NURSING RESEARCH Part 2 .......................................... 542COMMUNITY HEALTH NURSING Part 1........................ 444 Nursing Research Suggested Answer Key ................ 546COMMUNITY HEALTH NURSING Part 2........................ 4542
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  4. 4. 5. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in theNURSING PRACTICE I: FOUNDATION OF NURSING context of having:PRACTICE a. the ability to organize and plan activities b. having attained an advanced level ofSITUATION: Nursing is a profession. The nurse should educationhave a background on the theories and foundation of c. a holistic understanding and perceptionnursing as it influenced what is nursing today. of the client d. intuitive and analytic ability in new 1. Nursing is the protection, promotion and situations optimization of health and abilities, prevention of illness and injury, alleviation of suffering SITUATION: The nurse has been asked to administer an through the diagnosis and treatment of human injection via Z TRACK technique. Questions 6 to 10 refer response and advocacy in the care of the to this. individuals, families, communities and the population. This is the most accepted definition 6. The nurse prepares an IM injection for an adult of nursing as defined by the: client using the Z track technique. 4 ml of a. PNA medication is to be administered to the client. b. ANA Which of the following site will you choose? c. Nightingale a. Deltoid d. Henderson b. Rectus femoris c. Ventrogluteal 2. Advancement in Nursing leads to the d. Vastus lateralis development of the Expanded Career Roles. Which of the following is NOT an expanded 7. In infants 1 year old and below, which of the career role for nurses? following is the site of choice for intramuscular a. Nurse practitioner Injection? b. Nurse Researcher a. Deltoid c. Clinical nurse specialist b. Rectus femoris d. Nurse anaesthesiologist c. Ventrogluteal d. Vastus lateralis 3. The Board of Nursing regulated the Nursing profession in the Philippines and is responsible 8. In order to decrease discomfort in Z track for the maintenance of the quality of nursing in administration, which of the following is the country. Powers and duties of the board of applicable? nursing are the following, EXCEPT: a. Pierce the skin quickly and smoothly at a. Issue, suspend, revoke certificates of a 90 degree angle registration b. Inject the medication steadily at around b. Issue subpoena duces tecum, ad 10 minutes per millilitre testificandum c. Pull back the plunger and aspirate for 1 c. Open and close colleges of nursing minute to make sure that the needle did d. Supervise and regulate the practice of not hit a blood vessel nursing d. Pierce the skin slowly and carefully at a 90 degree angle 4. A nursing student or a beginning staff nurse who has not yet experienced enough real situations 9. After injection using the Z track technique, the to make judgments about them is in what stage nurse should know that she needs to wait for a of Nursing Expertise? few seconds before withdrawing the needle and a. Novice this is to allow the medication to disperse into b. Newbie the muscle tissue, thus decreasing the client’s c. Advanced Beginner discomfort. How many seconds should the nurse d. Competent wait before withdrawing the needle? a. 2 seconds4
  5. 5. 5 b. 5 seconds that the patient smokes and drinks coffee. When c. 10 seconds taking the blood pressure of a client who d. 15 seconds recently smoked or drank coffee, how long should the nurse wait before taking the client’s10. The rationale in using the Z track technique in an blood pressure for accurate reading? intramuscular injection is: a. 15 minutes a. It decreases the leakage of discolouring b. 30 minutes and irritating medication into the c. 1 hour subcutaneous tissues d. 5 minutes b. It will allow a faster absorption of the medication 15. While the client has pulse oximeter on his c. The Z track technique prevent irritation fingertip, you notice that the sunlight is shining of the muscle on the area where the oximeter is. Your action d. It is much more convenient for the nurse will be to: a. Set and turn on the alarm of theSITUATION: A Client was rushed to the emergency room oximeterand you are his attending nurse. You are performing a b. Do nothing since there is no identifiedvital sign assessment. problem c. Cover the fingertip sensor with a towel11. All of the following are correct methods in or bedsheet assessment of the blood pressure EXCEPT: d. Change the location of the sensor every a. Take the blood pressure reading on both four hours arms for comparison b. Listen to and identify the phases of 16. The nurse finds it necessary to recheck the blood Korotkoff’s sound pressure reading. In case of such re assessment, c. Pump the cuff to around 50 mmHg the nurse should wait for a period of: above the point where the pulse is a. 15 seconds obliterated b. 1 to 2 minutes d. Observe procedures for infection control c. 30 minutes d. 15 minutes12. You attached a pulse oximeter to the client. You know that the purpose is to: 17. If the arm is said to be elevated when taking the a. Determine if the client’s hemoglobin blood pressure, it will create a: level is low and if he needs blood a. False high reading transfusion b. False low reading b. Check level of client’s tissue perfusion c. True false reading c. Measure the efficacy of the client’s anti- d. Indeterminate hypertensive medications d. Detect oxygen saturation of arterial 18. You are to assessed the temperature of the blood before symptoms of hypoxemia client the next morning and found out that he develops ate ice cream. How many minutes should you wait before assessing the client’s oral13. After a few hours in the Emergency Room, The temperature? client is admitted to the ward with an order of a. 10 minutes hourly monitoring of blood pressure. The nurse b. 20 minutes finds that the cuff is too narrow and this will c. 30 minutes cause the blood pressure reading to be: d. 15 minutes a. inconsistent b. low systolic and high diastolic 19. When auscultating the client’s blood pressure c. higher than what the reading should be the nurse hears the following: From 150 mmHg d. lower than what the reading should be to 130 mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg; muffled sound14. Through the client’s health history, you gather continuing down to 80 mmHg and then silence.
  6. 6. What is the client’s blood pressure? to lungs. This can be avoided by: a. 130/80 a. Cleaning teeth and mouth with cotton b. 150/100 swabs soaked with mouthwash to avoid c. 100/80 rinsing the buccal cavity d. 150/100 b. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton20. In a client with a previous blood pressure of swabs 130/80 4 hours ago, how long will it take to c. use fingers wrapped with wet cotton release the blood pressure cuff to obtain an washcloth to rub inside the cheeks, accurate reading? tongue, lips and ums a. 10-20 seconds d. suctioning as needed while cleaning the b. 30-45 seconds buccal cavity c. 1-1.5 minutes d. 3-3.5 minutes 25. Your client has difficulty of breathing and is mouth breathing most of the time. This causesSituation: Oral care is an important part of hygienic dryness of the mouth with unpleasant odor. Oralpractices and promoting client comfort. hygiene is recommended for the client and in addition, you will keep the mouth moistened by21. An elderly client, 84 years old, is unconscious. using: Assessment of the mouth reveals excessive a. salt solution dryness and presence of sores. Which of the b. petroleum jelly following is BEST to use for oral care? c. water a. lemon glycerine d. mentholated ointment b. Mineral oil c. hydrogen peroxide Situation – Ensuring safety before, during and after a d. Normal saline solution diagnostic procedure is an important responsibility of the nurse.22. When performing oral care to an unconscious client, which of the following is a special 26. To help Fernan better tolerate the consideration to prevent aspiration of fluids into bronchoscopy, you should instruct him to the lungs? practice which of the following prior to the a. Put the client on a sidelying position procedure? with head of bed lowered a. Clenching his fist every 2 minutes b. Keep the client dry by placing towel b. Breathing in and out through the nose under the chin with his mouth open c. Wash hands and observes appropriate c. Tensing the shoulder muscles while lying infection control on his back d. Clean mouth with oral swabs in a careful d. Holding his breath periodically for 30 and an orderly progression seconds23. The advantages of oral care for a client include 27. Following a bronchoscopy, which of the all of the following, EXCEPT: following complains to Fernan should be noted a. decreases bacteria in the mouth and as a possible complication: teeth a. Nausea and vomiting b. reduces need to use commercial b. Shortness of breath and laryngeal mouthwash which irritate the buccal stridor mucosa c. Blood tinged sputum and coughing c. improves client’s appearance and self- d. Sore throat and hoarseness confidence d. improves appetite and taste of food 28. Immediately after bronchoscopy, you instructed Fernan to:24. A possible problem while providing oral care to a. Exercise the neck muscles unconscious clients is the risk of fluid aspiration b. Refrain from coughing and talking6
  7. 7. 7 c. Breathe deeply d. Weber’s test d. Clear his throat 34. A nurse is reviewing the arterial blood gas values29. Thoracentesis may be performed for cytologic of a client and notes that the ph is 7.31, Pco2 is study of pleural fluid. As a nurse your most 50 mmHg, and the bicarbonate is 27 mEq/L. The important function during the procedure is to: nurse concludes that which acid base a. Keep the sterile equipment from disturbance is present in this client? contamination a. Respiratory acidosis b. Assist the physician b. Metabolic acidosis c. Open and close the three-way stopcock c. Respiratory alkalosis d. Observe the patient’s vital signs d. Metabolic alkalosis30. Right after thoracentesis, which of the following 35. Allen’s test checks the patency of the: is most appropriate intervention? a. Ulnar artery a. Instruct the patient not to cough or deep b. Carotid artery breathe for two hours c. Radial artery b. Observe for symptoms of tightness of d. Brachial artery chest or bleeding c. Place an ice pack to the puncture site Situation 6: Eileen, 45 years old is admitted to the d. Remove the dressing to check for hospital with a diagnosis of renal calculi. She is bleeding experiencing severe flank pain, nauseated and with a temperature of 39 0C.Situation: Knowledge of the acid-base disturbance andthe functions of the electrolytes is necessary to 36. Given the above assessment data, the mostdetermine appropriate intervention and nursing actions. immediate goal of the nurse would be which of the following?31. A client with diabetes milletus has a blood a. Prevent urinary complication glucose level of 644 mg/dL. The nurse interprets b. maintains fluid and electrolytes that this client is at most risk for the c. Alleviate pain development of which type of acid-base d. Alleviating nausea imbalance? a. Respiratory acidosis 37. After IVP a renal stone was confirmed, a left b. Respiratory alkalosis nephrectomy was done. Her post-operative c. Metabolic acidosis order includes “daily urine specimen to be sent d. Metabolic alkalosis to the laboratory”. Eileen has a foley catheter attached to a urinary drainage system. How will32. In a client in the health care clinic, arterial blood you collect the urine specimen? gas analysis gives the following results: pH 7.48, a. remove urine from drainage tube with PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L. sterile needle and syringe and empty The nurse interprets that the client has which urine from the syringe into the acid base disturbance? specimen container a. Respiratory acidosis b. empty a sample urine from the b. Metabolic acidosis collecting bag into the specimen c. Respiratory alkalosis container d. Metabolic alkalosis c. Disconnect the drainage tube from the indwelling catheter and allow urine to33. A client has an order for ABG analysis on radial flow from catheter into the specimen artery specimens. The nurse ensures that which container. of the following has been performed or tested d. Disconnect the drainage from the before the ABG specimens are drawn? collecting bag and allow the urine to a. Guthrie test flow from the catheter into the b. Romberg’s test specimen container. c. Allen’s test
  8. 8. 38. Where would the nurse tape Eileen’s indwelling regulation is secreted in the: catheter in order to reduce urethral irritation? a. Thyroid gland a. to the patient’s inner thigh b. Parathyroid gland b. to the patient’ buttocks c. Hypothalamus c. to the patient’s lower thigh d. Anterior pituitary gland d. to the patient lower abdomen 45. While Parathormone, a hormone that negates39. Which of the following menu is appropriate for the effect of calcitonin is secreted by the: one with low sodium diet? a. Thyroid gland a. instant noodles, fresh fruits and ice tea b. Parathyroid gland b. ham and cheese sandwich, fresh fruits c. Hypothalamus and vegetables d. Anterior pituitary gland c. white chicken sandwich, vegetable salad and tea Situation: The staff nurse supervisor requests all the staff d. canned soup, potato salad, and diet soda nurses to “brainstorm” and learn ways to instruct diabetic clients on self-administration of insulin. She40. How will you prevent ascending infection to wants to ensure that there are nurses available daily to Eileen who has an indwelling catheter? do health education classes. a. see to it that the drainage tubing touches the level of the urine 46. The plan of the nurse supervisor is an example of b. change he catheter every eight hours a. in service education process c. see to it that the drainage tubing does b. efficient management of human not touch the level of the urine resources d. clean catheter may be used since c. increasing human resources urethral meatus is not a sterile area d. primary preventionSituation: Hormones are secreted by the various glands 47. When Mrs. Guevarra, a nurse, delegates aspectsin the body. Basic knowledge of the endocrine system is of the clients care to the nurse-aide who is annecessary. unlicensed staff, Mrs. Guevarra a. makes the assignment to teach the staff41. Somatocrinin or the Growth hormone releasing member hormone is secreted by the: b. is assigning the responsibility to the a. Hypothalamus aide but not the accountability for b. Posterior pituitary gland those tasks c. Anterior pituitary gland c. does not have to supervise or evaluate d. Thyroid gland the aide d. most know how to perform task42. All of the following are secreted by the anterior delegated pituitary gland except: a. Somatotropin/Growth hormone 48. Connie, the new nurse, appears tired and b. Thyroid stimulating hormone sluggish and lacks the enthusiasm she had six c. Follicle stimulating hormone weeks ago when she started the job. The nurse d. Gonadotropin hormone releasing supervisor should hormone a. empathize with the nurse and listen to her43. All of the following hormones are hormones b. tell her to take the day off secreted by the Posterior pituitary gland except: c. discuss how she is adjusting to her new a. Vasopressin job b. Anti-diuretic hormone d. ask about her family life c. Oxytocin d. Growth hormone 49. Process of formal negotiations of working conditions between a group of registered nurses44. Calcitonin, a hormone necessary for calcium and employer is8
  9. 9. 9 a. grievance d. It should disclose previous diagnosis, b. arbitration prognosis and alternative treatments c. collective bargaining available for the client d. strike 55. Delegation is the process of assigning tasks that50. You are attending a certification on can be performed by a subordinate. The RN cardiopulmonary resuscitation (CPR) offered and should always be accountable and should not required by the hospital employing you. This is lose his accountability. Which of the following is a. professional course towards credits a role included in delegation? b. in-service education a. The RN must supervise all delegated c. advance training tasks d. continuing education b. After a task has been delegated, it is no longer a responsibility of the RNSituation: As a nurse, you are aware that proper c. The RN is responsible and accountabledocumentation in the patient chart is your responsibility. for the delegated task in adjunct with the delegate51. Which of the following is not a legally binding d. Follow up with a delegated task is document but nevertheless very important in necessary only if the assistive personnel the care of all patients in any health care is not trustworthy setting? a. Bill of rights as provided in the Philippine Situation: When creating your lesson plan for constitution cerebrovascular disease or STROKE. It is important to b. Scope of nursing practice as defined by include the risk factors of stroke. RA 9173 c. Board of nursing resolution adopting the 56. The most important risk factor is: code of ethics a. Cigarette smoking d. Patient’s bill of rights b. binge drinking c. Hypertension52. A nurse gives a wrong medication to the client. d. heredity Another nurse employed by the same hospital as a risk manager will expect to receive which of 57. Part of your lesson plan is to talk about etiology the following communication? or cause of stroke. The types of stroke based on a. Incident report cause are the following EXCEPT: b. Nursing kardex a. Embolic stroke c. Oral report b. diabetic stroke d. Complain report c. Hemorrhagic stroke d. thrombotic stroke53. Performing a procedure on a client in the absence of an informed consent can lead to 58. Hemmorhagic stroke occurs suddenly usually which of the following charges? when the person is active. All are causes of a. Fraud hemorrhage, EXCEPT: b. Harassment a. phlebitis c. Assault and battery b. damage to blood vessel d. Breach of confidentiality c. trauma d. aneurysm54. Which of the following is the essence of informed consent? 59. The nurse emphasizes that intravenous drug a. It should have a durable power of abuse carries a high risk of stroke. Which drug is attorney closely linked to this? b. It should have coverage from an a. Amphetamines insurance company b. shabu c. It should respect the client’s freedom c. Cocaine from coercion d. Demerol
  10. 10. d. Iron 75 mg/100 ml60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is: 65. Which of the following laboratory test result a. “More red blood cells thicken blood indicate presence of an infectious process? and make clots more possible.” a. Erythrocyte sedimentation rate (ESR) 12 b. “Increased RBC count is linked to high mm/hr cholesterol.” b. White blood cells (WBC) 18,000/mm3 c. “More red blood cell increases c. Iron 90 g/100ml hemoglobin content.” d. Neutrophils 67% d. “High RBC count increases blood pressure.” Situation: Pleural effusion is the accumulation of fluid in the pleural space. Questions 66 to 70 refer to this.Situation: Recognition of normal values is vital inassessment of clients with various disorders. 66. Which of the following is a finding that the nurse will be able to assess in a client with Pleural61. A nurse is reviewing the laboratory test results effusion? for a client with a diagnosis of severe a. Reduced or absent breath sound at the dehydration. The nurse would expect the base of the lungs, dyspnea, tachpynea hematocrit level for this client to be which of the and shortness of breath following? b. Hypoxemia, hypercapnea and a. 60% respiratory acidosis b. 47% c. Noisy respiration, crackles, stridor and c. 45% wheezing d. 32% d. Tracheal deviation towards the affected side, increased fremitus and loud breath62. A nurse is reviewing the electrolyte results of an sounds assigned client and notes that the potassium level is 5.6 mEq/L. Which of the following would 67. Thoracentesis is performed to the client with the nurse expect to note on the ECG as a result effusion. The nurse knows that the removal of of this laboratory value? fluid should be slow. Rapid removal of fluid in a. ST depression thoracentesis might cause: b. Prominent U wave a. Pneumothorax c. Inverted T wave b. Cardiovascular collapse d. Tall peaked T waves c. Pleurisy or Pleuritis d. Hypertension63. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium 68. 3 Days after thoracentesis, the client again level is 3.2 mEq/L. Which of the following would exhibited respiratory distress. The nurse will the nurse expect to note on the ECG as a result know that pleural effusion has reoccurred when of this laboratory value? she noticed a sharp stabbing pain during a. U waves inspiration. The physician ordered a closed tube b. Elevated T waves thoracotomy for the client. The nurse knows c. Absent P waves that the primary function of the chest tube is to: d. Elevated ST Segment a. Restore positive intrathoracic pressure b. Restore negative intrathoracic pressure64. Dorothy underwent diagnostic test and the c. To visualize the intrathoracic content result of the blood examination are back. On d. As a method of air administration via reviewing the result the nurse notices which of ventilator the following as abnormal finding? a. Neutrophils 60% 69. The chest tube is functioning properly if: b. White blood cells (WBC) 9000/mm a. There is an oscillation c. Erythrocyte sedimentation rate (ESR) is b. There is no bubbling in the drainage 39 mm/hr bottle10
  11. 11. 11 c. There is a continuous bubbling in the waterseal 75. This form of Health Insurance provides d. The suction control bottle has a comprehensive prepaid health services to continuous bubbling enrollees for a fixed periodic payment. a. Health Maintenance Organization70. In a client with pleural effusion, the nurse is b. Medicare instructing appropriate breathing technique. c. Philippine Health Insurance Act Which of the following is included in the d. Hospital Maintenance Organization teaching? a. Breath normally Situation: Nursing ethics is an important part of the b. Hold the breath after each inspiration nursing profession. As the ethical situation arises, so is for 1 full minute the need to have an accurate and ethical decision c. Practice abdominal breathing making. d. Inhale slowly and hold the breath for 3 to 5 seconds after each inhalation 76. The purpose of having a nurses’ code of ethics is: a. Delineate the scope and areas of nursingSITUATION: Health care delivery system affects the practicehealth status of every filipino. As a Nurse, Knowledge of b. identify nursing action recommended forthis system is expected to ensure quality of life. specific health care situations c. To help the public understand71. When should rehabilitation commence? professional conduct expected of a. The day before discharge nurses b. When the patient desires d. To define the roles and functions of the c. Upon admission health care givers, nurses, clients d. 24 hours after discharge 77. The principles that govern right and proper72. What exemplified the preventive and promotive conduct of a person regarding life, biology and programs in the hospital? the health professionals is referred to as: a. Hospital as a center to prevent and a. Morality control infection b. Religion b. Program for smokers c. Values c. Program for alcoholics and drug addicts d. Bioethics d. Hospital Wellness Center 78. A subjective feeling about what is right or wrong73. Which makes nursing dynamic? is said to be: a. Every patient is a unique physical, a. Morality emotional, social and spiritual being b. Religion b. The patient participate in the overall c. Values nursing care plan d. Bioethics c. Nursing practice is expanding in the light of modern developments that takes 79. Values are said to be the enduring believe about place a worth of a person, ideas and belief. If Values d. The health status of the patient is are going to be a part of a research, this is constantly changing and the nurse must categorized under: be cognizant and responsive to these a. Qualitative changes b. Experimental c. Quantitative74. Prevention is an important responsibility of the d. Non Experimental nurse in: a. Hospitals 80. The most important nursing responsibility where b. Community ethical situations emerge in patient care is to: c. Workplace a. Act only when advised that the action is d. All of the above ethically sound
  12. 12. b. Not takes sides, remain neutral and fair c. Assume that ethical questions are the 85. Based on the Code of Ethics for Filipino Nurses, responsibility of the health team what is regarded as the hallmark of nursing d. Be accountable for his or her own responsibility and accountability? actions a. Human rights of clients, regardless of creed and gender81. Why is there an ethical dilemma? b. The privilege of being a registered a. the choices involved do not appear to be professional nurse clearly right or wrong c. Health, being a fundamental right of b. a client’s legal right co-exist with the every individual nurse’s professional obligation d. Accurate documentation of actions and c. decisions has to be made based on outcomes societal norms. d. decisions has to be mad quickly, often Situation: As a profession, nursing is dynamic and its under stressful conditions practice is directed by various theoretical models. To demonstrate caring behaviour, the nurse applies various82. According to the code of ethics, which of the nursing models in providing quality nursing care. following is the primary responsibility of the nurse? 86. When you clean the bedside unit and regularly a. Assist towards peaceful death attend to the personal hygiene of the patient as b. Health is a fundamental right well as in washing your hands before and after a c. Promotion of health, prevention of procedure and in between patients, you indent illness, alleviation of suffering and to facilitate the body’s reparative processes. restoration of health Which of the following nursing theory are you d. Preservation of health at all cost applying in the above nursing action? a. Hildegard Peplau83. Which of the following is TRUE about the Code b. Dorothea Orem of Ethics of Filipino Nurses, except: c. Virginia Henderson a. The Philippine Nurses Association for d. Florence Nightingale being the accredited professional organization was given the privilege to 87. A communication skill is one of the important formulate a Code of Ethics for Nurses competencies expected of a nurse. Interpersonal which the Board of Nursing process is viewed as human to human promulgated relationship. This statement is an application of b. Code for Nurses was first formulated in whose nursing model? 1982 published in the Proceedings of the a. Joyce Travelbee Third Annual Convention of the PNA b. Martha Rogers House of Delegates c. Callista Roy c. The present code utilized the Code of d. Imogene King Good Governance for the Professions in the Philippines 88. The statement “the health status of an individual d. Certificates of Registration of registered is constantly changing and the nurse must be nurses may be revoked or suspended for cognizant and responsive to these changes” best violations of any provisions of the Code explains which of the following facts about of Ethics. nursing? a. Dynamic84. Violation of the code of ethics might equate to b. Client centred the revocation of the nursing license. Who c. Holistic revokes the license? d. Art a. PRC b. PNA 89. Virginia Henderson professes that the goal of c. DOH nursing is to work interdependently with other d. BON health care working in assisting the patient to12
  13. 13. 13 gain independence as quickly as possible. Which include: of the following nursing actions best a. Prescription of the doctor to the demonstrates this theory in taking care of a 94 patient’s illness year old client with dementia who is totally b. Plan of care for patient immobile? c. Patient’s perception of one’s illness a. Feeds the patient, brushes his teeth, d. Nursing problem and Nursing diagnosis gives the sponge bath b. Supervise the watcher in rendering 94. The medical records that are organized into patient his morning care separate section from doctors or nurses has c. Put the patient in semi fowler’s position, more disadvantages than advantages. This is set the over bed table so the patient can classified as what type of recording? eat by himself, brush his teeth and a. POMR sponge himself b. Modified POMR d. Assist the patient to turn to his sides and c. SOAPIE allow him to brush and feed himself only d. SOMR when he feels ready 95. Which of the following is the advantage of SOMR90. In the self-care deficit theory by Dorothea Orem, or Traditional recording? nursing care becomes necessary when a patient a. Increases efficiency in data gathering is unable to fulfil his physiological, psychological b. Reinforces the use of the nursing and social needs. A pregnant client needing process prenatal check-up is classified as: c. The caregiver can easily locate proper a. Wholly compensatory section for making charting entries b. Supportive Educative d. Enhances effective communication c. Partially compensatory among health care team members d. Non compensatory Situation: June is a 24 year old client with symptoms ofSituation: Documentation and reporting are just as dyspnea, absent breath sounds on the right lung andimportant as providing patient care, As such, the nurse chest x ray revealed pleural effusion. The physician willmust be factual and accurate to ensure quality perform thoracentesis.documentation and reporting. 96. Thoracentesis is useful in treating all of the91. Health care reports have different purposes. The following pulmonary disorders except: availability of patients’ record to all health team a. Hemothorax members demonstrates which of the following b. Hydrothorax purposes: c. Tuberculosis a. Legal documentation d. Empyema b. Research c. Education 97. Which of the following psychological preparation d. Vehicle for communication is not relevant for him? a. Telling him that the gauge of the needle92. When a nurse commits medication error, she and anesthesia to be used should accurately document client’s response b. Telling him to keep still during the and her corresponding action. This is very procedure to facilitate the insertion of important for which of the following purposes: the needle in the correct place a. Research c. Allow June to express his feelings and b. Legal documentation concerns c. Nursing Audit d. Physician’s explanation on the purpose d. Vehicle for communication of the procedure and how it will be done93. POMR has been widely used in many teaching 98. Before thoracentesis, the legal consideration you hospitals. One of its unique features is SOAPIE must check is: charting. The P in SOAPIE charting should a. Consent is signed by the client
  14. 14. b. Medicine preparation is correct c. Position of the client is correct d. Consent is signed by relative and physician 99. As a nurse, you know that the position for June before thoracentesis is: a. Orthopneic b. Low fowlers c. Knee-chest d. Sidelying position on the affected side100. Which of the following anaesthetics drug is used for thoracentesis? a. Procaine 2% b. Demerol 75 mg c. Valium 250 mg d. Phenobartbital 50 mg14
  15. 15. 15 D. Follicle stimulating hormoneNURSING PRACTICE II 5. The following month, Mariah suspects she is pregnant. Her urine is positive for HumanSituation: Mariah is a 31 year old lawyer who has been chorionic gonadotrophin. Which structuremarried for 6 months. She consults you for guidance in produces Hcg?relation with her menstrual cycle and her desire to get A. Pituitary glandpregnant. B. Trophoblastic cells of the embryo C. Uterine deciduas 1. She wants to know the length of her menstrual D. Ovarian follicles cycle. Her previous menstrual period is October 22 to 26. Her LMB is November 21. Which of the Situation: Mariah came back and she is now pregnant. following number of days will be your correct response? 6. At 5 month gestation, which of the following A. 29 fetal development would probably be achieve? B. 28 A. Fetal movement are felt by Mariah C. 30 B. Vernix caseosa covers the entire body D. 31 C. Viable if delivered within this period D. Braxton hicks contractions are observed 2. You advised her to observe and record the signs of Ovulation. Which of the following signs will 7. The nurse palpates the abdomen of Mariah. she likely note down? Now At 5 month gestation, What level of the 1. A 1 degree Fahrenheit rise in basal body abdomen can the fundic height be palpated? temperature A. Symphysis pubis 2. Cervical mucus becomes copious and B. Midpoint between the umbilicus and the clear xiphoid process 3. One pound increase in weight C. Midpoint between the symphysis pubis 4. Mittelschmerz and the umbilicus A. 1, 2, 4 D. Umbilicus B. 1, 2, 3 C. 2, 3, 4 8. She worries about her small breasts, thinking D. 1, 3, 4 that she probably will not be able to breastfeed her baby. Which of the following responses of 3. You instruct Mariah to keep record of her basal the nurse is correct? temperature every day, which of the following A. “The size of your breast will not affect instructions is incorrect? your lactation” A. If coitus has occurred; this should be B. “You can switch to bottle feeding” reflected in the chart C. “You can try to have exercise to increase B. It is best to have coitus on the evening the size of your breast” following a drop in BBT to become D. “Manual expression of milk is possible” pregnant C. Temperature should be taken 9. She tells the nurse that she does not take milk immediately after waking and before regularly. She claims that she does not want to getting out of bed gain too much weight during her pregnancy. D. BBT is lowest during the secretory Which of the following nursing diagnosis is a phase priority? A. Potential self-esteem disturbance 4. She reports an increase in BBT on December 16. related to physiologic changes in Which hormone brings about this change in her pregnancy BBT? B. Ineffective individual coping related to A. Estrogen physiologic changes in pregnancy B. Gonadotropine C. Fear related to the effects of pregnancy C. Progesterone D. Knowledge deficit regarding nutritional
  16. 16. requirements of pregnancies related to 15. While talking with Susan, 2 new patients arrived lack of information sources and they are covered with large towels and the nurse noticed that there are many cameraman 10. Which of the following interventions will likely and news people outside of the OPD. Upon ensure compliance of Mariah? assessment the nurse noticed that both of them A. Incorporate her food preferences that are still nude and the male client’s penis is still are adequately nutritious in her meal inside the female client’s vagina and the male plan client said that “I can’t pull it”. Vaginismus was B. Consistently counsel toward optimum your first impression. You know that The nutritional intake psychological cause of Vaginismus is related to: C. Respect her right to reject dietary A. The male client inserted the penis too information if she chooses deeply that it stimulates vaginal closure D. Inform her of the adverse effects of B. The penis was too large that is why the inadequate nutrition to her fetus vagina triggered its defense to attempt to close itSituation: Susan is a patient in the clinic where you work. C. The vagina does not want to beShe is inquiring about pregnancy. penetrated D. It is due to learning patterns of the 11. Susan tells you she is worried because she female client where she views sex as develops breasts later than most of her friends. bad or sinful Breast development is termed as: A. Adrenarche Situation: Overpopulation is one problem in the B. Thelarche Philippines that causes economic drain. Most Filipinos C. Mamarche are against in legalizing abortion. As a nurse, Mastery of D. Menarche contraception is needed to contribute to the society and economic growth. 12. Kevin, Susan’s husband tells you that he is considering vasectomy After the birth of their 16. Supposed that Dana, 17 years old, tells you she new child. Vasectomy involves the incision of wants to use fertility awareness method of which organ? contraception. How will she determine her A. The testes fertile days? B. The epididymis A. She will notice that she feels hot, as if C. The vas deferens she has an elevated temperature. D. The scrotum B. She should assess whether her cervical mucus is thin, copious, clear and 13. On examination, Susan has been found of having watery. a cystocele. A cystocele is: C. She should monitor her emotions for A. A sebaceous cyst arising from the vulvar sudden anger or crying fold D. She should assess whether her breasts B. Protrusion of intestines into the vagina feel sensitive to cool air C. Prolapse of the uterus into the vagina D. Herniation of the bladder into the 17. Dana chooses to use COC as her family planning vaginal wall method. What is the danger sign of COC you would ask her to report? 14. Susan typically has menstrual cycle of 34 days. A. A stuffy or runny nose She told you she had coitus on days 8, 10, 15 and B. Slight weight gain 20 of her menstrual cycle. Which is the day on C. Arthritis like symptoms which she is most likely to conceive? D. Migraine headache A. 8th day B. Day 15 18. Dana asks about subcutaneous implants and she C. 10th day asks, how long will these implants be effective. D. Day 20 Your best answer is: A. One month16
  17. 17. 17 B. Five years C. Twelve months 23. Another client named Lilia is diagnosed as having D. 10 years endometriosis. This condition interferes with fertility because: 19. Dana asks about female condoms. Which of the A. Endometrial implants can block the following is true with regards to female fallopian tubes condoms? B. The uterine cervix becomes inflamed A. The hormone the condom releases and swollen might cause mild weight gain C. The ovaries stop producing adequate B. She should insert the condom before estrogen any penile penetration D. Pressure on the pituitary leads to C. She should coat the condom with decreased FSH levels spermicide before use D. Female condoms, unlike male condoms, 24. Lilia is scheduled to have a are reusable hysterosalphingogram. Which of the following instructions would you give her regarding this 20. Dana has asked about GIFT procedure. What procedure? makes her a good candidate for GIFT? A. She will not be able to conceive for 3 A. She has patent fallopian tubes, so months after the procedure fertilized ova can be implanted on them B. The sonogram of the uterus will reveal B. She is RH negative, a necessary any tumors present stipulation to rule out RH incompatibility C. Many women experience mild bleeding C. She has normal uterus, so the sperm can as an after effect be injected through the cervix into it D. She may feel some cramping when the D. Her husband is taking sildenafil, so all dye is inserted sperms will be motile 25. Lilia’s cousin on the other hand, knowing nurseSituation: Nurse Lorena is a Family Planning and Lorena’s specialization asks what artificialInfertility Nurse Specialist and currently attends to insemination by donor entails. Which would beFAMILY PLANNING CLIENTS AND INFERTILE COUPLES. your best answer if you were Nurse Lorena?The following conditions pertain to meeting the nursing A. Donor sperm are introduced vaginallyneeds of this particular population group. into the uterus or cervix B. Donor sperm are injected intra- 21. Dina, 17 years old, asks you how a tubal ligation abdominally into each ovary prevents pregnancy. Which would be the best C. Artificial sperm are injected vaginally to answer? test tubal patency A. Prostaglandins released from the cut D. The husband’s sperm is administered fallopian tubes can kill sperm intravenously weekly B. Sperm cannot enter the uterus because the cervical entrance is blocked. Situation: You are assigned to take care of a group of C. Sperm can no longer reach the ova, patients across the lifespan. because the fallopian tubes are blocked D. The ovary no longer releases ova as 26. Pain in the elder persons requires careful there is nowhere for them to go. assessment because they: A. experienced reduce sensory perception 22. The Dators are a couple undergoing testing for B. have increased sensory perception infertility. Infertility is said to exist when: C. are expected to experience chronic pain A. A woman has no uterus D. have a decreased pain threshold B. A woman has no children C. A couple has been trying to conceive for 27. Administration of analgesics to the older persons 1 year requires careful patient assessment because D. A couple has wanted a child for 6 older people: months A. are more sensitive to drugs
  18. 18. B. have increased hepatic, renal and D. Chronic poverty gastrointestinal function C. have increased sensory perception 34. Which of the following signs and symptoms D. mobilize drugs more rapidly would you most likely find when assessing and infant with Arnold-Chiari malformation? 28. The elderly patient is at higher risk for urinary A. Weakness of the leg muscles, loss of incontinence because of: sensation in the legs, and restlessness A. increased glomerular filtration B. Difficulty swallowing, diminished or B. decreased bladder capacity absent gag reflex, and respiratory C. diuretic use distress D. dilated urethra C. Difficulty sleeping, hypervigilant, and an arching of the back 29. Which of the following is the MOST COMMON D. Paradoxical irritability, diarrhea, and sign of infection among the elderly? vomiting. A. decreased breath sounds with crackles B. pain 35. A parent calls you and frantically reports that her C. fever child has gotten into her famous ferrous sulfate D. change in mental status pills and ingested a number of these pills. Her child is now vomiting, has bloody diarrhea, and is 30. Priorities when caring for the elderly trauma complaining of abdominal pain. You will tell the patient: mother to: A. circulation, airway, breathing A. Call emergency medical services (EMS) B. airway, breathing, disability (neurologic) and get the child to the emergency room C. disability (neurologic), airway, breathing B. Relax because these symptoms will pass D. airway, breathing, circulation and the child will be fine C. Administer syrup of ipecac 31. Preschoolers are able to see things from which D. Call the poison control center of the following perspectives? A. Their peers 36. A client says she heard from a friend that you B. Their own and their mother’s stop having periods once you are on the “pill”. C. Their own and their caregivers’ The most appropriate response would be: D. Only their own A. “The pill prevents the uterus from making such endometrial lining, that is 32. In conflict management, the win-win approach why periods may often be scant or occurs when: skipped occasionally.” A. There are two conflicts and the parties B. “If your friend has missed her period, agree to each one she should stop taking the pills and get a B. Each party gives in on 50% of the pregnancy test as soon as possible.” disagreements making up the conflict C. “The pill should cause a normal C. Both parties involved are committed to menstrual period every month. It solving the conflict sounds like your friend has not been D. The conflict is settled out of court so the taking the pills properly.” legal system and the parties win D. “Missed period can be very dangerous and may lead to the formation of 33. According to the social-interactional perspective precancerous cells.” of child abuse and neglect, four factors place the family members at risk for abuse. These risk 37. The nurse assessing newborn babies and infants factors are the family members at risk for abuse. during their hospital stay after birth will notice These risk factors are the family itself, the which of the following symptoms as a primary caregiver, the child, and manifestation of Hirschsprung’s disease? A. The presence of a family crisis A. A fine rash over the trunk B. The national emphasis on sex B. Failure to pass meconium during the C. Genetics first 24 to 48 hours after birth18
  19. 19. 19 C. The skin turns yellow and then brown release over the first 48 hours of life B. a woman is less able to keep the D. High-grade fever laceration clean because of her fatigue C. healing is limited during pregnancy so38. A client is 7 months pregnant and has just been these will not heal until after birth diagnosed as having a partial placenta previa. D. increased bleeding can occur from She is stable and has minimal spotting and is uterine pressure on leg veins being sent home. Which of these instructions to the client may indicate a need for further 43. In working with the caregivers of a client with an teaching? acute or chronic illness, the nurse would: A. Maintain bed rest with bathroom A. Teach care daily and let the caregivers privileges do a return demonstration just before B. Avoid intercourse for three days. discharge C. Call if contractions occur. B. Difficulty swallowing, diminished or D. Stay on left side as much as possible absent gag reflex, and respiratory when lying down. distress. C. Difficulty sleeping, hypervigilant, and an39. A woman has been rushed to the hospital with arching of the back ruptured membrane. Which of the following D. Paradoxical irritability, diarrhea, and should the nurse check first? vomiting A. Check for the presence of infection B. Assess for Prolapse of the umbilical 44. Which of the following roles BEST exemplifies cord the expanded role of the nurse? C. Check the maternal heart rate A. Circulating nurse in surgery D. Assess the color of the amniotic fluid B. Medication nurse C. Obstetrical nurse40. The nurse notes that the infant is wearing a D. Pediatric nurse practitioner plastic-coated diaper. If a topical medication were to be prescribed and it were to go on the 45. According to DeRosa and Kochura’s (2006) stomachs or buttocks, the nurse would teach the article entitled “Implement Culturally Competent caregivers to: Health Care in your work place,” cultures have A. avoid covering the area of the topical different patterns of verbal and nonverbal medication with the diaper communication. Which difference does? B. avoid the use of clothing on top of the A. NOT necessarily belong? diaper B. Personal behavior C. put the diaper on as usual C. Subject matter D. apply an icepack for 5 minutes to the D. Eye contact outside of the diaper E. Conversational style41. Which of the following factors is most important 46. You are the nurse assigned to work with a child in determining the success of relationships used with acute glomerulonephritis. By following the in delivering nursing care? prescribed treatment regimen, the child A. Type of illness of the client experiences a remission. You are now checking B. Transference and counter transference to make sure the child does not have a relapse. C. Effective communication Which finding would most lead you to the D. Personality of the participants conclusion that a relapse is happening? A. Elevated temperature, cough, sore42. Grace sustained a laceration on her leg from throat, changing complete blood count automobile accident. Why are lacerations of (CBC) with diiferential lower extremities potentially more serious B. A urine dipstick measurement of 2+ among pregnant women than other? proteinuria or more for 3 days, or the A. lacerations can provoke allergic child found to have 3-4+ proteinutria responses due to gonadotropic hormone plus edema.
  20. 20. C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase 51. If a child with diarrhea registers two signs in the in urine output, and a moon face. yellow row in the IMCI chart, we can classify the D. A temperature of 37.8 degrees (100 patient as: degrees F), flank pain, burning A. Moderate dehydration frequency, urgency on voiding, and B. Severe dehydration cloudy urine. C. Some dehydration D. No dehydration 47. The nurse is working with an adolescent who complains of being lonely and having a lack of 52. Celeste has had diarrhea for 8 days. There is no fulfillment in her life. This adolescent shies away blood in the stool, he is irritable, his eyes are from intimate relationships at times yet at other sunken, the nurse offers fluid to Celeste and he times she appears promiscuous. The nurse will drinks eagerly. When the nurse pinched the likely work with this adolescent in which of the abdomen it goes back slowly. How will you following areas? classify Celeste’s illness? A. Isolation A. Moderate dehydration B. Lack of fulfillment B. Severe dehydration C. Loneliness C. Some dehydration D. Identity D. No dehydration 48. The use of interpersonal decision making, 53. A child who is 7 weeks has had diarrhea for 14 psychomotor skills, and application of days but has no sign of dehydration is classified knowledge expected in the role of a licensed as: health care professional in the context of public A. Persistent diarrhea health welfare and safety is an example of: B. Dysentery A. Delegation C. Severe dysentery B. Responsibility D. Severe persistent diarrhea C. Supervision D. Competence 54. The child with no dehydration needs home treatment. Which of the following is not 49. The painful phenomenon known as “back labor” included in the rules for home treatment in this occurs in a client whose fetus in what position? case? A. Brow position A. Forced fluids B. Breech position B. When to return C. Right Occipito-Anterior Position C. Give vitamin A supplement D. Left Occipito-Posterior Position D. Feeding more 50. FOCUS methodology stands for: 55. Fever as used in IMCI includes: A. Focus, Organize, Clarify, Understand A. Axillary temperature of 37.5 or higher and Solution B. Rectal temperature of 38 or higher B. Focus, Opportunity, Continuous, Utilize, C. Feeling hot to touch Substantiate D. All of the above C. Focus, Organize, Clarify, Understand, E. A and C only Substantiate D. Focus, Opportunity, Continuous Situation: Prevention of Dengue is an important nursing (process), Understand, Solution responsibility and controlling it’s spread is a priority once outbreak has been observed.SITUATION: The infant and child mortality rate in the lowto middle income countries is ten times higher than 56. An important role of the community healthindustrialized countries. In response to this, the WHO nurse in the prevention and control of Dengueand UNICEF launched the protocol Integrated H-fever includes:Management of Childhood Illnesses to reduce the A. Advising the elimination of vectors bymorbidity and mortality against childhood illnesses. keeping water containers covered20
  21. 21. 21 B. Conducting strong health education health worker should first: drives/campaign directed towards A. Identify the myths and misconceptions proper garbage disposal prevailing in the community C. Explaining to the individuals, families, B. Identify the source of these myths and groups and community the nature of misconceptions the disease and its causation C. Explain how and why these myths came D. Practicing residual spraying with about insecticides D. Select the appropriate IEC strategies to correct them 57. Community health nurses should be alert in observing a Dengue suspect. The following is 62. How many percent of measles are prevented by NOT an indicator for hospitalization of H-fever immunization at 9 months of age? suspects? A. 80% A. Marked anorexia, abdominal pain and B. 99% vomiting C. 90% B. Increasing hematocrit count D. 95% C. Cough of 30 days D. Persistent headache 63. After TT3 vaccination a mother is said to be protected to tetanus by around: 58. The community health nurses’ primary concern A. 80% in the immediate control of hemorrhage among B. 99% patients with dengue is: C. 85% A. Advising low fiber and non-fat diet D. 90% B. Providing warmth through light weight covers 64. If ever convulsions occur after administering C. Observing closely the patient for vital DPT, what should the nurse best suggest to the signs leading to shock mother? D. Keeping the patient at rest A. Do not continue DPT vaccination anymore 59. Which of these signs may NOT be REGARDED as B. Advise mother to comeback after 1 week a truly positive signs indicative of Dengue H- C. Give DT instead of DPT fever? D. Give pertussis of the DPT and remove DT A. Prolonged bleeding time B. Appearance of at least 20 petechiae 65. These vaccines are given 3 doses at one month within 1cm square intervals: C. Steadily increasing hematocrit count A. DPT, BCG, TT D. Fall in the platelet count B. OPV, HEP. B, DPT C. DPT, TT, OPV 60. Which of the following is the most important D. Measles, OPV, DPT treatment of patients with Dengue H-fever? A. Give aspirin for fever Situation – With the increasing documented cases of B. Replacement of body fluids CANCER the best alternative to treatment still remains to C. Avoid unnecessary movement of patient be PREVENTION. The following conditions apply. D. Ice cap over the abdomen in case of melena 66. Which among the following is the primary focus of prevention of cancer?Situation: Health education and Health promotion is an A. Elimination of conditions causing cancerimportant part of nursing responsibility in the B. Diagnosis and treatmentcommunity. Immunization is a form of health promotion C. Treatment at early stagethat aims at preventing the common childhood illnesses. D. Early detection 61. In correcting misconceptions and myths about 67. In the prevention and control of cancer, which of certain diseases and their management, the the following activities is the most important

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