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comprehensive nursing board exam reviewer Document Transcript

  • 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. 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
  • 3. 3
  • 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 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. 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 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. 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 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. 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 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. 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 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. 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 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. 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 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. 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 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. 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 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
  • 22. function of the community health nurse? C. 30 breaths per minute or more A. Conduct community assemblies. D. 60 breaths per minute B. Referral to cancer specialist those clients with symptoms of cancer. 73. Nina, the 2nd child has diarrhea for 5 days. C. Use the nine warning signs of cancer as There is no blood in the stool. She is irritable, parameters in our process of detection, and her eyes are sunken. The nurse offered control and treatment modalities. fluids and and the child drinks eagerly. How D. Teach woman about proper/correct would you classify Nina’s illness? nutrition. A. Some dehydration B. Severe dehydration 68. Who among the following are recipients of the C. Dysentery secondary level of care for cancer cases? D. No dehydration A. Those under early case detection B. Those under post case treatment 74. Nina’s treatment should include the following C. Those scheduled for surgery EXCEPT: D. Those undergoing treatment A. reassess the child and classify him for dehydration 69. Who among the following are recipients of the B. for infants under 6 months old who are tertiary level of care for cancer cases? not breastfed, give 100-200 ml clean A. Those under early treatment water as well during this period B. Those under early detection C. Give in the health center the C. Those under supportive care recommended amount of ORS for 4 D. Those scheduled for surgery hours. D. Do not give any other foods to the child 70. In Community Health Nursing, despite the for home treatment availability and use of many equipment and devices to facilitate the job of the community 75. While on treatment, Nina 18 months old health nurse, the best tool any nurse should be weighed 18 kgs. and her temperature registered wel be prepared to apply is a scientific approach. at 37 degrees C. Her mother says she developed This approach ensures quality of care even at the cough 3 days ago. Nina has no general danger community setting. This is nursing parlance is signs. She has 45 breaths/minute, no chest in- nothing less than the: drawing, no stridor. How would you classify A. nursing diagnosis Nina’s manifestation? B. nursing research A. No pneumonia C. nursing protocol B. Pneumonia D. nursing process C. Severe pneumonia D. BronchopneumoniaSituation – Two children were brought to you. One withchest indrawing and the other had diarrhea. The 76. Carol is 15 months old and weighs 5.5 kgs and itfollowing questions apply: is her initial visit. Her mother says that Carol is not eating well and unable to breastfeed, he has 71. Using Integrated Management and Childhood no vomiting, has no convulsion and not Illness (IMCI) approach, how would you classify abnormally sleepy or difficult to awaken. Her the 1st child? temperature is 38.9 deg C. Using the integrated A. Bronchopneumonia management of childhood illness or IMCI B. Severe pneumonia strategy, if you were the nurse in charge of C. No pneumonia : cough or cold Carol, how will you classify her illness? D. Pneumonia A. a child at a general danger sign B. severe pneumonia 72. The 1st child who is 13 months has fast C. very severe febrile disease breathing using IMCI parameters he has: D. severe malnutrition A. 40 breaths per minute or more B. 50 breaths per minute 77. Why are small for gestational age newborns at22
  • 23. 23 risk for difficulty maintaining body temperature? B. give the child more fluids A. their skin is more susceptible to C. continue feeding the child conduction of cold D. inform when to return to the health B. they are preterm so are born relatively center small in size C. they do not have as many fat stored as 83. Ms. Jordan, RN, believes that a patient should be other infants treated as individual. This ethical principle that D. they are more active than usual so they the patient referred to: throw off comes A. beneficence B. respect for person78. Oxytocin is administered to Rita to augment C. nonmaleficence labor. What are the first symptoms of water D. autonomy intoxication to observe for during this procedure? 84. When patients cannot make decisions for A. headache and vomiting themselves, the nurse advocate relies on the B. a high choking voice ethical principle of: C. a swollen tender tongue A. justice and beneficence D. abdominal bleeding and pain B. beneficence and nonmaleficence C. fidelity and nonmaleficence79. Which of the following treatment should NOT be D. fidelity and justice considered if the child has severe dengue hemorrhagic fever? 85. Being a community health nurse, you have the A. use plan C if there is bleeding from the responsibility of participating in protecting the nose or gums health of people. Consider this situation: B. give ORS if there is skin Petechiae, Vendors selling bread with their bare hands. persistent vomiting, and positive They receive money with these hands. You do tourniquet test not see them washing their hands. What should C. give aspirin you say/do? D. prevent low blood sugar A. “Miss, may I get the bread myself because you have not washed your80. In assessing the patient’s condition using the hands” Integrated Management of Childhood Illness B. All of these approach strategy, the first thing that a nurse C. “Miss, it is better to use a pick up should do is to: forceps/ bread tong” D. “Miss, your hands are dirty. Wash your A. ask what are the child’s problem hands first before getting the bread” B. check for the four main symptoms C. check the patient’s level of Situation: The following questions refer to common consciousness clinical encounters experienced by an entry level nurse. D. check for the general danger signs 86. A female client asks the nurse about the use of a81. A child with diarrhea is observed for the cervical cap. Which statement is correct following EXCEPT: regarding the use of the cervical cap? A. how long the child has diarrhea A. It may affect Pap smear results. B. presence of blood in the stool B. It does not need to be fitted by the C. skin Petechiae physician. D. signs of dehydration C. It does not require the use of spermicide.82. The child with no dehydration needs home D. It must be removed within 24 hours. treatment. Which of the following is NOT included in the care for home management at 87. The major components of the communication this case? process are: A. give drugs every 4 hours A. Verbal, written and nonverbal
  • 24. B. Speaker, listener and reply D. Parasites C. Facial expression, tone of voice and gestures 93. You are assigned in a private room of Mike. D. Message, sender, channel, receiver and Which procedure should be of outmost feedback importance; A. Alcohol wash 88. The extent of burns in children are normally B. Washing Isolation assessed and expressed in terms of: C. Universal precaution A. The amount of body surface that is D. Gloving technique unburned B. Percentages of total body surface area 94. What primary health teaching would you give to (TBSA) mike; C. How deep the deepest burns are A. Daily exercise D. The severity of the burns on a 1 to 5 B. reverse isolation burn scale. C. Prevent infection D. Proper nutrition 89. The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry; 95. Exercise precaution must be taken to protect has no lunch money; and is always tired. When health worker dealing with the AIDS patients . the nurse asks the boy his tiredness, he talks of which among these must be done as priority: playing outside until midnight. The nurse will A. Boil used syringe and needles suspect that this child is: B. Use gloves when handling specimen A. Being raised by a parent of low C. Label personal belonging intelligence quotient (IQ) D. Avoid accidental wound B. An orphan C. A victim of child neglect Situation: Michelle is a 6 year old preschooler. She was D. The victim of poverty reported by her sister to have measles but she is at home because of fever, upper respiratory problem and 90. Which of the following indicates the type(s) of white sports in her mouth. acute renal failure? A. Four types: hemorrhagic with and 96. Rubeola is an Arabic term meaning Red, the rash without clotting, and nonhemorrhagic appears on the skin in invasive stage prior to with and without clottings eruption behind the ears. As a nurse, your B. One type: acute physical examination must determine C. Three types: prerenal, intrarenal and complication especially: postrenal A. Otitis media D. Two types: acute and subacute B. Inflammatory conjunctiva C. Bronchial pneumoniaSituation: Mike 16 y/o has been diagnosed to have AIDS; D. Membranous laryngitishe worked as entertainer in a cruise ship; 97. To render comfort measure is one of the 91. Which method of transmission is common to priorities, Which includes care of the skin, eyes, contract AIDS? ears, mouth and nose. To clean the mouth, your A. Syringe and needles antiseptic solution is in some form of which one B. Sexual contact below? C. Body fluids A. Water D. Transfusion B. Alkaline C. Sulfur 92. Causative organism in AIDS is one of the D. Salt following; A. Fungus 98. As a public health nurse, you teach mother and B. retrovirus family members the prevention of complication C. Bacteria of measles. Which of the following should be24
  • 25. 25 closely watched? A. Temperature fails to drop B. Inflammation of the nasophraynx C. Inflammation of the conjunctiva D. Ulcerative stomatitis99. Source of infection of measles is secretion of nose and throat of infection person. Filterable virus of measles is transmitted by: A. Water supply B. Food ingestion C. Droplet D. Sexual contact100. Method of prevention is to avoid exposure to an infection person. Nursing responsibility for rehabilitation of patient includes the provision of: A. Terminal disinfection B. Immunization C. Injection of gamma globulin D. Comfort measures
  • 26. c. 50 days d. 14 daysNURSING PRACTICE III Situation: As a nurse researcher you must have a verySituation: Leo lives in the squatter area. He goes to good understanding of the common terms of conceptnearby school. He helps his mother gather molasses used in research.after school. One day, he was absent because of fever,malaise, anorexia and abdominal discomfort. 6. The information that an investigator collects from the subjects or participants in a research 1. Upon assessment, Leo was diagnosed to have study is usually called; hepatitis A. Which mode of transmission has the a. Hypothesis infection agent taken? b. Variable a. Fecal-oral c. Data b. Droplet d. Concept c. Airborne d. Sexual contact 7. Which of the following usually refers to the independent variables in doing research 2. Which of the following is concurrent disinfection a. Result in the case of Leo? b. output a. Investigation of contact c. Cause b. Sanitary disposal of faeces, urine and d. Effect blood c. Quarantine of the sick individual 8. The recipients of experimental treatment is an d. removing all detachable objects in the experimental design or the individuals to be room, cleaning lighting and air duct observed in a non experimental design are surfaces in the ceiling, and cleaning called; everything downward to the floor a. Setting b. Treatment 3. Which of the following must be emphasized c. Subjects during mother’s class to Leo’s mother? d. Sample a. Administration of Immunoglobulin to families 9. The device or techniques an investigator b. Thorough hand washing before and employs to collect data is called; after eating and toileting a. Sample c. Use of attenuated vaccines b. hypothesis d. Boiling of food especially meat c. Instrument d. Concept 4. Disaster control should be undertaken when there are 3 or more hepatitis A cases. Which of 10. The use of another person’s ideas or wordings these measures is a priority? without giving appropriate credit results from a. Eliminate faecal contamination from inaccurate or incomplete attribution of materials foods to its sources. Which of the following is referred b. Mass vaccination of uninfected to when another person’s idea is inappropriate individuals credited as one’s own; c. Health promotion and education to a. Plagiarism families and communities about the b. assumption disease it’s cause and transmission c. Quotation d. Mass administration of Immunoglobulin d. Paraphrase 5. What is the average incubation period of Situation – Mrs. Pichay is admitted to your ward. The Hepatitis A? MD ordered “Prepare for thoracentesis this pm to a. 30 days remove excess air from the pleural cavity.” b. 60 days26
  • 27. 2711. Which of the following nursing responsibilities is a. Ease the patient to the floor essential in Mrs. Pichay who will undergo b. Lift the patient and put him on the bed thoracentesis? c. Insert a padded tongue depressor a. Support and reassure client during the between his jaws procedure d. Restraint patient’s body movement b. Ensure that informed consent has been signed 17. Mr Santos is scheduled for CT SCAN for the next c. Determine if client has allergic reaction day, noon time. Which of the following is the to local anesthesia correct preparation as instructed by the nurse? d. Ascertain if chest x-rays and other tests a. Shampoo hair thoroughly to remove oil have been prescribed and completed and dirt b. No special preparation is needed.12. Mrs. Pichay who is for thoracentesis is assigned Instruct the patient to keep his head by the nurse to which of the following positions? still and stead a. Trendelenburg position c. Give a cleansing enema and give fluids b. Supine position until 8 AM c. Dorsal Recumbent position d. Shave scalp and securely attach d. Orthopneic position electrodes to it13. During thoracentesis, which of the following 18. Mr Santos is placed on seizure precaution. nursing intervention will be most crucial? Which of the following would be a. Place patient in a quiet and cool room contraindicated? b. Maintain strict aseptic technique a. Obtain his oral temperature c. Advice patient to sit perfectly still b. Encourage to perform his own personal during needle insertion until it has been hygiene withdrawn from the chest c. Allow him to wear his own clothing d. Apply pressure over the puncture site as d. Encourage him to be out of bed soon as the needle is withdrawn 19. Usually, how does the patient behave after his14. To prevent leakage of fluid in the thoracic cavity, seizure has subsided? how will you position the client after a. Most comfortable walking and moving thoracentesis? about a. Place flat in bed b. Becomes restless and agitated b. Turn on the unaffected side c. Sleeps for a period of time c. Turn on the affected side d. Say he is thirsty and hungry d. On bed rest 20. Before, during and after seizure. The nurse15. Chest x-ray was ordered after thoracentesis. knows that the patient is ALWAYS placed in what When your client asks what is the reason for position? another chest x-ray, you will explain: a. Low fowler’s a. To rule out pneumothorax b. Side lying b. To rule out any possible perforation c. Modified trendelenburg c. To decongest d. Supine d. To rule out any foreign body Situation: Mrs. Damian an immediate post opSituation: A computer analyst, Mr. Ricardo J. Santos, 25 cholecystectomy and choledocholithotomy patient,was brought to the hospital for diagnostic workup after complained of severe pain at the wound site.he had experienced seizure in his office. 21. Choledocholithotomy is:16. Just as the nurse was entering the room, the a. The removal of the gallbladder patient who was sitting on his chair begins to b. The removal of the stones in the have a seizure. Which of the following must the gallbladder nurse do first? c. The removal of the stones in the
  • 28. common bile duct alleviate anxiety d. The removal of the stones in the kidney c. Avoid overdosing to prevent dependence/tolerance22. The simplest pain relieving technique is: d. Monitor VS, more importantly RR a. Distraction b. Deep breathing exercise 28. The client complained of abdominal distention c. Taking aspirin and pain. Your nursing intervention that can d. Positioning alleviate pain is: a. Instruct client to go to sleep and relax23. Which of the following statement on pain is b. Advice the client to close the lips and TRUE? avoid deep breathing and talking a. Culture and pain are not associated c. Offer hot and clear soup b. Pain accompanies acute illness d. Turn to sides frequently and avoid too c. Patient’s reaction to pain Varies much talking d. Pain produces the same reaction such as groaning and moaning 29. Surgical pain might be minimized by which nursing action in the O.R.24. In pain assessment, which of the following a. Skill of surgical team and lesser condition is a more reliable indicator? manipulation a. Pain rating scale of 1 to 10 b. Appropriate preparation for the b. Facial expression and gestures scheduled procedure c. Physiological responses c. Use of modern technology in closing the d. Patients description of the pain wound sensation d. Proper positioning and draping of clients25. When a client complains of pain, your initial 30. Inadequate anesthesia is said to be one of the response is: common cause of pain both in intra and post op a. Record the description of pain patients. If General anesthesia is desired, it will b. Verbally acknowledge the pain involve loss of consciousness. Which of the c. Refer the complaint to the doctor following are the 2 general types of GA? d. Change to a more comfortable position a. Epidural and Spinal b. Subarachnoid block and IntravenousSituation: You are assigned at the surgical ward and c. Inhalation and Regionalclients have been complaining of post pain at varying d. Intravenous and Inhalationdegrees. Pain as you know, is very subjective. Situation: Nurse’s attitudes toward the pain influence26. A one-day postoperative abdominal surgery the way they perceive and interact with clients in pain. client has been complaining of severe throbbing abdominal pain described as 9 in a 1-10 pain 31. Nurses should be aware that older adults are at rating. Your assessment reveals bowel sounds on risk of underrated pain. Nursing assessment and all quadrants and the dressing is dry and intact. management of pain should address the What nursing intervention would you take? following beliefs EXCEPT: a. Medicate client as prescribed a. Older patients seldom tend to report b. Encourage client to do imagery pain than the younger ones c. Encourage deep breathing and turning b. Pain is a sign of weakness d. Call surgeon stat c. Older patients do not believe in analgesics, they are tolerant27. Pentoxidone 5 mg IV every 8 hours was d. Complaining of pain will lead to being prescribed for post abdominal pain. Which will labeled a ‘bad’ patient be your priority nursing action? a. Check abdominal dressing for possible 32. Nurses should understand that when a client swelling responds favorably to a placebo, it is known as b. Explain the proper use of PCA to the ‘placebo effect’. Placebos do not indicate28
  • 29. 29 whether or not a client has: acting insulin first a. Conscience b. Disease 37. Janevi complains of nausea, vomiting, c. Real pain diaphoresis and headache. Which of the d. Drug tolerance following nursing intervention are you going to carry out first?33. You are the nurse in the pain clinic where you a. Withhold the client’s next insulin have client who has difficulty specifying the injection location of pain. How can you assist such client? b. Test the client’s blood glucose level a. The pain is vague c. Administer Tylenol as ordered b. By charting-it hurts all over d. Offer fruit juice, gelatine and chicken c. Identify the absence and presence of bouillon pain d. As the client to point to the painful are 38. Janevi administered regular insulin at 7 A.M and by just one finger the nurse should instruct Jane to avoid exercising at around:34. What symptom, more distressing than pain, a. 9 to 11 A.M should the nurse monitor when giving opioids b. Between 8 A.M to 9 A.M especially among elderly clients who are in pain? c. After 8 hours a. Forgetfulness d. In the afternoon, after taking lunch b. Drowsiness c. Constipation 39. Janevi was brought at the emergency room after d. Allergic reactions like pruritis four month because she fainted in her clinic. The nurse should monitor which of the following test35. Physical dependence occurs in anyone who to evaluate the overall therapeutic compliance takes opiods over a period of time. What do you of a diabetic patient? tell a mother of a ‘dependent’ when asked for a. Glycosylated hemoglobin advice? b. Ketone levels a. Start another drug and slowly lessen the c. Fasting blood glucose opioid dosage d. Urine glucose level b. Indulge in recreational outdoor activities c. Isolate opioid dependent to a restful 40. Upon the assessment of Hba1c of Mrs. Segovia, resort The nurse has been informed of a 9% Hba1c d. Instruct slow tapering of the drug result. In this case, she will teach the patient to: dosage and alleviate physical a. Avoid infection withdrawal symptoms b. Prevent and recognize hyperglycaemia c. Take adequate food and nutritionSituation: The nurse is performing health education d. Prevent and recognize hypoglycaemiaactivities for Janevi Segovia, a 30 year old Dentist withInsulin dependent diabetes Miletus. 41. The nurse is teaching plan of care for Jane with regards to proper foot care. Which of the36. Janevi is preparing a mixed dose of insulin. The following should be included in the plan? nurse is satisfied with her performance when a. Soak feet in hot water she: b. Avoid using mild soap on the feet a. Draw insulin from the vial of clear c. Apply a moisturizing lotion to dry feet insulin first but not between the toes b. Draw insulin from the vial of the d. Always have a podiatrist to cut your toe intermediate acting insulin first nails; never cut them yourself c. Fill both syringes with the prescribed insulin dosage then shake the bottle 42. Another patient was brought to the emergency vigorously room in an unresponsive state and a diagnosis of d. Withdraw the intermediate acting hyperglycaemic hyperosmolar nonketotic insulin first before withdrawing the short syndrome is made. The nurse immediately
  • 30. prepares to initiate which of the following of which of the following physiologic changes anticipated physician’s order? associated with aging. a. Endotracheal intubation a. Ineffective airway clearance b. 100 unites of NPH insulin b. Decreased alveolar surfaced area c. Intravenous infusion of normal saline c. Decreased anterior-posterior chest d. Intravenous infusion of sodium diameter bicarbonate d. Hyperventilation43. Jane eventually developed DKA and is being 47. The older patient is at higher risk for treated in the emergency room. Which finding incontinence because of: would the nurse expect to note as confirming a. Dilated urethra this diagnosis? b. Increased glomerular filtration rate a. Comatose state c. Diuretic use b. Decreased urine output d. Decreased bladder capacity c. Increased respiration and an increase in pH 48. Merle, age 86, is complaining of dizziness when d. Elevated blood glucose level and low she stands up. This may indicate: plasma bicarbonate level a. Dementia b. Functional decline44. The nurse teaches Jane to know the difference c. A visual problem between hypoglycaemia and ketoacidosis. Jane d. Drug toxicity demonstrates understanding of the teaching by stating that glucose will be taken if which of the 49. Cardiac ischemia in an older patient usually following symptoms develops? produces: a. Polyuria a. ST-T wave changes b. Shakiness b. Chest pain radiating to the left arm c. Blurred Vision c. Very high creatinine kinase level d. Fruity breath odour d. Acute confusion45. Jane has been scheduled to have a FBS taken in 50. The most dependable sign of infection in the the morning. The nurse tells Jane not to eat or older patient is: drink after midnight. Prior to taking the blood a. Change in mental status specimen, the nurse noticed that Jane is holding b. Fever a bottle of distilled water. The nurse asked Jane c. Pain if she drink any, and she said “yes.” Which of the d. Decreased breath sounds with crackles following is the best nursing action? a. Administer syrup of ipecac to remove Situation – In the OR, there are safety protocols that the distilled water from the stomach should be followed. The OR nurse should be well versed b. Suction the stomach content using NGT with all these to safeguard the safety and quality of prior to specimen collection patient delivery outcome. c. Advice to physician to reschedule to diagnostic examination next day 51. Which of the following should be given highest d. Continue as usual and have the FBS priority when receiving patient in the OR? analysis performed and specimen be a. Assess level of consciousness taken b. Verify patient identification and informed consentSituation: Elderly clients usually produce unusual signs c. Assess vital signswhen it comes to different diseases. The ageing process d. Check for jewelry, gown, manicure, andis a complicated process and the nurse should denturesunderstand that it is an inevitable fact and she must beprepared to care for the growing elderly population. 52. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but46. Hypoxia may occur in the older patients because considered ‘dirty cases’. When are these30
  • 31. 31 procedures best scheduled? The nurse knows that the temperature and time a. Last case is set to the optimum level to destroy not only b. In between cases the microorganism, but also the spores. Which c. According to availability of of the following is the ideal setting of the anaesthesiologist autoclave machine? d. According to the surgeon’s preference a. 10,000 degree Celsius for 1 hour b. 5,000 degree Celsius for 30 minutes53. OR nurses should be aware that maintaining the c. 37 degree Celsius for 15 minutes client’s safety is the overall goal of nursing care d. 121 degree Celsius for 15 minutes during the intraoperative phase. As the circulating nurse, you make certain that 58. It is important that before a nurse prepares the throughout the procedure… material to be sterilized, a chemical indicator a. the surgeon greets his client before strip should be placed above the package, induction of anesthesia preferably, Muslin sheet. What is the color of b. the surgeon and anesthesiologist are in the striped produced after autoclaving? tandem a. Black c. strap made of strong non-abrasive b. Blue materials are fastened securely around c. Gray the joints of the knees and ankles and d. Purple around the 2 hands around an arm board. 59. Chemical indicators communicate that: d. Client is monitored throughout the a. The items are sterile surgery by the assistant anesthesiologist b. That the items had undergone sterilization process but not necessarily54. Another nursing check that should not be missed sterile before the induction of general anesthesia is: c. The items are disinfected a. check for presence underwear d. That the items had undergone b. check for presence dentures disinfection process but not necessarily c. check patient’s ID disinfected d. check baseline vital signs 60. If a nurse will sterilize a heat and moisture labile55. Some lifetime habits and hobbies affect instruments, It is according to AORN postoperative respiratory function. If your client recommendation to use which of the following smokes 3 packs of cigarettes a day for the past method of sterilization? 10 years, you will anticipate increased risk for: a. Ethylene oxide gas a. perioperative anxiety and stress b. Autoclaving b. delayed coagulation time c. Flash sterilizer c. delayed wound healing d. Alcohol immersion d. postoperative respiratory infection Situation 5 – Nurses hold a variety of roles whenSituation: Sterilization is the process of removing ALL providing care to a perioperative patient.living microorganism. To be free of ALL livingmicroorganism is sterility. 61. Which of the following role would be the responsibility of the scrub nurse?56. There are 3 general types of sterilization use in a. Assess the readiness of the client prior the hospital, which one is not included? to surgery a. Steam sterilization b. Ensure that the airway is adequate b. Physical sterilization c. Account for the number of sponges, c. Chemical sterilization needles, supplies, used during the d. Sterilization by boiling surgical procedure. d. Evaluate the type of anesthesia57. Autoclave or steam under pressure is the most appropriate for the surgical client common method of sterilization in the hospital.
  • 32. 62. As a perioperative nurse, how can you best meet patients will need surgical amputation but there the safety need of the client after administering are no sterile surgical equipments. In this case, preoperative narcotic? which of the following will the nurse expect? a. Put side rails up and ask the client not a. Equipments needed for surgery need not to get out of bed be sterilized if this is an emergency b. Send the client to OR with the family necessitating life saving measures c. Allow client to get up to go to the b. Forwarding the trauma client to the comfort room nearest hospital that has available sterile d. Obtain consent form equipments is appropriate c. The nurse will need to sterilize the item63. It is the responsibility of the pre-op nurse to do before using it to the client using the skin prep for patients undergoing surgery. If hair regular sterilization setting at 121 at the operative site is not shaved, what should degree Celsius in 15 minutes be done to make suturing easy and lessen d. In such cases, flash sterlizer will be use chance of incision infection? at 132 degree Celsius in 3 minutes a. Draped b. Pulled 68. Tess, the PACU nurse, discovered that Malou, c. Clipped who weighs 110 lbs prior to surgery, is in severe d. Shampooed pain 3 hrs after cholecystectomy. Upon checking the chart, Malou found out that she has an order64. It is also the nurse’s function to determine when of Demerol 100 mg I.M. prn for pain. Tess should infection is developing in the surgical incision. verify the order with: The perioperative nurse should observe for what a. Nurse Supervisor signs of impending infection? b. Surgeon a. Localized heat and redness c. Anesthesiologist b. Serosanguinous exudates and skin d. Intern on duty blanching c. Separation of the incision 69. Rosie, 57, who is diabetic is for debridement if d. Blood clots and scar tissue are visible incision wound. When the circulating nurse checked the present IV fluid, she found out that65. Which of the following nursing interventions is there is no insulin incorporated as ordered. done when examining the incision wound and What should the circulating nurse do? changing the dressing? a. Double check the doctor’s order and a. Observe the dressing and type and odor call the attending MD of drainage if any b. Communicate with the ward nurse to b. Get patient’s consent verify if insulin was incorporated or not c. Wash hands c. Communicate with the client to verify if d. Request the client to expose the incision insulin was incorporated wound d. Incorporate insulin as ordered.Situation – The preoperative nurse collaborates with the 70. The documentation of all nursing activitiesclient significant others, and healthcare providers. performed is legally and professionally vital. Which of the following should NOT be included66. To control environmental hazards in the OR, the in the patient’s chart? nurse collaborates with the following a. Presence of prosthetoid devices such as departments EXCEPT: dentures, artificial limbs hearing aid, etc. a. Biomedical division b. Baseline physical, emotional, and b. Infection control committee psychosocial data c. Chaplaincy services c. Arguments between nurses and d. Pathology department residents regarding treatments d. Observed untoward signs and symptoms67. An air crash occurred near the hospital leading and interventions including contaminant to a surge of trauma patient. One of the last intervening factors32
  • 33. 33 Situation: Basic knowledge on Intravenous solutions isSituation – Team efforts is best demonstrated in the OR. necessary for care of clients with problems with fluids and electrolytes.71. If you are the nurse in charge for scheduling surgical cases, what important information do 76. A client involved in a motor vehicle crash you need to ask the surgeon? presents to the emergency department with a. Who is your internist severe internal bleeding. The client is severely b. Who is your assistant and hypotensive and unresponsive. The nurse anaesthesiologist, and what is your anticipates which of the following intravenous preferred time and type of surgery? solutions will most likely be prescribed to c. Who are your anaesthesiologist, increase intravascular volume, replace internist, and assistant immediate blood loss and increase blood d. Who is your anaesthesiologist pressure? a. 0.45% sodium chloride72. In the OR, the nursing tandem for every surgery b. 0.33% sodium chloride is: c. Normal saline solution a. Instrument technician and circulating d. Lactated ringer’s solution nurse b. Nurse anaesthetist, nurse assistant, and 77. The physician orders the nurse to prepare an instrument technician isotonic solution. Which of the following IV c. Scrub nurse and nurse anaesthetist solution would the nurse expect the intern to d. Scrub and circulating nurses prescribe? a. 5% dextrose in water73. While team effort is needed in the OR for b. 0.45% sodium chloride efficient and quality patient care delivery, we c. 10% dextrose in water should limit the number of people in the room d. 5% dextrose in 0.9% sodium chloride for infection control. Who comprise this team? a. Surgeon, anaesthesiologist, scrub nurse, 78. The nurse is making initial rounds on the nursing radiologist, orderly unit to assess the condition of assigned clients. b. Surgeon, assistants, scrub nurse, The nurse notes that the client’s IV Site is cool, circulating nurse, anaesthesiologist pale and swollen and the solution is not infusing. c. Surgeon, assistant surgeon, The nurse concludes that which of the following anaesthesiologist, scrub nurse, complications has been experienced by the pathologist client? d. Surgeon, assistant surgeon, a. Infection anaesthesiologist, intern, scrub nurse b. Phlebitis c. Infiltration74. Who usually act as an important part of the OR d. Thrombophelibitis personnel by getting the wheelchair or stretcher, and pushing/pulling them towards the operating 79. A nurse reviews the client’s electrolyte room? laboratory report and notes that the potassium a. Orderly/clerk level is 3.2 mEq/L. Which of the following would b. Nurse Supervisor the nurse note on the electrocardiogram as a c. Circulating Nurse result of the laboratory value? d. Anaesthesiologist a. U waves b. Absend P waves75. The breakdown in teamwork is often times a c. Elevated T waves failure in: d. Elevated ST segment a. Electricity b. Inadequate supply 80. One patient had a ‘runaway’ IV of 50% dextrose. c. Leg work To prevent temporary excess of insulin or d. Communication transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s
  • 34. order? a. Any IV solution available to KVO 86. As an OR nurse, what are your foremost b. Isotonic solution considerations for selecting chemical agents for c. Hypertonic solution disinfection? d. Hypotonic solution a. Material compatibility and efficiency b. Odor and availability81. An informed consent is required for: c. Cost and duration of disinfection process a. closed reduction of a fracture d. Duration of disinfection and efficiency b. irrigation of the external ear canal c. insertion of intravenous catheter 87. Before you use a disinfected instrument it is d. urethral catheterization essential that you: a. Rinse with tap water followed by alcohol82. Which of the following is not true with regards b. Wrap the instrument with sterile water to the informed consent? c. Dry the instrument thoroughly a. It should describe different treatment d. Rinse with sterile water alternatives b. It should contain a thorough and 88. You have a critical heat labile instrument to detailed explanation of the procedure sterilize and are considering to use high level to be done disinfectant. What should you do? c. It should describe the client’s diagnosis a. Cover the soaking vessel to contain the d. It should give an explanation of the vapor client’s prognosis b. Double the amount of high level disinfectant83. You know that the hallmark of nursing c. Test the potency of the high level accountability is the: disinfectant a. accurate documentation and reporting d. Prolong the exposure time according to b. admitting your mistakes manufacturer’s direction c. filing an incidence report d. reporting a medication error 89. To achieve sterilization using disinfectants, which of the following is used?84. A nurse is assigned to care for a group of clients. a. Low level disinfectants immersion in 24 On review of the client’s medical records, the hours nurse determines that which client is at risk for b. Intermediate level disinfectants excess fluid volume? immersion in 12 hours a. The client taking diuretics c. High level disinfectants immersion in 1 b. The client with renal failure hour c. The client with an ileostomy d. High level disinfectant immersion in 10 d. The client who requires gastrointestinal hours suctioning 90. Bronchoscope, Thermometer, Endoscope, ET85. A nurse is assigned to care for a group of clients. tube, Cytoscope are all BEST sterilized using On review of the client’s medical records, the which of the following? nurse determines that which client is at risk for a. Autoclaving at 121 degree Celsius in 15 deficient fluid volume? minutes a. A client with colostomy b. Flash sterilizer at 132 degree Celsius in 3 b. A client with congestive heart failure minutes c. A client with decreased kidney function c. Ethylene Oxide gas aeration for 20 hours d. A client receiving frequent wound d. 2% Glutaraldehyde immersion for 10 irrigation hoursSituation: As a perioperative nurse, you are aware of the Situation: The OR is divided into three zones to controlcorrect processing methods for preparing instruments traffic flow and contaminationand other devices for patient use to prevent infection.34
  • 35. 3591. What OR attires are worn in the restricted area? process a. Scrub suit, OR shoes, head cap b. Head cap, scrub suit, mask, OR shoes 97. 2 organizations endorsed that sterility are c. Mask, OR shoes, scrub suit affected by factors other than the time itself, d. Cap, mask, gloves, shoes these are: a. The PNA and the PRC92. Nursing intervention for a patient on low dose IV b. AORN and JCAHO insulin therapy includes the following, EXCEPT: c. ORNAP and MCNAP a. Elevation of serum ketones to monitor d. MMDA and DILG ketosis b. Vital signs including BP 98. All of these factors affect the sterility of the OR c. Estimate serum potassium equipments, these are the following except: d. Elevation of blood glucose levels a. The material used for packaging b. The handling of the materials as well as93. The doctor ordered to incorporate 1000”u” its transport insulin to the remaining on-going IV. The c. Storage strength is 500 /ml. How much should you d. The chemical or process used in incorporate into the IV solution? sterililzing the material a. 10 ml b. 0.5 ml 99. When you say sterile, it means: c. 2 ml a. The material is clean d. 5 ml b. The material as well as the equipments are sterilized and had undergone a94. Multiple vial-dose-insulin when in use should be rigorous sterilization process a. Kept at room temperature c. There is a black stripe on the paper b. Kept in narcotic cabinet indicator c. Kept in the refrigerator d. The material has no microorganism nor d. Store in the freezer spores present that might cause an infection95. Insulins using insulin syringe are given using how many degrees of needle insertion? 100. In using liquid sterilizer versus autoclave a. 45 machine, which of the following is true? b. 180 a. Autoclave is better in sterilizing OR c. 90 supplies versus liquid sterilizer d. 15 b. They are both capable of sterilizing the equipments, however, it is necessary toSituation: Maintenance of sterility is an important soak supplies in the liquid sterilizer forfunction a nurse should perform in any OR setting. a longer period of time c. Sharps are sterilized using autoclave and96. Which of the following is true with regards to not cidex sterility? d. If liquid sterilizer is used, rinsing it a. Sterility is time related, items are not before using is not necessary considered sterile after a period of 30 days of being not use. b. for 9 months, sterile items are considered sterile as long as they are covered with sterile muslin cover and stored in a dust proof covers. c. Sterility is event related, not time related d. For 3 weeks, items double covered with muslin are considered sterile as long as they have undergone the sterilization
  • 36. d. CT Scan and Incidence reportNURSING PRACTICE IV Situation: An entry level nurse should be able to apply theoretical knowledge in the performance of the basicSituation: After an abdominal surgery, the circulating nursing skills.and scrub nurses have critical responsibility aboutsponge and instrument count. 6. A client has an indwelling urinary catheter and she is suspected of having urinary infection. How 1. Counting is performed thrice: During the should you collect a urine specimen for culture preincision phase, the operative phase and and sensitivity? closing phase. Who counts the sponges, needles a. clamp tubing for 60 minutes and insert a and instruments? sterile needle into the tubing above the a. The scrub nurse only clamp to aspirate urine b. The circulating nurse only b. drain urine from the drainage bag into c. The surgeon and the assistant surgeon the sterile container d. The scrub nurse and the circulating c. disconnect the tubing from the urinary nurse catheter and let urine flow into a sterile container 2. The layer of the abdomen is divided into 5. d. wipe the self-sealing aspiration port Arrange the following from the first layer going with antiseptic solution and insert a to the deepest layer: sterile needle into the self-sealing port 1. Fascia 2. Muscle 7. To obtain specimen for sputum culture and 3. Peritoneum sensitivity, which of the following instruction is 4. Subcutaneous/Fat best? 5. Skin a. Upon waking up, cough deeply and a. 5,4,3,2,1 expectorate into container b. 5,4,1,3,2 b. Cough after pursed lip breathing c. 5,4,2,1,3 c. Save sputum for two days in covered d. 5,4,1,2,3 container d. After respiratory treatment, expectorate 3. When is the first sponge/instrument count into a container reported? a. Before closing the subcutaneous layer 8. The best time for collecting the sputum b. Before peritoneum is closed specimen for culture and sensitivity is: c. Before closing the skin a. Before retiring at night d. Before the fascia is sutured b. Anytime of the day c. Upon waking up in the morning 4. Like any nursing interventions, counts should be d. Before meals documented. To whom does the scrub nurse report any discrepancy of counts so that 9. When suctioning the endotracheal tube, the immediate and appropriate action is instituted? nurse should: a. Anaesthesiologists a. Explain procedure to patient; insert b. Surgeon catheter gently applying suction. c. OR nurse supervisor Withdrawn using twisting motion d. Circulating nurse b. Insert catheter until resistance is met, and then withdraw slightly, applying 5. Which of the following are 2 interventions of the suction intermittently as catheter is surgical team when an instrument was withdrawn confirmed missing? c. Hyperoxygenate client insert catheter a. MRI and Incidence report using back and forth motion b. CT Scan, MRI, Incidence report d. Insert suction catheter four inches into c. X-RAY and Incidence report the tube, suction 30 seconds using36
  • 37. 37 twirling motion as catheter is withdrawn Nursing intervention includes: a. Bed rest10. The purpose of NGT IMMEDIATELY after an b. Warm moist soak operation is: c. Early ambulation a. For feeding or gavage d. Hot sitz bath b. For gastric decompression c. For lavage, or the cleansing of the Situation – Mang Felix, a 79 year old man who is brought stomach content to the Surgical Unit from PACU after a transurethral d. For the rapid return of peristalsis resection. You are assigned to receive him. You noted that he has a 3-way indwelling urinary catheter forSituation - Mr. Santos, 50, is to undergo cystoscopy due continuous fast drip bladder irrigation which isto multiple problems like scantly urination, hematuria connected to a straight drainage.and dysuria. 16. Immediately after surgery, what would you11. You are the nurse in charge in Mr. Santos. When expect his urine to be? asked what are the organs to be examined a. Light yellow during cystoscopy, you will enumerate as b. Bright red follows: c. Amber a. Urethra, kidney, bladder, urethra d. Pinkish to red b. Urethra, bladder wall, trigone, ureteral opening 17. The purpose of the continuous bladder irrigation c. Bladder wall, uterine wall, and urethral is to: opening a. Allow continuous monitoring of the fluid d. Urethral opening, ureteral opening output status bladder b. Provide continuous flushing of clots and debris from the bladder12. In the OR, you will position Mr. Santos who is c. Allow for proper exchange of cystoscopy in: electrolytes and fluid a. Supine d. Ensure accurate monitoring of intake b. Lithotomy and output c. Semi-fowler d. Trendelenburg 18. Mang Felix informs you that he feels some discomfort on the hypogastric area and he has to13. After cystoscopy, Mr. Santos asked you to void. What will be your most appropriate action? explain why there is no incision of any kind. a. Remove his catheter then allow him to What do you tell him? void on his own a. “Cystoscopy is direct visualization and b. Irrigate his catheter examination by urologist”. c. Tell him to “Go ahead and void. You b. “Cystoscopy is done by x-ray have an indwelling catheter.” visualization of the urinary tract”. d. Assess color and rate of outflow, if c. “Cystoscopy is done by using lasers on there is changes refer to urologist for the urinary tract”. possible irrigation. d. “Cystoscopy is an endoscopic procedure of the urinary tract”. 19. You decided to check on Mang Felix’s IV fluid infusion. You noted a change in flow rate, pallor14. Within 24-48 hours post cystoscopy, it is normal and coldness around the insertion site. What is to observe one the following: your assessment finding? a. Pink-tinged urine a. Phlebitis b. Distended bladder b. Infiltration to subcutaneous tissue c. Signs of infection c. Pyrogenic reaction d. Prolonged hematuria d. Air embolism15. Leg cramps are NOT uncommon post cystoscopy. 20. Knowing that proper documentation of
  • 38. assessment findings and interventions are d. Fever, Irritability and a large output of important responsibilities of the nurse during diluted urine first post-operative day, which of the following is the LEAST relevant to document in the case of 25. What kind of renal failure will melamine Mang Felix? poisoning cause? a. Chest pain and vital signs a. Chronic, Prerenal b. Intravenous infusion rate b. Chronic, Intrarenal c. Amount, color, and consistency of c. Acute, Postrenal bladder irrigation drainage d. Acute, Prerenal d. Activities of daily living started Situation: Leukemia is the most common type ofSituation: Melamine contamination in milk has brought childhood cancer. Acute Lymphoid Leukemia is the causeworldwide crisis both in the milk production sector as of almost 1/3 of all cancer that occurs in children underwell as the health and economy. Being aware of the age 15.current events is one quality that a nurse should possessto prove that nursing is a dynamic profession that will 26. The survival rate for Acute Lymphoid Leukemia isadapt depending on the patient’s needs. approximately: a. 25%21. Melamine is a synthetic resin used for b. 40% whiteboards, hard plastics and jewellery box c. 75% covers due to its fire retardant properties. Milk d. 95% and food manufacturers add melamine in order to: 27. Whereas acute nonlymphoid leukemia has a a. It has a bacteriostatic property leading survival rate of: to increase food and milk life as a way of a. 25% preserving the foods b. 40% b. Gives a glazy and more edible look on c. 75% foods d. 95% c. Make milks more tasty and creamy d. Create an illusion of a high protein 28. The three main consequence of leukemia that content on their products cause the most danger is: a. Neutropenia causing infection, anemia22. Most of the milks contaminated by Melamine causing impaired oxygenation and came from which country? thrombocytopenia leading to bleeding a. India tendencies b. China b. Central nervous system infiltration, c. Philippines anemia causing impaired oxygenation d. Korea and thrombocytopenia leading to bleeding tendencies23. Which government agency is responsible for c. Splenomegaly, hepatomegaly, fractures testing the melamine content of foods and food d. Invasion by the leukemic cells to the products? bone causing severe bone pain a. DOH b. MMDA 29. Gold standard in the diagnosis of leukemia is by c. NBI which of the following? d. BFAD a. Blood culture and sensitivity b. Bone marrow biopsy24. Infants are the most vulnerable to melamine c. Blood biopsy poisoning. Which of the following is NOT a sign d. CSF aspiration and examination of melamine poisoning? a. Irritability, Back ache, Urolithiasis 30. Adriamycin,Vincristine,Prednisone and L b. High blood pressure, fever asparaginase are given to the client for long c. Anuria, Oliguria or Hematuria term therapy. One common side effect,38
  • 39. 39 especially of adriamycin is alopecia. The child sensitivity of the breast. asks: “Will I get my hair back once again?” The nurse best respond is by saying: 34. Carmen, who is asking the nurse the most a. “Don’t be silly, ofcourse you will get your appropriate time of the month to do her self- hair back” examination of the breast. The MOST b. “We are not sure, let’s hope it’ll grow” appropriate reply by the nurse would be: c. “This side effect is usually permanent, a. the 26th day of the menstrual cycle But I will get the doctor to discuss it for b. 7 to 8 days after conclusion of the you” menstrual period d. “Your hair will regrow in 3 to 6 months c. during her menstruation but of different color, usually darker d. the same day each month and of different texture” 35. Carmen being treated with radiation therapy.Situation: Breast Cancer is the 2nd most common type of What should be included in the plan of care tocancer after lung cancer and 99% of which, occurs in minimize skin damage from the radiationwoman. Survival rate is 98% if this is detected early and therapy?treated promptly. Carmen is a 53 year old patient in the a. Cover the areas with thick clothinghigh risk group for breast cancer was recently diagnosed materialswith Breast cancer. b. Apply a heating pad to the site c. Wash skin with water after the therapy31. All of the following are factors that said to d. Avoid applying creams and powders to contribute to the development of breast cancer the area except: a. Prolonged exposure to estrogen such as 36. Based on the DOH and World Health an early menarche or late menopause, Organization (WHO) guidelines, the mainstay for nulliparity and childbirth after age 30 early detection method for breast cancer that is b. Genetics recommended for developing countries is: c. Increasing Age a. a monthly breast self-examination (BSE) d. Prolonged intake of Tamoxifen and an annual health worker breast (Nolvadex) examination (HWBE) b. an annual hormone receptor assay32. Protective factors for the development of breast c. an annual mammogram cancer includes which of the following except: d. a physician conduct a breast clinical a. Exercise examination every 2 years b. Breast feeding c. Prophylactic Tamoxifen 37. The purpose of performing the breast self- d. Alcohol intake examination (BSE) regularly is to discover: a. fibrocystic masses33. A patient diagnosed with breast cancer has been b. areas of thickness or fullness offered the treatment choices of breast c. cancerous lumps conservation surgery with radiation or a d. changes from previous BSE modified radical mastectomy. When questioned by the patient about these options, the nurse 38. If you are to instruct a postmenopausal woman informs the patient that the lumpectomy with about BSE, when would you tell her to do BSE: radiation: a. on the same day of each month a. reduces the fear and anxiety that b. on the first day of her menstruation accompany the diagnosis and treatment c. right after the menstrual period of cancer d. on the last day of her menstruation b. has about the same 10-year survival rate as the modified radical mastectomy 39. During breast self-examination, the purpose of c. provides a shorter treatment period with standing in front of the mirror it to observe the a fewer long term complications breast for: d. preserves the normal appearance and a. thickening of the tissue
  • 40. b. lumps in the breast tissue d. Ineffective tissue perfusion, peripheral, c. axillary lymphnodes cerebral, cardiovascular, d. change in size and contour gastrointestinal, renal40. When preparing to examine the left breast in a 45. What intervention should you include in your reclining position, the purpose of placing a small care plan? folded towel under the client’s left shoulder is a. Inspect his skin for petechiae, bruising, to: GI bleeding regularly a. bring the breast closer to the examiner’s b. Place Albert on strict isolation right hand precaution b. tense the pectoral muscle c. Provide rest in between activities c. balance the breast tissue more evenly d. Administer antipyretics if his on the chest wall temperature exceeds 38C d. facilitate lateral positioning of the breast Situation: Burn are cause by transfer of heat source toSituation – Radiation therapy is another modality of the body. It can be thermal, electrical, radiation orcancer management. With emphasis on multidisciplinary chemical.management you have important responsibilities asnurse. 46. A burn characterized by Pale white appearance, charred or with fat exposed and painlessness is:41. Albert is receiving external radiation therapy and a. Superficial partial thickness burn he complains of fatigue and malaise. Which of b. Deep partial thickness burn the following nursing interventions would be c. Full thickness burn most helpful for Albert? d. Deep full thickness burn a. Tell him that sometimes these feelings can be psychogenic 47. Which of the following BEST describes superficial b. Refer him to the physician partial thickness burn or first degree burn? c. Reassure him that these feelings are a. Structures beneath the skin are damage normal b. Dermis is partially damaged d. Help him plan his activities c. Epidermis and dermis are both damaged d. Epidermis is damaged42. Immediately following the radiation teletherapy, Albert is 48. A burn that is said to be “WEEPING” is classified a. Considered radioactive for 24 hrs as: b. Given a complete bath a. Superficial partial thickness burn c. Placed on isolation for 6 hours b. Deep partial thickness burn d. Free from radiation c. Full thickness burn d. Deep full thickness burn43. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should 49. During the Acute phase of the burn injury, which observe the following symptoms: of the following is a priority? a. Petechiae, ecchymosis, epistaxis a. wound healing b. Weakness, easy fatigability, pallor b. emotional support c. Headache, dizziness, blurred vision c. reconstructive surgery d. Severe sore throat, bacteremia, d. fluid resuscitation hepatomegaly 50. While in the emergent phase, the nurse knows44. What nursing diagnosis should be of highest that the priority is to: priority? a. Prevent infection a. Knowledge deficit regarding b. Prevent deformities and contractures thrombocytopenia precautions c. Control pain b. Activity intolerance d. Return the hemodynamic stability via c. Impaired tissue integrity fluid resuscitation40
  • 41. 41 the client is developing:51. The MOST effective method of delivering pain a. Cerebral hypoxia medication during the emergent phase is: b. metabolic acidosis a. intramuscularly c. Hypervolemia b. orally d. Renal failure c. subcutaneously d. intravenously 58. A 165 lbs trauma client was rushed to the emergency room with full thickness burns on the52. When a client accidentally splashes chemicals to whole face, right and left arm, and at the his eyes, The initial priority care following the anterior upper chest sparing the abdominal area. chemical burn is to: He also has superficial partial thickness burn at a. irrigate with normal saline for 1 to 15 the posterior trunk and at the half upper portion minutes of the left leg. He is at the emergent phase of b. transport to a physician immediately burn. Using the parkland’s formula, you know c. irrigate with water for 15 minutes or that during the first 8 hours of burn, the amount longer of fluid will be given is: d. cover the eyes with a sterile gauze a. 5,400 ml b. 9, 450 ml53. Which of the following can be a fatal c. 10,800 ml complication of upper airway burns? d. 6,750 ml a. stress ulcers b. shock 59. The doctor incorporated insulin on the client’s c. hemorrhage fluid during the emergent phase. The nurse d. laryngeal spasms and swelling knows that insulin is given because: a. Clients with burn also develops54. When a client will rush towards you and he has a Metabolic acidosis burning clothes on, It is your priority to do which b. Clients with burn also develops of the following first? hyperglycemia a. log roll on the grass/ground c. Insulin is needed for additional energy b. slap the flames with his hands and glucose burning after the stressful c. Try to remove the burning clothes incidence to hasten wound healing, d. Splash the client with 1 bucket of cool regain of consciousness and rapid return water of hemodynamic stability d. For hyperkalemia55. Once the flames are extinguished, it is most important to: 60. The IV fluid of choice for burn as well as a. cover clientwith a warm blanket dehydration is: b. give him sips of water a. 0.45% NaCl c. calculate the extent of his burns b. Sterile water d. assess the Sergio’s breathing c. NSS d. D5LR56. During the first 24 hours after the thermal injury, you should asses Sergio for: Situation: ENTEROSTOMAL THERAPY is now considered a a. hypokalemia and hypernatremia specialty in nursing. You are participating in the OSTOMY b. hypokalemia and hyponatremia CARE CLASS. c. hyperkalemia and hyponatremia d. hyperkalemia and hypernatremia 61. You plan to teach Fermin how to irrigate the colostomy when:57. A client who sustained deep partial thickness a. The perineal wound heals And Fermin and full thickness burns of the face, whole can sit comfortably on the commode anterior chest and both upper extremities two b. Fermin can lie on the side comfortably, days ago begins to exhibit extreme restlessness. about the 3rd postoperative day You recognize that this most likely indicates that c. The abdominal incision is closed and
  • 42. contamination is no longer a danger it is important for nurses to gather as much information d. The stools starts to become formed, to be able to address their needs for nursing care. around the 7th postoperative day 66. Critically ill patients frequently complain about62. When preparing to teach Fermin how to irrigate which of the following when hospitalized? colostomy, you should plan to do the procedure: a. Hospital food a. When Fermin would have normal bowel b. Lack of privacy movement c. Lack of blankets b. At least 2 hours before visiting hours d. Inadequate nursing staff c. Prior to breakfast and morning care d. After Fermin accepts alteration in body 67. Who of the following is at greatest risk of image developing sensory problem? a. Female patient63. When observing a return demonstration of a b. Transplant patient colostomy irrigation, you know that more c. Adoloscent teaching is required if Fermin: d. Unresponsive patient a. Lubricates the tip of the catheter prior to inserting into the stoma 68. Which of the following factors may inhibit b. Hangs the irrigating bag on the learning in critically ill patients? bathroom door cloth hook during fluid a. Gender insertion b. Educational level c. Discontinues the insertion of fluid after c. Medication 500 ml of fluid has been instilled d. Previous knowledge of illness d. Clamps of the flow of fluid when felling uncomfortable 69. Which of the following statements does not apply to critically ill patients?64. You are aware that teaching about colostomy a. Majority need extensive rehabilitation care is understood when Fermin states, “I will b. All have been hospitalized previously contact my physician and report: c. Are physically unstable a. If I have any difficulty inserting the d. Most have chronic illness irrigating tub into the stoma.” b. If I noticed a loss of sensation to touch in 70. Families of critically ill patients desire which of the stoma tissue.” the following needs to be met first by the nurse? c. The expulsion of flatus while the a. Provision of comfortable space irrigating fluid is running out.” b. Emotional support d. When mucus is passed from the stoma c. Updated information on client’s status between the irrigations.” d. Spiritual counselling65. You would know after teaching Fermin that Situation: Johnny, sought consultation to the hospital dietary instruction for him is effective when he because of fatigability, irritability, jittery and he has been states, “It is important that I eat: experiencing this sign and symptoms for the past 5 a. Soft food that is easily digested and months. absorbed by my large intestines.” b. Bland food so that my intestines do not 71. His diagnosis was hyperthyroidism, the following become irritated.” are expected symptoms except: c. Food low in fiber so that there are fewer a. Anorexia stools.” b. Fine tremors of the hand d. Everything that I ate before the c. Palpitation operation, while avoiding foods that d. Hyper alertness cause gas”. 72. She has to take drugs to treat herSituation: Based on studies of nurses working in special hyperthyroidism. Which of the following will youunits like the intensive care unit and coronary care unit, NOT expect that the doctor will prescribe?42
  • 43. 43 a. Colace (Docusate) to: b. Tapazole (Methimazole) a. Decrease the vascularity and size of the c. Cytomel (Liothyronine) thyroid gland d. Synthroid (Levothyroxine) b. Decrease the size of the thyroid gland only73. The nurse knows that Tapazole has which of the c. Increase the vascularity and size of the following side effect that will warrant immediate thyroid gland withholding of the medication? d. Increase the size of the thyroid gland a. Death only b. Hyperthermia c. Sore throat 79. Which of the following is a side effect of Lugol’s d. Thrombocytosis solution? a. Hypokalemia74. You asked questions as soon as she regained b. Enlargement of the Thryoid gland consciousness from thyroidectomy primarily to c. Nystagmus assess the evidence of: d. Excessive salivation a. Thyroid storm b. Damage to the laryngeal nerve 80. In administering Lugol’s solution, the c. Mediastinal shift precautionary measure should include: d. Hypocalcaemia tetany a. Administer with glass only b. Dilute with juice and administer with a75. Should you check for haemorrhage, you will: straw a. Slip your hand under the nape of her c. Administer it with milk and drink it neck d. Follow it with milk of magnesia b. Check for hypotension c. Apply neck collar to prevent Situation: Pharmacological treatment was not effective haemorrhage for Johnny’s hyperthyroidism and now, he is scheduled d. Observe the dressing if it is soaked with for Thyroidectomy. blood 81. Instruments in the surgical suite for surgery is76. Basal Metabolic rate is assessed on Johnny to classified as either CRITICAL, SEMI CRITICAL and determine his metabolic rate. In assessing the NON CRITICAL. If the instrument are introduced BMR using the standard procedure, you need to directly into the blood stream or into any tell Johnny that: normally sterile cavity or area of the body it is a. Obstructing his vision classified as: b. Restraining his upper and lower a. Critical extremities b. Non Critical c. Obstructing his hearing c. Semi Critical d. Obstructing his nostrils with a clamp d. Ultra Critical77. The BMR is based on the measurement that: 82. Instruments that do not touch the patient or a. Rate of respiration under different have contact only to intact skin is classified as: condition of activities and rest a. Critical b. Amount of oxygen consumption under b. Non Critical resting condition over a measured c. Semi Critical period of time d. Ultra Critical c. Amount of oxygen consumption under stressed condition over a measured 83. If an instrument is classified as Semi Critical, an period of time acceptable method of making the instrument d. Ratio of respiration to pulse rate over a ready for surgery is through: measured period of time a. Sterilization b. Disinfection78. Her physician ordered lugol’s solution in order c. Decontamination
  • 44. d. Cleaning d. Tetany84. While critical items and should be: 90. After surgery Johnny develops peripheral a. Clean numbness, tingling and muscle twitching and b. Sterilized spasm. What would you anticipate to c. Decontaminated administer? d. Disinfected a. Magnesium sulfate b. Potassium iodide85. As a nurse, you know that intact skin acts as an c. Calcium gluconate effective barrier to most microorganisms. d. Potassium chloride Therefore, items that come in contact with the intact skin or mucus membranes should be: Situation: Budgeting is an important part of a nurse a. Disinfected managerial activity. The correct allocation and b. Clean distribution of resources is vital in the harmonious c. Sterile operation of the financial balance of the agency. d. Alcoholized 91. Which of the following best defines Budget?86. You are caring for Johnny who is scheduled to a. Plan for the allocation of resources for undergo total thyroidectomy because of a future use diagnosis of thyroid cancer. Prior to total b. The process of allocating resources for thyroidectomy, you should instruct Johnny to: future use a. Perform range and motion exercise on c. Estimate cost of expenses the head and neck d. Continuous process in seeing that the b. Apply gentle pressure against the goals and objective of the agency is met incision when swallowing c. Cough and deep breathe every 2 hours 92. Which of the following best defines Capital d. Support head with the hands when Budget? changing position a. Budget to estimate the cost of direct labour, number of staff to be hired and87. As Johnny’s nurse, you plan to set up emergency necessary number of workers to meet equipment at her bedside following the general patient needs thyroidectomy. You should include: b. Includes the monthly and daily expenses a. An airway and rebreathing tube and expected revenue and expenses b. A tracheostomy set and oxygen c. These are related to long term planning c. A crush cart with bed board and includes major replacement or d. Two ampules of sodium bicarbonate expansion of the plant, major equipment and inventories.88. Which of the following nursing interventions is d. These are expenses that are not appropriate after a total thyroidectomy? dependent on the level of production or a. Place pillows under your patient’s sales. They tend to be time-related, such shoulders. as salaries or rents being paid per month b. Raise the knee-gatch to 30 degrees c. Keep you patient in a high-fowler’s 93. Which of the following best described position. Operational Budget? d. Support the patient’s head and neck a. Budget to estimate the cost of direct with pillows and sandbags. labour, number of staff to be hired and necessary number of workers to meet89. If there is an accidental injury to the parathyroid the general patient needs gland during a thyroidectomy which of the b. Includes the monthly and daily following might Leda develops postoperatively? expenses and expected revenue and a. Cardiac arrest expenses b. Respiratory failure c. These are related to long term planning c. Dyspnea and includes major replacement or44
  • 45. 45 expansion of the plant, major c. The Chinese Triad equipments and inventories. d. Charcot’s Triad d. These are expenses that are not dependent on the level of production or 98. Which of the following is true with the Triad sales. They tend to be time-related, such seen in head injuries? as rent a. Narrowing of Pulse pressure, Cheyne stokes respiration, Tachycardia94. Which of the following accurately describes a b. Widening Pulse pressure, Irregular Fixed Cost in budgeting? respiration, Bradycardia a. These are usually the raw materials and c. Hypertension, Kussmaul’s respiration, labour salaries that depend on the Tachycardia production or sales d. Hypotension, Irregular respiration, b. These are expenses that change in Bradycardia proportion to the activity of a business c. These are expenses that are not 99. In a client with a Cheyne stokes respiration, dependent on the level of production or which of the following is the most appropriate sales. They tend to be time-related, nursing diagnosis? such as rent a. Ineffective airway clearance d. This is the summation of the Variable b. Impaired gas exchange Cost and the Fixed Cost c. Ineffective breathing pattern d. Activity intolerance95. Which of the following accurately describes Variable Cost in budgeting? 100. You know the apnea is seen in client’s with a. These are related to long term planning cheyne stokes respiration, APNEA is defined as: and include major replacement or a. Inability to breathe in a supine position expansion of the plant, major so the patient sits up in bed to breathe equipments and inventories. b. The patient is dead, the breathing stops b. These are expenses that change in c. There is an absence of breathing for a proportion to the activity of a business period of time, usually 15 seconds or c. These are expenses that are not more dependent on the level of production or d. A period of hypercapnea and hypoxia sales. They tend to be time-related, such due to the cessation of respiratory effort as rent inspite of normal respiratory functioning d. This is the summation of the Variable Cost and the Fixed CostSituation – Andrea is admitted to the ER following anassault where she was hit in the face and head. She wasbrought to the ER by a police woman. Emergencymeasures were started.96. Andrea’s respiration is described as waxing and waning. You know that this rhythm of respiration is defined as: a. Biot’s b. Cheyne stokes c. Kussmaul’s d. Eupnea97. What do you call the triad of sign and symptoms seen in a client with increasing ICP? a. Virchow’s Triad b. Cushing’s Triad
  • 46. 5. A Client state, “I get down on myself when INURSING PRACTICE V make mistake.” Using Cognitive therapy approach, the nurse should:Situation: Understanding different models of care is a A. Teach the client relaxation exercise tonecessary part of the nurse patient relationship. diminish stress B. Provide the client with Mastery 1. The focus of this therapy is to have a positive experience to boost self esteem environmental manipulation, physical and social C. Explore the client’s past experiences that to effect a positive change. causes the illness A. Milieu D. Help client modify the belief that B. Psychotherapy anything less than perfect is horrible C. Behaviour D. Group 6. The most advantageous therapy for a preschool age child with a history of physical and sexual 2. The client asks the nurse about Milieu therapy. abuse would be: The nurse responds knowing that the primary A. Play focus of milieu therapy can be best described by B. Psychoanalysis which of the following? C. Group A. A form of behavior modification therapy D. Family B. A cognitive approach of changing the behaviour 7. An 18 year old client is admitted with the C. A living, learning or working diagnosis of anorexia nervosa. A cognitive environment behavioural approach is used as part of her D. A behavioural approach to changing treatment plan. The nurse understands that the behaviour purpose of this approach is to: A. Help the client identify and examine 3. A nurse is caring for a client with phobia who is dysfunctional thoughts and beliefs being treated for the condition. The client is B. Emphasize social interaction with clients introduced to short periods of exposure to the who withdraw phobic object while in relaxed state. The nurse C. Provide a supportive environment and a understands that this form of behaviour therapeutic community modification can be best described as: D. Examine intrapsychic conflicts and past A. Systematic desensitization events in life B. Self-control therapy C. Aversion Therapy 8. The nurse is preparing to provide reminiscence D. Operant conditioning therapy for a group of clients. Which of the following clients will the nurse select for this 4. A client with major depression is considering group? cognitive therapy. The client say to the nurse, A. A client who experiences profound “How does this treatment works?” The nurse depression with moderate cognitive responds by telling the client that: impairment A. “This type of treatment helps you B. A catatonic, immobile client with examine how your thoughts and moderate cognitive impairment feelings contribute to your difficulties” C. An undifferentiated schizophrenic client B. “This type of treatment helps you with moderate cognitive impairment examine how your past life has D. A client with mild depression who contributed to your problems.” exhibits who demonstrates normal C. “This type of treatment helps you to cognition confront your fears by exposing you to the feared object abruptly. 9. Which intervention would be typical of a nurse D. “This type of treatment will help you using cognitive-behavioral approach to a client relax and develop new coping skills.” experiencing low self-esteem?46
  • 47. 47 A. Use of unconditional positive regard C. refer the client to the psychiatrist B. Analysis of free association D. refer the matter to the police C. Classical conditioning D. Examination of negative thought Situation: Rose seeks psychiatric consultation because of patterns intense fear of flying in an airplane which has greatly affected her chances of success in her job.10. Which of the following therapies has been strongly advocated for the treatment of post- 16. The most common defense mechanism used by traumatic stress disorders? phobic clients is: A. ECT A. Supression B. Group Therapy B. Denial C. Hypnotherapy C. Rationalization D. Psychoanalysis D. Displacement11. The nurse knows that in group therapy, the 17. The goal of the therapy in phobia is: maximum number of members to include is: A. Change her lifestyle A. 4 B. Ignore tension producing situation B. 8 C. Change her reaction towards anxiety C. 10 D. Eliminate fear producing situations D. 16 18. The therapy most effective for client’s with12. The nurse is providing information to a client phobia is: with the use of disulfiram (antabuse) for the A. Hypnotherapy treatment of alcohol abuse. The nurse B. Cognitive therapy understands that this form of therapy works on C. Group therapy what principle? D. Behavior therapy A. Negative Reinforcement B. Operant Conditioning 19. The fear and anxiety related to phobia is said to C. Aversion Therapy be abruptly decreased when the patient is D. Gestalt therapy exposed to what is feared through: A. Guided Imagery13. A biological or medical approach in treating B. Systematic desensitization psychiatric patient is: C. Flooding A. Million therapy D. Hypotherapy B. Behavioral therapy C. Somatic therapy 20. Based on the presence of symptom, the D. Psychotherapy appropriate nursing diagnosis is: A. Self-esteem disturbance14. Which of these nursing actions belong to the B. Activity intolerance secondary level of preventive intervention? C. Impaired adjustment A. Providing mental health consultation to D. Ineffective individual coping health care providers B. Providing emergency psychiatric Situation: Mang Jose, 39 year old farmer, unmarried, had services been confined in the National center for mental health C. Being politically active in relation to for three years with a diagnosis of schizophrenia. mental health issues D. Providing mental health education to 21. The most common defense mechanism used by members of the community a paranoid client is: A. Displacement15. When the nurse identifies a client who has B. Rationalization attempted to commit suicide the nurse should: C. Suppression A. call a priest D. Projection B. counsel the client
  • 48. 22. When Mang Jose says to you: “The voices are is best described in one of the following telling me bad things again!” The best response statements: is: A. Unacceptable feelings or behavior are A. “Whose voices are those?” kept out of awareness by developing the B. “I doubt what the voices are telling you” opposite behavior or emotion C. “I do not hear the voice you say you B. Consciously unacceptable instinctual hear” drives are diverted into personally and D. “Are you sure you hear these voices?” socially acceptable channels C. Something unacceptable already done 23. A relevant nursing diagnosis for clients with is symbolically acted out in reverse auditory hallucination is: D. Transfer of emotions associated with a A. Sensory perceptual alteration particular person, object or situation to B. Altered thought process another less threatening person, object C. Impaired social interaction or situation D. Impaired verbal communication 29. To be more effective, the nurse who cares for 24. During mealtime, Jose refused to eat telling that persons with obsessive compulsive disorder the food was poisoned. The nurse should: must possess one of the following qualities: A. Ignore his remark A. Compassion B. Offer him food in his own container B. Patience C. Show him how irrational his thinking is C. Consistency D. Respect his refusal to eat D. Friendliness 25. When communicating with Jose, The nurse 30. Persons with OCD usually manifest: considers the following except: A. Fear A. Be warm and enthusiastic B. Apathy B. Refrain from touching Jose C. Suspiciousness C. Do not argue regarding his hallucination D. Anxiety and delusion D. Use simple, clear language Situation: The patient who is depressed will undergo electroconvulsive therapy.Situation: Gringo seeks psychiatric counselling for hisritualistic behavior of counting his money as many as 10 31. Studies on biological depression supporttimes before leaving home. electroconvulsive therapy as a mode of treatment. The rationale is: 26. An initial appropriate nursing diagnosis is: A. ECT produces massive brain damage A. Impaired social interaction which destroys the specific area B. Ineffective individual coping containing memories related to the C. Impaired adjustment events surrounding the development of D. Anxiety Moderate psychotic condition B. The treatment serves as a symbolic 27. Obsessive compulsive disorder is BEST described punishment for the client who feels by: guilty and worthless A. Uncontrollable impulse to perform an C. ECT relieves depression psychologically act or ritual repeatedly by increasing the norepinephrine level B. Persistent thoughts D. ECT is seen as a life-threatening C. Recurring unwanted and disturbing experience and depressed patients thought alternating with a behavior mobilize all their bodily defences to deal D. Pathological persistence of unwilled with this attack. thought, feeling or impulse 32. The preparation of a patient for ECT ideally is 28. The defense mechanism used by persons with MOST similar to preparation for a patient for: obsessive compulsive disorder is undoing and it A. electroencephalogram48
  • 49. 49 B. general anesthesia A. Emotional crisis C. X-ray B. Cholinergic crisis D. electrocardiogram C. Menopausal crisis D. Myasthenia crisis 33. Which of the following is a possible side effect which you will discuss with the patient? 40. If you are not extra careful and by chance you A. hemorrhage within the brain give over medication, this would lead to; B. encephalitis A. Cholinergic crisis C. robot-like body stiffness B. Menopausal crisis D. confusion, disorientation and short C. Emotional crisis term memory loss D. Myasthenia crisis 34. Informed consent is necessary for the treatment Situation: Rosanna 20 y/o unmarried patient believes for involuntary clients. When this cannot be that the toilet for the female patient in contaminated obtained, permission may be taken from the: with AIDS virus and refuses to use it unless she flushes it A. social worker three times and wipes the seat same number of times B. next of kin or guardian with antiseptic solution. C. doctor D. chief nurse 41. The fear of using “contaminated” toilet seat can be attributed to Rosanna’s inability to; 35. After ECT, the nurse should do this action before A. Adjust to a strange environment giving the client fluids, food or medication: B. Express her anxiety A. assess the gag reflex C. Develop the sense of trust in other B. next of kin or guardian person C. assess the sensorium D. Control unacceptable impulses or D. check O2 Sat with a pulse oximeter feelingsSituation: Mrs Ethel Agustin 50 y/o, teacher is afflicted 42. Assessment data upon admission help the nursewith myasthenia gravis. to identify this appropriate nursing diagnosis A. Ineffective denial 36. Looking at Mrs Agustin, your assessment would B. Impaired adjustment include the following except; C. Ineffective individual coping A. Nystagmus D. Impaired social interaction B. Difficulty of hearing C. Weakness of the levator palpebrae 43. An effective nursing intervention to help Rosana D. Weakness of the ocular muscle is; A. Convincing her to use the toilet after the 37. In an effort to combat complications which nurse has used it first might occur relatives should he taught; B. Explaining to her that AIDS cannot be A. Checking cardiac rate transmitted by using the toilet B. Taking blood pressure reading C. Allowing her to flush and clear the C. Techniques of oxygen inhalation toilet seat until she can manage her D. Administration of oxygen inhalation anxiety D. Explaining to her how AIDS is 38. The drug of choice for her condition is; transmitted A. Prostigmine B. Morphine 44. The goal for treatment for Rosana must be C. Codeine directed toward helping her to; D. Prednisone A. Walk freely about her past experience B. Develop trusting relationship with others 39. As her nurse, you have to be cautious about C. Gain insight that her behaviour is due administration of medication, if she is under to feeling of anxiety medicated this can cause; D. Accept the environment unconditionally
  • 50. B. Self-esteem disturbance 45. Psychotherapy which is prescribed for Rosana is C. Ineffective individual coping described as; D. Defensive coping A. Establishing an environment adapted to an individual patient needs 50. Most appropriate nursing intervention for a B. Sustained interaction between the client with suspicious behavior is one of the therapist and client to help her develop following; more functional behaviour A. Talk to the client constantly to reinforce C. Using dramatic techniques to portray reality interpersonal conflicts B. Involve him in competitive activities D. Biologic treatment for mental disorder C. Use Non Judgmental and Consistent approachSituation: Dennis 40 y/o married man, an electrical D. Project cheerfulness in interacting withengineer was admitted with the diagnosis of paranoid the patientdisorders. He has become suspicious and distrustful 2months before admission. Upon admission, he kept on Situation: Clients with Bipolar disorder receives a verysaying, “my wife has been planning to kill me.” high nursing attention due to the increasing rate of suicide related to the illness. 46. A paranoid individual who cannot accept the guilt demonstrate one of the following defense 51. The nurse is assigned to care for a recently mechanism; admitted client who has attempted suicide. A. Denial What should the nurse do? B. Projection A. Search the clients belongings and room C. Rationalization carefully for items that could be used to D. Displacement attempt suicide. B. Express trust that the client wont cause 47. One morning, Dennis was seen tilting his head as self-harm while in the facility. if he was listening to someone. An appropriate C. Respect the clients privacy by not nursing intervention would be; searching any belongings. A. Tell him to socialize with other patient to D. Remind all staff members to check on divert his attention the client frequently. B. Involve him in group activities C. Address him by name to ask if he is 52. In planning activities for the depressed client, hearing voices again especially during the early stages of D. Request for an order of antipsychotic hospitalization, which of the following plan is medicine best? A. Provide an activity that is quiet and 48. When he says, “these voices are telling me my solitary to avoid increased fatigue such wife is going to kill me.” A therapeutic as working on a puzzle and reading a communication of the nurse is which one of the book. following; B. Plan nothing until the client asks to A. “i do not hear the voices you say you participate in the milieu hear” C. Offer the client a menu of daily activities B. “are you really sure you heard those and ask the client to participate in all of voices?” them C. “I do not think you heard those D. Provide a structured daily program of voices?” activities and encourage the client to D. “Whose voices are those?” participate 49. The nurse confirms that Dennis is manifesting 53. A client with a diagnosis of major depression, auditory hallucination. The appropriate nursing recurrent with psychotic features is admitted to diagnosis she identifiesis; the mental health unit. To create a safe A. Sensory perceptual alteration environment for the client, the nurse most50
  • 51. 51 importantly devises a plan of care that deals The nurse would initially: specifically with the clients: A. Ask the client to leave the group session A. Disturbed thought process B. Tell the client that she will not be B. Imbalanced nutrition allowed to attend any more group C. Self-Care Deficit sessions D. Deficient Knowledge C. Tell the client that she needs to allow other client in a group time to talk54. The client is taking a Tricyclic anti-depressant, D. Ask another nurse to escort the client which of the following is an example of TCA? out of the group session A. Paxil B. Nardil 59. A professional artist is admitted to the C. Zoloft psychiatric unit for treatment of bipolar D. Pamelor disorder. During the last 2 weeks, the client has created 154 paintings, slept only 2 to 3 hours55. A client visits the physicians office to seek every 2 days, and lost 18 lb (8.2 kg). Based on treatment for depression, feelings of Maslows hierarchy of needs, what should the hopelessness, poor appetite, insomnia, fatigue, nurse provide this client with first? low self-esteem, poor concentration, and A. The opportunity to explore family difficulty making decisions. The client states that dynamics these symptoms began at least 2 years ago. B. Help with re-establishing a normal Based on this report, the nurse suspects: sleep pattern A. cyclothymic disorder. C. Experiences that build self-esteem B. Bipolar disorder D. Art materials and equipment C. major depression. D. dysthymic disorder. 60. The physician orders lithium carbonate (Lithonate) for a client whos in the manic phase56. The nurse is planning activities for a client who of bipolar disorder. During lithium therapy, the has bipolar disorder, which aggressive social nurse should watch for which adverse reactions? behaviour. Which of the following activities A. Anxiety, restlessness, and sleep would be most appropriate for this client? disturbance A. Ping Pong B. Nausea, diarrhea, tremor, and lethargy B. Linen delivery C. Constipation, lethargy, and ataxia C. Chess D. Weakness, tremor, and urine retention D. Basketball Situation – Annie has a morbid fear of heights. She asks57. The nurse assesses a client with admitted the nurse what desensitization therapy is: diagnosis of bipolar affective disorder, mania. The symptom presented by the client that 61. The accurate information of the nurse of the requires the nurse’s immediate intervention is goal of desensitization is: the client’s: A. To help the clients relax and A. Outlandish behaviour and inappropriate progressively work up a list of anxiety dress provoking situations through imagery. B. Grandiose delusion of being a royal B. To provide corrective emotional descendant of king arthut experiences through a one-to-one C. Nonstop physical activity and poor intensive relationship. nutritional intake C. To help clients in a group therapy setting D. Constant incessant talking that includes to take on specific roles and reenact in sexual topics and teasing the staff front of an audience, situations in which interpersonal conflict is involved.58. A nurse is conducting a group therapy session D. To help clients cope with their problems and during the session, A client with mania by learning behaviors that are more consistently talks and dominates the group. The functional and be better equipped to behaviour is disrupting the group interaction. face reality and make decisions.
  • 52. problem. After the identification of the research 62. It is essential in desensitization for the patient problem, which of the following should be done? to: A. Methodology A. Have rapport with the therapist B. Acknowledgement B. Use deep breathing or another C. Review of related literature relaxation technique D. Formulate hypothesis C. Assess one’s self for the need of an anxiolytic drug 68. Which of the following communicate the results D. Work through unresolved unconscious of the research to the readers. They facilitate the conflicts description of the data. A. Hypothesis 63. In this level of anxiety, cognitive capacity B. Research problem diminishes. Focus becomes limited and client C. Statistics experiences tunnel vision. Physical signs of D. Tables and Graphs anxiety become more pronounced. A. Severe anxiety 69. In Quantitative date, which of the following is B. Mild anxiety described as the distance in the scoring unites of C. Panic the variable from the highest to the lower? D. Moderate anxiety A. Frequency B. Median 64. Antianxiety medications should be used with C. Mean extreme caution because long term use can lead D. Range to: A. Parkinsonian like syndrome 70. This expresses the variability of the data in B. Hepatic failure reference to the mean. It provides as with a C. Hypertensive crisis numerical estimate of how far, on the average D. Risk of addiction the separate observation are from the mean: A. Mode 65. The nursing management of anxiety related with B. Median post-traumatic stress disorder includes all of the C. Standard deviation following EXCEPT: D. Frequency A. Encourage participation in recreation or sports activities Situation: Survey and Statistics are important part of B. Reassure client’s safety while touching research that is necessary to explain the characteristics client of the population. C. Speak in a calm soothing voice D. Remain with the client while fear level is 71. According to the WHO statistics on the Homeless high population around the world, which of the following groups of people in the worldSITUATION: You are fortunate to be chosen as part of disproportionately represents the homelessthe research team in the hospital. A review of the population?following IMPORTANT nursing concepts was made. A. Hispanics B. Asians 66. As a professional, a nurse can do research for C. African Americans varied reason except: D. Caucasians A. Professional advancement through research participation 72. All but one of the following is not a measure of B. To validate results of new nursing Central Tendency: modalities A. Mode C. For financial gains B. Standard Deviation D. To improve nursing care C. Variance D. Range 67. Each nurse participants was asked to identify a52
  • 53. 5373. In the value: 87, 85, 88, 92, 90; what is the A. There is a control group mean? B. There is an experimental group A. 88.2 C. Selection of subjects in the control group B. 88.4 is randomized C. 87 D. There is a careful selection of subjects D. 90 in the experimental group74. In the value: 80, 80, 80, 82, 82, 90, 90, 100; what 80. The researcher implemented a medication is the mode? regimen using a new type of combination drugs A. 80 to manic patients while another group of manic B. 82 patient receives the routine drugs. The C. 90 researcher however handpicked the D. 85.5 experimental group for they are the clients with75. In the value: 80, 80, 10, 10, 25, 65, 100, 200; multiple episodes of bipolar disorder. The what is the median? researcher utilized which research design? A. 71.25 A. Quasi-experimental B. 22.5 B. Phenomenological C. 10 and 25 C. Pure experimental D. 72.5 D. Longitudinal76. Draw Lots, Lottery, Table of random numbers or Situation 19: As a nurse, you are expected to participate a sampling that ensures that each element of the in initiating or participating in the conduct of research population has an equal and independent studies to improve nursing practice. You to be updated chance of being chosen is called: on the latest trends and issues affected the profession A. Cluster and the best practices arrived at by the profession. B. Stratified C. Simple 81. You are interested to study the effects of D. Systematic mediation and relaxation on the pain experienced by cancer patients. What type of77. An investigator wants to determine some of the variable is pain? problems that are experienced by diabetic A. Dependent clients when using an insulin pump. The B. Independent investigator went into a clinic where he C. Correlational personally knows several diabetic clients having D. Demographic problem with insulin pump. The type of sampling done by the investigator is called: 82. You would like to compare the support system A. Probability of patient with chronic illness to those with B. Snowball acute illness. How will you best state your C. Purposive problem? D. Incidental A. A descriptive study to compare the support system of patients with chronic78. If the researcher implemented a new structured illness and those with acute illness in counselling program with a randomized group of terms of demographic data and subject and a routine counselling program with knowledge about intervention. another randomized group of subject, the B. The effects of the types of support research is utilizing which design? system of patients with chronic illness A. Quasi experimental and those with acute illness. B. Comparative C. A comparative analysis of the support C. Experimental system of patients with chronic illness D. Methodological and those with acute illness. D. A study to compare the support system79. Which of the following is not true about a Pure of patients with chronic illness and those Experimental research? with acute illness.
  • 54. E. What are the differences of the support 87. Which of the following studies is based on system being received by patient with quantitative research? chronic illness and patients with acute A. A study examining the bereavement illness? process in spouse of clients with terminal cancer 83. You would like to compare the support system B. A study exploring the factors influencing of patients with chronic illness to those with weight control behaviour acute illness. Considering that the hypothesis C. A Study measuring the effects of sleep was: “Client’s with chronic illness have lesser deprivation on wound healing support system than client’s with acute illness.” D. A study examining client’s feelings What type of research is this? before, during and after bone marrow A. Descriptive aspiration. B. Correlational, Non experimental C. Experimental 88. Which of the following studies is based on the D. Quasi Experimental qualitative research? A. A study examining clients’ reaction to 84. In any research study where individual persons stress after open heart surgery are involved, it is important that an informed B. A study measuring nutrition and weight consent of the study is obtained. The following loss/gain in clients with cancer are essential information about the consent that C. A study examining oxygen levels after you should disclose to the prospective subjects endotracheal suctioning except: D. A study measuring differences in blood A. Consent to incomplete disclosure pressure before, during and after B. Description of benefits, risks and procedure discomforts C. Explanation of procedure 89. An 85 year old client in a nursing home tells a D. Assurance of anonymity and nurse, “I signed the papers of that research confidentiality study because the doctor was so insistent and I want him to continue taking care for me” Which 85. In the Hypothesis: “The utilization of technology client right is being violated? in teaching improves the retention and attention A. Right of self determination of the nursing students.” Which is the B. Right to full disclosure dependent variable? C. Right to privacy and confidentiality A. Utilization of technology D. Right not to be harmed B. Improvement in the retention and attention 90. A supposition or system of ideas that is C. Nursing students proposed to explain a given phenomenon best D. Teaching defines: A. A paradigmSituation: You are actively practicing nurse who has just B. A theoryfinished you graduate studies. You learned the value of C. A Conceptresearch and would like to utilize the knowledge and D. A conceptual frameworkskills gained in the application of research to the nursing Situation: Mastery of research design determination isservice. The following questions apply to research. essential in passing the NLE. 86. Which type of research inquiry investigates the 91. Ana wants to know if the length of time she will issues of human complexity (e.g understanding study for the board examination is proportional the human expertise)? to her board rating. During the June 2008 board A. Logical position examination, she studied for 6 months and B. Positivism gained 68%, On the next board exam, she C. Naturalistic inquiry studied for 6 months again for a total of 1 year D. Quantitative research and gained 74%, On the third board exam, She studied for 6 months for a total of 1 and a half54
  • 55. 55 year and gained 82%. The research design she collected 100 random individuals and determine used is: who is their favourite comedian actor. 50% said A. Comparative Dolphy, 20% said Vic Sotto, while some B. Experimental answered Joey de Leon, Allan K, Michael V. C. Correlational Tonyo conducted what type of research study? D. Qualitative A. Phenomenological B. Non experimental92. Anton was always eating high fat diet. You want C. Case Study to determine if what will be the effect of high D. Survey cholesterol food to Anton in the next 10 years. You will use: 98. Jane visited a tribe located somewhere in China, A. Comparative it is called the Shin Jea tribe. She studied the way B. Historical of life, tradition and the societal structure of C. Correlational these people. Jane will best use which research D. Longitudinal design? A. Historical93. Community A was selected randomly as well as B. Phenomenological community B, nurse Edna conducted teaching to C. Case Study community A and assess if community A will D. Ethnographic have a better status than community B. This is an example of: 99. Anjoe researched on TB. Its transmission, A. Comparative Causative agent and factors, treatment sign and B. Experimental symptoms as well as medication and all other in C. Correlational depth information about tuberculosis. This study D. Qualitative is best suited for which research design? A. Historical94. Ana researched on the development of a new B. Phenomenological way to measure intelligence by creating a 100 C. Case Study item questionnaire that will assess the cognitive D. Ethnographic skills of an individual. The design best suited for this study is: 100. Diana is to conduct a study about the A. Historical relationship of the number of family members in B. Survey the household and the electricity bill. Which of C. Methodological the following is the best research design suited D. Case study for this study? 1. Descriptive95. Gen is conducting a research study on how mark, 2. Exploratory an AIDS client lives his life. A design suited for 3. Explanatory this is: 4. Correlational A. Historical 5. Comparative B. Phenomenological 6. Experimental C. Case Study A. 1,4 D. Ethnographic B. 2,5 C. 3,696. Marco is to perform a study about how nurses D. 1,5 perform surgical asepsis during World War II. A E. 2,4 design best for this study is: A. Historical B. Phenomenological C. Case Study D. Ethnographic97. Tonyo conducts sampling at barangay 412. He
  • 56. TEST I - Foundation of Professional Nursing 5. Nurse Betty is assigned to the following clients.Practice The client that the nurse would see first after endorsement? 1. The nurse In-charge in labor and delivery unit a. A 34 year-old post-operative administered a dose of terbutaline to a client appendectomy client of five hours who without checking the client’s pulse. The standard is complaining of pain. that would be used to determine if the nurse b. A 44 year-old myocardial infarction (MI) was negligent is: client who is complaining of nausea. a. The physician’s orders. c. A 26 year-old client admitted for b. The action of a clinical nurse specialist dehydration whose intravenous (IV) has who is recognized expert in the field. infiltrated. c. The statement in the drug literature d. A 63 year-old post operative’s about administration of terbutaline. abdominal hysterectomy client of three d. The actions of a reasonably prudent days whose incisional dressing is nurse with similar education and saturated with serosanguinous fluid. experience. 6. Nurse Gail places a client in a four-point restraint 2. Nurse Trish is caring for a female client with a following orders from the physician. The client history of GI bleeding, sickle cell disease, and a care plan should include: platelet count of 22,000/μl. The female client is a. Assess temperature frequently. dehydrated and receiving dextrose 5% in half- b. Provide diversional activities. normal saline solution at 150 ml/hr. The client c. Check circulation every 15-30 minutes. complains of severe bone pain and is scheduled d. Socialize with other patients once a shift. to receive a dose of morphine sulfate. In administering the medication, Nurse Trish 7. A male client who has severe burns is receiving should avoid which route? H2 receptor antagonist therapy. The nurse In- a. I.V charge knows the purpose of this therapy is to: b. I.M a. Prevent stress ulcer c. Oral b. Block prostaglandin synthesis d. S.C c. Facilitate protein synthesis. d. Enhance gas exchange 3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin 8. The doctor orders hourly urine output .125 mg P.O. once daily.” To prevent a dosage measurement for a postoperative male client. error, how should the nurse document this order The nurse Trish records the following amounts of onto the medication administration record? output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a. “Digoxin .1250 mg P.O. once daily” a.m.: 60 ml. Based on these amounts, which b. “Digoxin 0.1250 mg P.O. once daily” action should the nurse take? c. “Digoxin 0.125 mg P.O. once daily” a. Increase the I.V. fluid infusion rate d. “Digoxin .125 mg P.O. once daily” b. Irrigate the indwelling urinary catheter c. Notify the physician 4. A newly admitted female client was diagnosed d. Continue to monitor and record hourly with deep vein thrombosis. Which nursing urine output diagnosis should receive the highest priority? a. Ineffective peripheral tissue perfusion 9. Tony, a basketball player twist his right ankle related to venous congestion. while playing on the court and seeks care for b. Risk for injury related to edema. ankle pain and swelling. After the nurse applies c. Excess fluid volume related to peripheral ice to the ankle for 30 minutes, which statement vascular disease. by Tony suggests that ice application has been d. Impaired gas exchange related to effective? increased blood flow. a. “My ankle looks less swollen now”. b. “My ankle feels warm”. c. “My ankle appears redder now”.56
  • 57. 57 d. “I need something stronger for pain d. Pulling the lobule down and forward relief” 16. Which instruction should nurse Tom give to a10. The physician prescribes a loop diuretic for a male client who is having external radiation client. When administering this drug, the nurse therapy: anticipates that the client may develop which a. Protect the irritated skin from sunlight. electrolyte imbalance? b. Eat 3 to 4 hours before treatment. a. Hypernatremia c. Wash the skin over regularly. b. Hyperkalemia d. Apply lotion or oil to the radiated area c. Hypokalemia when it is red or sore. d. Hypervolemia 17. In assisting a female client for immediate11. She finds out that some managers have surgery, the nurse In-charge is aware that she benevolent-authoritative style of management. should: Which of the following behaviors will she exhibit a. Encourage the client to void following most likely? preoperative medication. a. Have condescending trust and b. Explore the client’s fears and anxieties confidence in their subordinates. about the surgery. b. Gives economic and ego awards. c. Assist the client in removing dentures c. Communicates downward to staffs. and nail polish. d. Allows decision making among d. Encourage the client to drink water prior subordinates. to surgery.12. Nurse Amy is aware that the following is true 18. A male client is admitted and diagnosed with about functional nursing acute pancreatitis after a holiday celebration of a. Provides continuous, coordinated and excessive food and alcohol. Which assessment comprehensive nursing services. finding reflects this diagnosis? b. One-to-one nurse patient ratio. a. Blood pressure above normal range. c. Emphasize the use of group b. Presence of crackles in both lung fields. collaboration. c. Hyperactive bowel sounds d. Concentrates on tasks and activities. d. Sudden onset of continuous epigastric and back pain.13. Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?" 19. Which dietary guidelines are important for nurse a. Single order Oliver to implement in caring for the client with b. Standard written order burns? c. Standing order a. Provide high-fiber, high-fat diet d. Stat order b. Provide high-protein, high-carbohydrate diet.14. A female client with a fecal impaction frequently c. Monitor intake to prevent weight gain. exhibits which clinical manifestation? d. Provide ice chips or water intake. a. Increased appetite b. Loss of urge to defecate 20. Nurse Hazel will administer a unit of whole c. Hard, brown, formed stools blood, which priority information should the d. Liquid or semi-liquid stools nurse have about the client? a. Blood pressure and pulse rate.15. Nurse Linda prepares to perform an otoscopic b. Height and weight. examination on a female client. For proper c. Calcium and potassium levels visualization, the nurse should position the d. Hgb and Hct levels. clients ear by: 21. Nurse Michelle witnesses a female client sustain a. Pulling the lobule down and back a fall and suspects that the leg may be broken. b. Pulling the helix up and forward The nurse takes which priority action? c. Pulling the helix up and back a. Takes a set of vital signs.
  • 58. b. Call the radiology department for X-ray. c. 1.5 cc c. Reassure the client that everything will d. 2.5 cc be alright. d. Immobilize the leg before moving the 27. A child of 10 years old is to receive 400 cc of IV client. fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is: 22. A male client is being transferred to the nursing a. 50 cc/ hour unit for admission after receiving a radium b. 55 cc/ hour implant for bladder cancer. The nurse in-charge c. 24 cc/ hour would take which priority action in the care of d. 66 cc/ hour this client? a. Place client on reverse isolation. 28. The nurse is aware that the most important b. Admit the client into a private room. nursing action when a client returns from c. Encourage the client to take frequent surgery is: rest periods. a. Assess the IV for type of fluid and rate of d. Encourage family and friends to visit. flow. b. Assess the client for presence of pain. 23. A newly admitted female client was diagnosed c. Assess the Foley catheter for patency with agranulocytosis. The nurse formulates and urine output which priority nursing diagnosis? d. Assess the dressing for drainage. a. Constipation b. Diarrhea 29. Which of the following vital sign assessments c. Risk for infection that may indicate cardiogenic shock after d. Deficient knowledge myocardial infarction? a. BP – 80/60, Pulse – 110 irregular 24. A male client is receiving total parenteral b. BP – 90/50, Pulse – 50 regular nutrition suddenly demonstrates signs and c. BP – 130/80, Pulse – 100 regular symptoms of an air embolism. What is the d. BP – 180/100, Pulse – 90 irregular priority action by the nurse? a. Notify the physician. 30. Which is the most appropriate nursing action in b. Place the client on the left side in the obtaining a blood pressure measurement? Trendelenburg position. a. Take the proper equipment, place the c. Place the client in high-Fowlers position. client in a comfortable position, and d. Stop the total parenteral nutrition. record the appropriate information in the client’s chart. 25. Nurse May attends an educational conference b. Measure the client’s arm, if you are not on leadership styles. The nurse is sitting with a sure of the size of cuff to use. nurse employed at a large trauma center who c. Have the client recline or sit comfortably states that the leadership style at the trauma in a chair with the forearm at the level of center is task-oriented and directive. The nurse the heart. determines that the leadership style used at the d. Document the measurement, which trauma center is: extremity was used, and the position a. Autocratic. that the client was in during the b. Laissez-faire. measurement. c. Democratic. d. Situational 31. Asking the questions to determine if the person 26. The physician orders DS 500 cc with KCl 10 understands the health teaching provided by the mEq/liter at 30 cc/hr. The nurse in-charge is nurse would be included during which step of going to hang a 500 cc bag. KCl is supplied 20 the nursing process? mEq/10 cc. How many cc’s of KCl will be added to the IV solution? a. Assessment a. .5 cc b. Evaluation b. 5 cc c. Implementation58
  • 59. 59 d. Planning and goals “Meperidine, 100 mg/ml.” How many milliliters of meperidine should the client receive?32. Which of the following item is considered the a. 0.75 single most important factor in assisting the b. 0.6 health professional in arriving at a diagnosis or c. 0.5 determining the person’s needs? d. 0.25 a. Diagnostic test results b. Biographical date 38. A male client with diabetes mellitus is receiving c. History of present illness insulin. Which statement correctly describes an d. Physical examination insulin unit? a. It’s a common measurement in the33. In preventing the development of an external metric system. rotation deformity of the hip in a client who b. It’s the basis for solids in the avoirdupois must remain in bed for any period of time, the system. most appropriate nursing action would be to c. It’s the smallest measurement in the use: apothecary system. a. Trochanter roll extending from the crest d. It’s a measure of effect, not a standard of the ileum to the mid-thigh. measure of weight or quantity. b. Pillows under the lower legs. c. Footboard 39. Nurse Oliver measures a client’s temperature at d. Hip-abductor pillow 102° F. What is the equivalent Centigrade temperature?34. Which stage of pressure ulcer development does a. 40.1 °C the ulcer extend into the subcutaneous tissue? b. 38.9 °C a. Stage I c. 48 °C b. Stage II d. 38 °C c. Stage III 40. The nurse is assessing a 48-year-old client who d. Stage IV has come to the physician’s office for his annual physical exam. One of the first physical signs of35. When the method of wound healing is one in aging is: which wound edges are not surgically a. Accepting limitations while developing approximated and integumentary continuity is assets. restored by granulations, the wound healing is b. Increasing loss of muscle tone. termed c. Failing eyesight, especially close vision. a. Second intention healing d. Having more frequent aches and pains. b. Primary intention healing c. Third intention healing 41. The physician inserts a chest tube into a female d. First intention healing client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-36. An 80-year-old male client is admitted to the charge can prevent chest tube air leaks by: hospital with a diagnosis of pneumonia. Nurse a. Checking and taping all connections. Oliver learns that the client lives alone and b. Checking patency of the chest tube. hasn’t been eating or drinking. When assessing c. Keeping the head of the bed slightly him for dehydration, nurse Oliver would expect elevated. to find: d. Keeping the chest drainage system a. Hypothermia below the level of the chest. b. Hypertension c. Distended neck veins 42. Nurse Trish must verify the client’s identity d. Tachycardia before administering medication. She is aware that the safest way to verify identity is to:37. The physician prescribes meperidine (Demerol), a. Check the client’s identification band. 75 mg I.M. every 4 hours as needed, to control a b. Ask the client to state his name. client’s postoperative pain. The package insert is
  • 60. c. State the client’s name out loud and c. Every 2 years wait a client to repeat it. d. Once, to establish baseline d. Check the room number and the client’s name on the bed. 49. A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 43. The physician orders dextrose 5 % in water, mmHg; and HCO3 26mEq/L. Based on these 1,000 ml to be infused over 8 hours. The I.V. values, Nurse Patricia should expect which tubing delivers 15 drops/ml. Nurse John should condition? run the I.V. infusion at a rate of: a. Respiratory acidosis a. 30 drops/minute b. Respiratory alkalosis b. 32 drops/minute c. Metabolic acidosis c. 20 drops/minute d. Metabolic alkalosis d. 18 drops/minute 50. Nurse Len refers a female client with terminal 44. If a central venous catheter becomes cancer to a local hospice. What is the goal of this disconnected accidentally, what should the referral? nurse in-charge do immediately? a. To help the client find appropriate a. Clamp the catheter treatment options. b. Call another nurse b. To provide support for the client and c. Call the physician family in coping with terminal illness. d. Apply a dry sterile dressing to the site. c. To ensure that the client gets counseling regarding health care costs. 45. A female client was recently admitted. She has d. To teach the client and family about fever, weight loss, and watery diarrhea is being cancer and its treatment. admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen 51. When caring for a male client with a 3-cm stage I and notice that it is slightly concave. Additional pressure ulcer on the coccyx, which of the assessment should proceed in which order: following actions can the nurse institute a. Palpation, auscultation, and percussion. independently? b. Percussion, palpation, and auscultation. a. Massaging the area with an astringent c. Palpation, percussion, and auscultation. every 2 hours. d. Auscultation, percussion, and palpation. b. Applying an antibiotic cream to the area three times per day. 46. Nurse Betty is assessing tactile fremitus in a c. Using normal saline solution to clean the client with pneumonia. For this examination, ulcer and applying a protective dressing nurse Betty should use the: as necessary. a. Fingertips d. Using a povidone-iodine wash on the b. Finger pads ulceration three times per day. c. Dorsal surface of the hand 52. Nurse Oliver must apply an elastic bandage to a d. Ulnar surface of the hand client’s ankle and calf. He should apply the bandage beginning at the client’s: 47. Which type of evaluation occurs continuously a. Knee throughout the teaching and learning process? b. Ankle a. Summative c. Lower thigh b. Informative d. Foot c. Formative d. Retrospective 53. A 10 year old child with type 1 diabetes develops 48. A 45 year old client, has no family history of diabetic ketoacidosis and receives a continuous breast cancer or other risk factors for this insulin infusion. Which condition represents the disease. Nurse John should instruct her to have greatest risk to this child? mammogram how often? a. Hypernatremia a. Twice per year b. Hypokalemia b. Once per year c. Hyperphosphatemia60
  • 61. 61 d. Hypercalcemia d. Obtaining the specimen from the urinary drainage bag.54. Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client. 59. Nurse Meredith is in the process of giving a Immediately afterward, the client may client a bed bath. In the middle of the experience: procedure, the unit secretary calls the nurse on a. Throbbing headache or dizziness the intercom to tell the nurse that there is an b. Nervousness or paresthesia. emergency phone call. The appropriate nursing c. Drowsiness or blurred vision. action is to: d. Tinnitus or diplopia. a. Immediately walk out of the client’s room and answer the phone call. b. Cover the client, place the call light55. Nurse Michelle hears the alarm sound on the within reach, and answer the phone call. telemetry monitor. The nurse quickly looks at c. Finish the bed bath before answering the monitor and notes that a client is in a the phone call. ventricular tachycardia. The nurse rushes to the d. Leave the client’s door open so the client client’s room. Upon reaching the client’s can be monitored and the nurse can bedside, the nurse would take which action answer the phone call. first? a. Prepare for cardioversion 60. Nurse Janah is collecting a sputum specimen for b. Prepare to defibrillate the client culture and sensitivity testing from a client who c. Call a code has a productive cough. Nurse Janah plans to d. Check the client’s level of consciousness implement which intervention to obtain the specimen?56. Nurse Hazel is preparing to ambulate a female a. Ask the client to expectorate a small client. The best and the safest position for the amount of sputum into the emesis basin. nurse in assisting the client is to stand: b. Ask the client to obtain the specimen a. On the unaffected side of the client. after breakfast. b. On the affected side of the client. c. Use a sterile plastic container for c. In front of the client. obtaining the specimen. d. Behind the client. d. Provide tissues for expectoration and obtaining the specimen.57. Nurse Janah is monitoring the ongoing care given to the potential organ donor who has been 61. Nurse Ron is observing a male client using a diagnosed with brain death. The nurse walker. The nurse determines that the client is determines that the standard of care had been using the walker correctly if the client: maintained if which of the following data is a. Puts all the four points of the walker flat observed? on the floor, puts weight on the hand a. Urine output: 45 ml/hr pieces, and then walks into it. b. Capillary refill: 5 seconds b. Puts weight on the hand pieces, moves c. Serum pH: 7.32 the walker forward, and then walks into d. Blood pressure: 90/48 mmHg it. c. Puts weight on the hand pieces, slides58. Nurse Amy has an order to obtain a urinalysis the walker forward, and then walks into from a male client with an indwelling urinary it. catheter. The nurse avoids which of the d. Walks into the walker, puts weight on following, which contaminate the specimen? the hand pieces, and then puts all four a. Wiping the port with an alcohol swab points of the walker flat on the floor. before inserting the syringe. b. Aspirating a sample from the port on the 62. Nurse Amy has documented an entry regarding drainage bag. client care in the client’s medical record. When c. Clamping the tubing of the drainage bag. checking the entry, the nurse realizes that
  • 62. incorrect information was documented. How a. Prone with head turned toward the side does the nurse correct this error? supported by a pillow. a. Erases the error and writes in the correct b. Sims’ position with the head of the bed information. flat. b. Uses correction fluid to cover up the c. Right side-lying with the head of the bed incorrect information and writes in the elevated 45 degrees. correct information. d. Left side-lying with the head of the bed c. Draws one line to cross out the incorrect elevated 45 degrees. information and then initials the change. d. Covers up the incorrect information 67. Nurse John develops methods for data completely using a black pen and writes gathering. Which of the following criteria of a in the correct information good instrument refers to the ability of the instrument to yield the same results upon its 63. Nurse Ron is assisting with transferring a client repeated administration? from the operating room table to a stretcher. To a. Validity provide safety to the client, the nurse should: b. Specificity a. Moves the client rapidly from the table c. Sensitivity to the stretcher. d. Reliability b. Uncovers the client completely before transferring to the stretcher. 68. Harry knows that he has to protect the rights of c. Secures the client safety belts after human research subjects. Which of the following transferring to the stretcher. actions of Harry ensures anonymity? d. Instructs the client to move self from the a. Keep the identities of the subject secret table to the stretcher. b. Obtain informed consent c. Provide equal treatment to all the 64. Nurse Myrna is providing instructions to a subjects of the study. nursing assistant assigned to give a bed bath to a d. Release findings only to the participants client who is on contact precautions. Nurse of the study Myrna instructs the nursing assistant to use which of the following protective items when 69. Patient’s refusal to divulge information is a giving bed bath? limitation because it is beyond the control of a. Gown and goggles Tifanny”. What type of research is appropriate b. Gown and gloves for this study? c. Gloves and shoe protectors a. Descriptive- correlational d. Gloves and goggles b. Experiment c. Quasi-experiment 65. Nurse Oliver is caring for a client with impaired d. Historical mobility that occurred as a result of a stroke. The client has right sided arm and leg weakness. The 70. Nurse Ronald is aware that the best tool for data nurse would suggest that the client use which of gathering is? the following assistive devices that would a. Interview schedule provide the best stability for ambulating? b. Questionnaire a. Crutches c. Use of laboratory data b. Single straight-legged cane d. Observation c. Quad cane d. Walker 71. Monica is aware that there are times when only manipulation of study variables is possible and 66. A male client with a right pleural effusion noted the elements of control or randomization are on a chest X-ray is being prepared for not attendant. Which type of research is thoracentesis. The client experiences severe referred to this? dizziness when sitting upright. To provide a safe a. Field study environment, the nurse assists the client to b. Quasi-experiment which position for the procedure? c. Solomon-Four group design62
  • 63. 63 d. Post-test only design d. Will remain unable to practice professional nursing72. Cherry notes down ideas that were derived from the description of an investigation written by the 77. Ronald plans to conduct a research on the use of person who conducted it. Which type of a new method of pain assessment scale. Which reference source refers to this? of the following is the second step in the a. Footnote conceptualizing phase of the research process? b. Bibliography a. Formulating the research hypothesis c. Primary source b. Review related literature d. Endnotes c. Formulating and delimiting the research problem73. When Nurse Trish is providing care to his d. Design the theoretical and conceptual patient, she must remember that her duty is framework bound not to do doing any action that will cause the patient harm. This is the meaning of the 78. The leader of the study knows that certain bioethical principle: patients who are in a specialized research setting a. Non-maleficence tend to respond psychologically to the b. Beneficence conditions of the study. This referred to as : c. Justice a. Cause and effect d. Solidarity b. Hawthorne effect c. Halo effect74. When a nurse in-charge causes an injury to a d. Horns effect female patient and the injury caused becomes the proof of the negligent act, the presence of 79. Mary finally decides to use judgment sampling the injury is said to exemplify the principle of: on her research. Which of the following actions a. Force majeure of is correct? b. Respondeat superior a. Plans to include whoever is there during c. Res ipsa loquitor his study. d. Holdover doctrine b. Determines the different nationality of patients frequently admitted and75. Nurse Myrna is aware that the Board of Nursing decides to get representations samples has quasi-judicial power. An example of this from each. power is: c. Assigns numbers for each of the a. The Board can issue rules and patients, place these in a fishbowl and regulations that will govern the practice draw 10 from it. of nursing d. Decides to get 20 samples from the b. The Board can investigate violations of admitted patients the nursing law and code of ethics c. The Board can visit a school applying for 80. The nursing theorist who developed a permit in collaboration with CHED transcultural nursing theory is: d. The Board prepares the board a. Florence Nightingale examinations b. Madeleine Leininger c. Albert Moore76. When the license of nurse Krina is revoked, it d. Sr. Callista Roy means that she: a. Is no longer allowed to practice the 81. Marion is aware that the sampling method that profession for the rest of her life gives equal chance to all units in the population b. Will never have her/his license re-issued to get picked is: since it has been revoked a. Random c. May apply for re-issuance of his/her b. Accidental license based on certain conditions c. Quota stipulated in RA 9173 d. Judgment
  • 64. 82. John plans to use a Likert Scale to his study to determine the: 89. Nurse Marian is preparing to administer a blood a. Degree of agreement and disagreement transfusion. Which action should the nurse take b. Compliance to expected standards first? c. Level of satisfaction a. Arrange for typing and cross matching of d. Degree of acceptance the client’s blood. b. Compare the client’s identification 83. Which of the following theory addresses the four wristband with the tag on the unit of modes of adaptation? blood. a. Madeleine Leininger c. Start an I.V. infusion of normal saline b. Sr. Callista Roy solution. c. Florence Nightingale d. Measure the client’s vital signs. d. Jean Watson 90. A 65 years old male client requests his 84. Ms. Garcia is responsible to the number of medication at 9 p.m. instead of 10 p.m. so that personnel reporting to her. This principle refers he can go to sleep earlier. Which type of nursing to: intervention is required? a. Span of control a. Independent b. Unity of command b. Dependent c. Downward communication c. Interdependent d. Leader d. Intradependent 85. Ensuring that there is an informed consent on 91. A female client is to be discharged from an acute the part of the patient before a surgery is done, care facility after treatment for right leg illustrates the bioethical principle of: thrombophlebitis. The Nurse Betty notes that a. Beneficence the clients leg is pain-free, without redness or b. Autonomy edema. The nurses actions reflect which step of c. Veracity the nursing process? d. Non-maleficence a. Assessment b. Diagnosis 86. Nurse Reese is teaching a female client with c. Implementation peripheral vascular disease about foot care; d. Evaluation Nurse Reese should include which instruction? a. Avoid wearing cotton socks. 92. Nursing care for a female client includes b. Avoid using a nail clipper to cut toenails. removing elastic stockings once per day. The c. Avoid wearing canvas shoes. Nurse Betty is aware that the rationale for this d. Avoid using cornstarch on feet. intervention? a. To increase blood flow to the heart 87. A client is admitted with multiple pressure b. To observe the lower extremities ulcers. When developing the clients diet plan, c. To allow the leg muscles to stretch and the nurse should include: relax a. Fresh orange slices d. To permit veins in the legs to fill with b. Steamed broccoli blood. c. Ice cream d. Ground beef patties 93. Which nursing intervention takes highest priority when caring for a newly admitted client whos 88. The nurse prepares to administer a cleansing receiving a blood transfusion? enema. What is the most common client a. Instructing the client to report any position used for this procedure? itching, swelling, or dyspnea. a. Lithotomy b. Informing the client that the transfusion b. Supine usually take 1 ½ to 2 hours. c. Prone c. Documenting blood administration in d. Sims’ left lateral the client care record.64
  • 65. 65 d. Assessing the client’s vital signs when d. 30 minutes after administering the next the transfusion ends. dose.94. A male client complains of abdominal discomfort 99. Nurse May is aware that the main advantage of and nausea while receiving tube feedings. Which using a floor stock system is: intervention is most appropriate for this a. The nurse can implement medication problem? orders quickly. a. Give the feedings at room temperature. b. The nurse receives input from the b. Decrease the rate of feedings and the pharmacist. concentration of the formula. c. The system minimizes transcription c. Place the client in semi-Fowlers position errors. while feeding. d. The system reinforces accurate d. Change the feeding container every 12 calculations. hours. 100. Nurse Oliver is assessing a clients abdomen.95. Nurse Patricia is reconstituting a powdered Which finding should the nurse report as medication in a vial. After adding the solution to abnormal? the powder, she nurse should: a. Dullness over the liver. a. Do nothing. b. Bowel sounds occurring every 10 b. Invert the vial and let it stand for 3 to 5 seconds. minutes. c. Shifting dullness over the abdomen. c. Shake the vial vigorously. d. Vascular sounds heard over the renal d. Roll the vial gently between the palms. arteries.96. Which intervention should the nurse Trish use when administering oxygen by face mask to a female client? a. Secure the elastic band tightly around the clients head. b. Assist the client to the semi-Fowler position if possible. c. Apply the face mask from the clients chin up over the nose. d. Loosen the connectors between the oxygen equipment and humidifier.97. The maximum transfusion time for a unit of packed red blood cells (RBCs) is: a. 6 hours b. 4 hours c. 3 hours d. 2 hours98. Nurse Monique is monitoring the effectiveness of a clients drug therapy. When should the nurse Monique obtain a blood sample to measure the trough drug level? a. 1 hour before administering the next dose. b. Immediately before administering the next dose. c. Immediately after administering the next dose.
  • 66. Rationale: Curling’s ulcer occurs as a generalized stress response in burn patients.Answers and Rationale – Foundation of This results in a decreased production ofProfessional Nursing Practice mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers. 1. Answer: (D) The actions of a reasonably 8. Answer: (D) Continue to monitor and record prudent nurse with similar education and hourly urine output experience. Rationale: Normal urine output for an adult is Rationale: The standard of care is determined approximately 1 ml/minute (60 ml/hour). by the average degree of skill, care, and Therefore, this clients output is normal. diligence by nurses in similar circumstances. Beyond continued evaluation, no nursing 2. Answer: (B) I.M action is warranted. Rationale: With a platelet count of 22,000/μl, 9. Answer: (B) “My ankle feels warm”. the clients tends to bleed easily. Therefore, Rationale: Ice application decreases pain and the nurse should avoid using the I.M. route swelling. Continued or increased pain, redness, because the area is a highly vascular and can and increased warmth are signs of bleed readily when penetrated by a needle. inflammation that shouldnt occur after ice The bleeding can be difficult to stop. application 3. Answer: (C) “Digoxin 0.125 mg P.O. once daily” 10. Answer: (B) Hyperkalemia Rationale: The nurse should always place a Rationale: A loop diuretic removes water and, zero before a decimal point so that no one along with it, sodium and potassium. This may misreads the figure, which could result in a result in hypokalemia, hypovolemia, and dosage error. The nurse should never insert a hyponatremia. zero at the end of a dosage that includes a 11. Answer:(A) Have condescending trust and decimal point because this could be misread, confidence in their subordinates possibly leading to a tenfold increase in the Rationale: Benevolent-authoritative managers dosage. pretentiously show their trust and confidence 4. Answer: (A) Ineffective peripheral tissue to their followers. perfusion related to venous congestion. 12. Answer: (A) Provides continuous, coordinated Rationale: Ineffective peripheral tissue and comprehensive nursing services. perfusion related to venous congestion takes Rationale: Functional nursing is focused on the highest priority because venous tasks and activities and not on the care of the inflammation and clot formation impede blood patients. flow in a client with deep vein thrombosis. 13. Answer: (B) Standard written order 5. Answer: (B) A 44 year-old myocardial Rationale: This is a standard written order. infarction (MI) client who is complaining of Prescribers write a single order for nausea. medications given only once. A stat order is Rationale: Nausea is a symptom of impending written for medications given immediately for myocardial infarction (MI) and should be an urgent client problem. A standing order, assessed immediately so that treatment can also known as a protocol, establishes be instituted and further damage to the heart guidelines for treating a particular disease or is avoided. set of symptoms in special care areas such as 6. Answer: (C) Check circulation every 15-30 the coronary care unit. Facilities also may minutes. institute medication protocols that specifically Rationale: Restraints encircle the limbs, which designate drugs that a nurse may not give. place the client at risk for circulation being 14. Answer: (D) Liquid or semi-liquid stools restricted to the distal areas of the Rationale: Passage of liquid or semi-liquid extremities. Checking the client’s circulation stools results from seepage of unformed every 15-30 minutes will allow the nurse to bowel contents around the impacted stool in adjust the restraints before injury from the rectum. Clients with fecal impaction dont decreased blood flow occurs. pass hard, brown, formed stools because the 7. Answer: (A) Prevent stress ulcer feces cant move past the impaction. These66
  • 67. 67 clients typically report the urge to defecate Rationale: The client who has a radiation (although they cant pass stool) and a implant is placed in a private room and has a decreased appetite. limited number of visitors. This reduces the15. Answer: (C) Pulling the helix up and back exposure of others to the radiation. Rationale: To perform an otoscopic 23. Answer: (C) Risk for infection examination on an adult, the nurse grasps the Rationale: Agranulocytosis is characterized by helix of the ear and pulls it up and back to a reduced number of leukocytes (leucopenia) straighten the ear canal. For a child, the nurse and neutrophils (neutropenia) in the blood. grasps the helix and pulls it down to straighten The client is at high risk for infection because the ear canal. Pulling the lobule in any of the decreased body defenses against direction wouldnt straighten the ear canal for microorganisms. Deficient knowledge related visualization. to the nature of the disorder may be16. Answer: (A) Protect the irritated skin from appropriate diagnosis but is not the priority. sunlight. 24. Answer: (B) Place the client on the left side in Rationale: Irradiated skin is very sensitive and the Trendelenburg position. must be protected with clothing or sunblock. Rationale: Lying on the left side may prevent The priority approach is the avoidance of air from flowing into the pulmonary veins. The strong sunlight. Trendelenburg position increases intrathoracic17. Answer: (C) Assist the client in removing pressure, which decreases the amount of dentures and nail polish. blood pulled into the vena cava during Rationale: Dentures, hairpins, and combs must aspiration. be removed. Nail polish must be removed so 25. Answer: (A) Autocratic. that cyanosis can be easily monitored by Rationale: The autocratic style of leadership is observing the nail beds. a task-oriented and directive.18. Answer: (D) Sudden onset of continuous 26. Answer: (D) 2.5 cc epigastric and back pain. Rationale: 2.5 cc is to be added, because only a Rationale: The autodigestion of tissue by the 500 cc bag of solution is being medicated pancreatic enzymes results in pain from instead of a 1 liter. inflammation, edema, and possible 27. Answer: (A) 50 cc/ hour hemorrhage. Continuous, unrelieved epigastric Rationale: A rate of 50 cc/hr. The child is to or back pain reflects the inflammatory process receive 400 cc over a period of 8 hours = 50 in the pancreas. cc/hr.19. Answer: (B) Provide high-protein, high- 28. Answer: (B) Assess the client for presence of carbohydrate diet. pain. Rationale: A positive nitrogen balance is Rationale: Assessing the client for pain is a important for meeting metabolic needs, tissue very important measure. Postoperative pain is repair, and resistance to infection. Caloric an indication of complication. The nurse goals may be as high as 5000 calories per day. should also assess the client for pain to20. Answer: (A) Blood pressure and pulse rate. provide for the client’s comfort. Rationale: The baseline must be established to 29. Answer: (A) BP – 80/60, Pulse – 110 irregular recognize the signs of an anaphylactic or Rationale: The classic signs of cardiogenic hemolytic reaction to the transfusion. shock are low blood pressure, rapid and weak21. Answer: (D) Immobilize the leg before moving irregular pulse, cold, clammy skin, decreased the client. urinary output, and cerebral hypoxia. Rationale: If the nurse suspects a fracture, 30. Answer: (A) Take the proper equipment, place splinting the area before moving the client is the client in a comfortable position, and imperative. The nurse should call for record the appropriate information in the emergency help if the client is not hospitalized client’s chart. and call for a physician for the hospitalized Rationale: It is a general or comprehensive client. statement about the correct procedure, and it22. Answer: (B) Admit the client into a private includes the basic ideas which are found in the room. other options 31. Answer: (B) Evaluation
  • 68. Rationale: Evaluation includes observing the Rationale: Failing eyesight, especially close person, asking questions, and comparing the vision, is one of the first signs of aging in patient’s behavioral responses with the middle life (ages 46 to 64). More frequent expected outcomes. aches and pains begin in the early late years 32. Answer: (C) History of present illness (ages 65 to 79). Increase in loss of muscle tone Rationale: The history of present illness is the occurs in later years (age 80 and older). single most important factor in assisting the 41. Answer: (A) Checking and taping all health professional in arriving at a diagnosis or connections determining the person’s needs. Rationale: Air leaks commonly occur if the 33. Answer: (A) Trochanter roll extending from the system isn’t secure. Checking all connections crest of the ileum to the mid-thigh. and taping them will prevent air leaks. The Rationale: A trochanter roll, properly placed, chest drainage system is kept lower to provides resistance to the external rotation of promote drainage – not to prevent leaks. the hip. 42. Answer: (A) Check the client’s identification 34. Answer: (C) Stage III band. Rationale: Clinically, a deep crater or without Rationale: Checking the client’s identification undermining of adjacent tissue is noted. band is the safest way to verify a client’s 35. Answer: (A) Second intention healing identity because the band is assigned on Rationale: When wounds dehisce, they will admission and isn’t be removed at any time. (If allowed to heal by secondary Intention it is removed, it must be replaced). Asking the 36. Answer: (D) Tachycardia client’s name or having the client repeated his Rationale: With an extracellular fluid or plasma name would be appropriate only for a client volume deficit, compensatory mechanisms who’s alert, oriented, and able to understand stimulate the heart, causing an increase in what is being said, but isn’t the safe standard heart rate. of practice. Names on bed aren’t always 37. Answer: (A) 0.75 reliable Rationale: To determine the number of 43. Answer: (B) 32 drops/minute milliliters the client should receive, the nurse Rationale: Giving 1,000 ml over 8 hours is the uses the fraction method in the following same as giving 125 ml over 1 hour (60 equation. minutes). Find the number of milliliters per 75 mg/X ml = 100 mg/1 ml minute as follows: To solve for X, cross-multiply: 125/60 minutes = X/1 minute 75 mg x 1 ml = X ml x 100 mg 60X = 125 = 2.1 ml/minute 75 = 100X To find the number of drops per minute: 75/100 = X 2.1 ml/X gtt = 1 ml/ 15 gtt 0.75 ml (or ¾ ml) = X X = 32 gtt/minute, or 32 drops/minute 38. Answer: (D) it’s a measure of effect, not a 44. Answer: (A) Clamp the catheter standard measure of weight or quantity. Rationale: If a central venous catheter Rationale: An insulin unit is a measure of becomes disconnected, the nurse should effect, not a standard measure of weight or immediately apply a catheter clamp, if quantity. Different drugs measured in units available. If a clamp isn’t available, the nurse may have no relationship to one another in can place a sterile syringe or catheter plug in quality or quantity. the catheter hub. After cleaning the hub with 39. Answer: (B) 38.9 °C alcohol or povidone-iodine solution, the nurse Rationale: To convert Fahrenheit degreed to must replace the I.V. extension and restart the Centigrade, use this formula infusion. °C = (°F – 32) ÷ 1.8 45. Answer: (D) Auscultation, percussion, and °C = (102 – 32) ÷ 1.8 palpation. °C = 70 ÷ 1.8 Rationale: The correct order of assessment for °C = 38.9 examining the abdomen is inspection, 40. Answer: (C) Failing eyesight, especially close auscultation, percussion, and palpation. The vision. reason for this approach is that the less intrusive techniques should be performed68
  • 69. 69 before the more intrusive techniques. interventions and will protect the area. Using a Percussion and palpation can alter natural povidone-iodine wash and an antibiotic cream findings during auscultation. require a physician’s order. Massaging with an46. Answer: (D) Ulnar surface of the hand astringent can further damage the skin. Rationale: The nurse uses the ulnar surface, or 52. Answer: (D) Foot ball, of the hand to assess tactile fremitus, Rationale: An elastic bandage should be thrills, and vocal vibrations through the chest applied form the distal area to the proximal wall. The fingertips and finger pads best area. This method promotes venous return. In distinguish texture and shape. The dorsal this case, the nurse should begin applying the surface best feels warmth. bandage at the client’s foot. Beginning at the47. Answer: (C) Formative ankle, lower thigh, or knee does not promote Rationale: Formative (or concurrent) venous return. evaluation occurs continuously throughout the 53. Answer: (B) Hypokalemia teaching and learning process. One benefit is Rationale: Insulin administration causes that the nurse can adjust teaching strategies glucose and potassium to move into the cells, as necessary to enhance learning. Summative, causing hypokalemia. or retrospective, evaluation occurs at the 54. Answer: (A) Throbbing headache or dizziness conclusion of the teaching and learning Rationale: Headache and dizziness often occur session. Informative is not a type of when nitroglycerin is taken at the beginning of evaluation. therapy. However, the client usually develops48. Answer: (B) Once per year tolerance Rationale: Yearly mammograms should begin 55. Answer: (D) Check the client’s level of at age 40 and continue for as long as the consciousness woman is in good health. If health risks, such Rationale: Determining unresponsiveness is as family history, genetic tendency, or past the first step assessment action to take. When breast cancer, exist, more frequent a client is in ventricular tachycardia, there is a examinations may be necessary. significant decrease in cardiac output.49. Answer: (A) Respiratory acidosis However, checking the unresponsiveness Rationale: The client has a below-normal ensures whether the client is affected by the (acidic) blood pH value and an above-normal decreased cardiac output. partial pressure of arterial carbon dioxide 56. Answer: (B) On the affected side of the client. (Paco2) value, indicating respiratory acidosis. Rationale: When walking with clients, the In respiratory alkalosis, the pH value is above nurse should stand on the affected side and normal and in the Paco2 value is below grasp the security belt in the midspine area of normal. In metabolic acidosis, the pH and the small of the back. The nurse should bicarbonate (Hco3) values are below normal. position the free hand at the shoulder area so In metabolic alkalosis, the pH and Hco3 values that the client can be pulled toward the nurse are above normal. in the event that there is a forward fall. The50. Answer: (B) To provide support for the client client is instructed to look up and outward and family in coping with terminal illness. rather than at his or her feet. Rationale: Hospices provide supportive care 57. Answer: (A) Urine output: 45 ml/hr for terminally ill clients and their families. Rationale: Adequate perfusion must be Hospice care doesn’t focus on counseling maintained to all vital organs in order for the regarding health care costs. Most client client to remain visible as an organ donor. A referred to hospices have been treated for urine output of 45 ml per hour indicates their disease without success and will receive adequate renal perfusion. Low blood pressure only palliative care in the hospice. and delayed capillary refill time are circulatory51. Answer: (C) Using normal saline solution to system indicators of inadequate perfusion. A clean the ulcer and applying a protective serum pH of 7.32 is acidotic, which adversely dressing as necessary. affects all body tissues. Rationale: Washing the area with normal 58. Answer: (D ) Obtaining the specimen from the saline solution and applying a protective urinary drainage bag. dressing are within the nurse’s realm of
  • 70. Rationale: A urine specimen is not taken from because of the risk for potential heat loss. the urinary drainage bag. Urine undergoes Hurried movements and rapid changes in the chemical changes while sitting in the bag and position should be avoided because these does not necessarily reflect the current client predispose the client to hypotension. At the status. In addition, it may become time of the transfer from the surgery table to contaminated with bacteria from opening the the stretcher, the client is still affected by the system. effects of the anesthesia; therefore, the client 59. Answer: (B) Cover the client, place the call should not move self. Safety belts can prevent light within reach, and answer the phone call. the client from falling off the stretcher. Rationale: Because telephone call is an 64. Answer: (B) Gown and gloves emergency, the nurse may need to answer it. Rationale: Contact precautions require the use The other appropriate action is to ask another of gloves and a gown if direct client contact is nurse to accept the call. However, is not one of anticipated. Goggles are not necessary unless the options. To maintain privacy and safety, the nurse anticipates the splashes of blood, the nurse covers the client and places the call body fluids, secretions, or excretions may light within the client’s reach. Additionally, the occur. Shoe protectors are not necessary. client’s door should be closed or the room 65. Answer: (C) Quad cane curtains pulled around the bathing area. Rationale: Crutches and a walker can be 60. Answer: (C) Use a sterile plastic container for difficult to maneuver for a client with obtaining the specimen. weakness on one side. A cane is better suited Rationale: Sputum specimens for culture and for client with weakness of the arm and leg on sensitivity testing need to be obtained using one side. However, the quad cane would sterile techniques because the test is done to provide the most stability because of the determine the presence of organisms. If the structure of the cane and because a quad cane procedure for obtaining the specimen is not has four legs. sterile, then the specimen is not sterile, then 66. Answer: (D) Left side-lying with the head of the specimen would be contaminated and the the bed elevated 45 degrees. results of the test would be invalid. Rationale: To facilitate removal of fluid from 61. Answer: (A) Puts all the four points of the the chest wall, the client is positioned sitting at walker flat on the floor, puts weight on the the edge of the bed leaning over the bedside hand pieces, and then walks into it. table with the feet supported on a stool. If the Rationale: When the client uses a walker, the client is unable to sit up, the client is nurse stands adjacent to the affected side. The positioned lying in bed on the unaffected side client is instructed to put all four points of the with the head of the bed elevated 30 to 45 walker 2 feet forward flat on the floor before degrees. putting weight on hand pieces. This will ensure 67. Answer: (D) Reliability client safety and prevent stress cracks in the Rationale: Reliability is consistency of the walker. The client is then instructed to move research instrument. It refers to the the walker forward and walk into it. repeatability of the instrument in extracting 62. Answer: (C) Draws one line to cross out the the same responses upon its repeated incorrect information and then initials the administration. change. 68. Answer: (A) Keep the identities of the subject Rationale: To correct an error documented in a secret medical record, the nurse draws one line Rationale: Keeping the identities of the through the incorrect information and then research subject secret will ensure anonymity initials the error. An error is never erased and because this will hinder providing link between correction fluid is never used in the medical the information given to whoever is its source. record. 69. Answer: (A) Descriptive- correlational 63. Answer: (C) Secures the client safety belts Rationale: Descriptive- correlational study is after transferring to the stretcher. the most appropriate for this study because it Rationale: During the transfer of the client studies the variables that could be the after the surgical procedure is complete, the antecedents of the increased incidence of nurse should avoid exposure of the client nosocomial infection.70
  • 71. 7170. Answer: (C) Use of laboratory data working conditions of the workers on their Rationale: Incidence of nosocomial infection is productivity. It resulted to an increased best collected through the use of productivity but not due to the intervention biophysiologic measures, particularly in vitro but due to the psychological effects of being measurements, hence laboratory data is observed. They performed differently because essential. they were under observation.71. Answer: (B) Quasi-experiment 79. Answer: (B) Determines the different Rationale: Quasi-experiment is done when nationality of patients frequently admitted and randomization and control of the variables are decides to get representations samples from not possible. each.72. Answer: (C) Primary source Rationale: Judgment sampling involves Rationale: This refers to a primary source including samples according to the knowledge which is a direct account of the investigation of the investigator about the participants in done by the investigator. In contrast to this is a the study. secondary source, which is written by 80. Answer: (B) Madeleine Leininger someone other than the original researcher. Rationale: Madeleine Leininger developed the73. Answer: (A) Non-maleficence theory on transcultural theory based on her Rationale: Non-maleficence means do not observations on the behavior of selected cause harm or do any action that will cause people within a culture. any harm to the patient/client. To do good is 81. Answer: (A) Random referred as beneficence. Rationale: Random sampling gives equal74. Answer: (C) Res ipsa loquitor chance for all the elements in the population Rationale: Res ipsa loquitor literally means the to be picked as part of the sample. thing speaks for itself. This means in 82. Answer: (A) Degree of agreement and operational terms that the injury caused is the disagreement proof that there was a negligent act. Rationale: Likert scale is a 5-point summated75. Answer: (B) The Board can investigate scale used to determine the degree of violations of the nursing law and code of ethics agreement or disagreement of the Rationale: Quasi-judicial power means that the respondents to a statement in a study Board of Nursing has the authority to 83. Answer: (B) Sr. Callista Roy investigate violations of the nursing law and Rationale: Sr. Callista Roy developed the can issue summons, subpoena or subpoena Adaptation Model which involves the duces tecum as needed. physiologic mode, self-concept mode, role76. Answer: (C) May apply for re-issuance of function mode and dependence mode. his/her license based on certain conditions 84. Answer: (A) Span of control stipulated in RA 9173 Rationale: Span of control refers to the Rationale: RA 9173 sec. 24 states that for number of workers who report directly to a equity and justice, a revoked license maybe re- manager. issued provided that the following conditions 85. Answer: (B) Autonomy are met: a) the cause for revocation of license Rationale: Informed consent means that the has already been corrected or removed; and, patient fully understands about the surgery, b) at least four years has elapsed since the including the risks involved and the alternative license has been revoked. solutions. In giving consent it is done with full77. Answer: (B) Review related literature knowledge and is given freely. The action of Rationale: After formulating and delimiting the allowing the patient to decide whether a research problem, the researcher conducts a surgery is to be done or not exemplifies the review of related literature to determine the bioethical principle of autonomy. extent of what has been done on the study by 86. Answer: (C) Avoid wearing canvas shoes. previous researchers. Rationale: The client should be instructed to78. Answer: (B) Hawthorne effect avoid wearing canvas shoes. Canvas shoes Rationale: Hawthorne effect is based on the cause the feet to perspire, which may, in turn, study of Elton Mayo and company about the cause skin irritation and breakdown. Both effect of an intervention done to improve the cotton and cornstarch absorb perspiration.
  • 72. The client should be instructed to cut toenails nursing process where the nurse puts the plan straight across with nail clippers. of care into action. 87. Answer: (D) Ground beef patties 92. Answer: (B) To observe the lower extremities Rationale: Meat is an excellent source of Rationale: Elastic stockings are used to complete protein, which this client needs to promote venous return. The nurse needs to repair the tissue breakdown caused by remove them once per day to observe the pressure ulcers. Oranges and broccoli supply condition of the skin underneath the stockings. vitamin C but not protein. Ice cream supplies Applying the stockings increases blood flow to only some incomplete protein, making it less the heart. When the stockings are in place, the helpful in tissue repair. leg muscles can still stretch and relax, and the 88. Answer: (D) Sims’ left lateral veins can fill with blood. Rationale: The Sims left lateral position is the 93. Answer :(A) Instructing the client to report any most common position used to administer a itching, swelling, or dyspnea. cleansing enema because it allows gravity to Rationale: Because administration of blood or aid the flow of fluid along the curve of the blood products may cause serious adverse sigmoid colon. If the client cant assume this effects such as allergic reactions, the nurse position nor has poor sphincter control, the must monitor the client for these effects. Signs dorsal recumbent or right lateral position may and symptoms of life-threatening allergic be used. The supine and prone positions are reactions include itching, swelling, and inappropriate and uncomfortable for the dyspnea. Although the nurse should inform client. the client of the duration of the transfusion 89. Answer: (A) Arrange for typing and cross and should document its administration, these matching of the client’s blood. actions are less critical to the clients Rationale: The nurse first arranges for typing immediate health. The nurse should assess and cross matching of the clients blood to vital signs at least hourly during the ensure compatibility with donor blood. The transfusion. other options, although appropriate when 94. Answer: (B) Decrease the rate of feedings and preparing to administer a blood transfusion, the concentration of the formula. come later. Rationale: Complaints of abdominal 90. Answer: (A) Independent discomfort and nausea are common in clients Rationale: Nursing interventions are classified receiving tube feedings. Decreasing the rate of as independent, interdependent, or the feeding and the concentration of the dependent. Altering the drug schedule to formula should decrease the clients coincide with the clients daily routine discomfort. Feedings are normally given at represents an independent intervention, room temperature to minimize abdominal whereas consulting with the physician and cramping. To prevent aspiration during pharmacist to change a clients medication feeding, the head of the clients bed should be because of adverse reactions represents an elevated at least 30 degrees. Also, to prevent interdependent intervention. Administering an bacterial growth, feeding containers should be already-prescribed drug on time is a routinely changed every 8 to 12 hours. dependent intervention. An intradependent 95. Answer: (D) Roll the vial gently between the nursing intervention doesnt exist. palms. 91. Answer: (D) Evaluation Rationale: Rolling the vial gently between the Rationale: The nursing actions described palms produces heat, which helps dissolve the constitute evaluation of the expected medication. Doing nothing or inverting the vial outcomes. The findings show that the wouldnt help dissolve the medication. Shaking expected outcomes have been achieved. the vial vigorously could cause the medication Assessment consists of the clients history, to break down, altering its action. physical examination, and laboratory studies. 96. Answer: (B) Assist the client to the semi- Analysis consists of considering assessment Fowler position if possible. information to derive the appropriate nursing Rationale: By assisting the client to the semi- diagnosis. Implementation is the phase of the Fowler position, the nurse promotes easier chest expansion, breathing, and oxygen intake.72
  • 73. 73 The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could lead to irritation. The nurse should apply the face mask from the clients nose down to the chin — not vice versa. The nurse should check the connectors between the oxygen equipment and humidifier to ensure that theyre airtight; loosened connectors can cause loss of oxygen.97. Answer: (B) 4 hours Rationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldnt infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Discard or return to the blood bank any blood not given within this time, according to facility policy.98. Answer: (B) Immediately before administering the next dose. Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved the therapeutic goal. For measurement of the trough, or lowest, blood level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on the drugs duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose.99. Answer: (A) The nurse can implement medication orders quickly. Rationale: A floor stock system enables the nurse to implement medication orders quickly. It doesnt allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.100. Answer: (C) Shifting dullness over the abdomen. Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options are normal abdominal findings.
  • 74. TEST II - Community Health Nursing and Care of the a. Excessive fetal activity.Mother and Child b. Larger than normal uterus for gestational age. 1. May arrives at the health care clinic and tells the c. Vaginal bleeding nurse that her last menstrual period was 9 d. Elevated levels of human chorionic weeks ago. She also tells the nurse that a home gonadotropin. pregnancy test was positive but she began to have mild cramps and is now having moderate 6. A pregnant client is receiving magnesium sulfate vaginal bleeding. During the physical for severe pregnancy induced hypertension examination of the client, the nurse notes that (PIH). The clinical findings that would warrant May has a dilated cervix. The nurse determines use of the antidote , calcium gluconate is: that May is experiencing which type of abortion? a. Urinary output 90 cc in 2 hours. a. Inevitable b. Absent patellar reflexes. b. Incomplete c. Rapid respiratory rate above 40/min. c. Threatened d. Rapid rise in blood pressure. d. Septic 7. During vaginal examination of Janah who is in 2. Nurse Reese is reviewing the record of a labor, the presenting part is at station plus two. pregnant client for her first prenatal visit. Which Nurse, correctly interprets it as: of the following data, if noted on the client’s a. Presenting part is 2 cm above the plane record, would alert the nurse that the client is at of the ischial spines. risk for a spontaneous abortion? b. Biparietal diameter is at the level of the a. Age 36 years ischial spines. b. History of syphilis c. Presenting part in 2 cm below the plane c. History of genital herpes of the ischial spines. d. History of diabetes mellitus d. Biparietal diameter is 2 cm above the ischial spines. 3. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible 8. A pregnant client is receiving oxytocin (Pitocin) diagnosis of ectopic pregnancy. Nurse Hazel for induction of labor. A condition that warrant develops a plan of care for the client and the nurse in-charge to discontinue I.V. infusion determines that which of the following nursing of Pitocin is: actions is the priority? a. Contractions every 1 ½ minutes lasting a. Monitoring weight 70-80 seconds. b. Assessing for edema b. Maternal temperature 101.2 c. Monitoring apical pulse c. Early decelerations in the fetal heart d. Monitoring temperature rate. d. Fetal heart rate baseline 140-160 bpm. 4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during 9. Calcium gluconate is being administered to a pregnancy. The nurse determines that the client client with pregnancy induced hypertension understands dietary and insulin needs if the (PIH). A nursing action that must be initiated as client states that the second half of pregnancy the plan of care throughout injection of the drug requires: is: a. Decreased caloric intake a. Ventilator assistance b. Increased caloric intake b. CVP readings c. Decreased Insulin c. EKG tracings d. Increase Insulin d. Continuous CPR 5. Nurse Michelle is assessing a 24 year old client 10. A trial for vaginal delivery after an earlier with a diagnosis of hydatidiform mole. She is caesarean, would likely to be given to a gravida, aware that one of the following is unassociated who had: with this condition?74
  • 75. 75 a. First low transverse cesarean was for infant looks for it. The nurse is aware that active herpes type 2 infections; vaginal estimated age of the infant would be: culture at 39 weeks pregnancy was a. 6 months positive. b. 4 months b. First and second caesareans were for c. 8 months cephalopelvic disproportion. d. 10 months c. First caesarean through a classic incision as a result of severe fetal distress. 16. Which of the following is the most prominent d. First low transverse caesarean was for feature of public health nursing? breech position. Fetus in this pregnancy a. It involves providing home care to sick is in a vertex presentation. people who are not confined in the hospital.11. Nurse Ryan is aware that the best initial b. Services are provided free of charge to approach when trying to take a crying toddler’s people within the catchments area. temperature is: c. The public health nurse functions as part a. Talk to the mother first and then to the of a team providing a public health toddler. nursing services. b. Bring extra help so it can be done d. Public health nursing focuses on quickly. preventive, not curative, services. c. Encourage the mother to hold the child. d. Ignore the crying and screaming. 17. When the nurse determines whether resources were maximized in implementing Ligtas Tigdas,12. Baby Tina a 3 month old infant just had a cleft lip she is evaluating and palate repair. What should the nurse do to a. Effectiveness prevent trauma to operative site? b. Efficiency a. Avoid touching the suture line, even c. Adequacy when cleaning. d. Appropriateness b. Place the baby in prone position. c. Give the baby a pacifier. 18. Vangie is a new B.S.N. graduate. She wants to d. Place the infant’s arms in soft elbow become a Public Health Nurse. Where should restraints. she apply? a. Department of Health13. Which action should nurse Marian include in the b. Provincial Health Office care plan for a 2 month old with heart failure? c. Regional Health Office a. Feed the infant when he cries. d. Rural Health Unit b. Allow the infant to rest before feeding. c. Bathe the infant and administer 19. Tony is aware the Chairman of the Municipal medications before feeding. Health Board is: d. Weigh and bathe the infant before a. Mayor feeding. b. Municipal Health Officer c. Public Health Nurse14. Nurse Hazel is teaching a mother who plans to d. Any qualified physician discontinue breast feeding after 5 months. The nurse should advise her to include which foods 20. Myra is the public health nurse in a municipality in her infant’s diet? with a total population of about 20,000. There a. Skim milk and baby food. are 3 rural health midwives among the RHU b. Whole milk and baby food. personnel. How many more midwife items will c. Iron-rich formula only. the RHU need? d. Iron-rich formula and baby food. a. 1 b. 215. Mommy Linda is playing with her infant, who is c. 3 sitting securely alone on the floor of the clinic. d. The RHU does not need any more The mother hides a toy behind her back and the midwife item.
  • 76. 26. The nurse is caring for a primigravid client in the 21. According to Freeman and Heinrich, community labor and delivery area. Which condition would health nursing is a developmental service. Which place the client at risk for disseminated of the following best illustrates this statement? intravascular coagulation (DIC)? a. The community health nurse a. Intrauterine fetal death. continuously develops himself b. Placenta accreta. personally and professionally. c. Dysfunctional labor. b. Health education and community d. Premature rupture of the membranes. organizing are necessary in providing community health services. 27. A fullterm client is in labor. Nurse Betty is aware c. Community health nursing is intended that the fetal heart rate would be: primarily for health promotion and a. 80 to 100 beats/minute prevention and treatment of disease. b. 100 to 120 beats/minute d. The goal of community health nursing is c. 120 to 160 beats/minute to provide nursing services to people in d. 160 to 180 beats/minute their own places of residence. 28. The skin in the diaper area of a 7 month old 22. Nurse Tina is aware that the disease declared infant is excoriated and red. Nurse Hazel should through Presidential Proclamation No. 4 as a instruct the mother to: target for eradication in the Philippines is? a. Change the diaper more often. a. Poliomyelitis b. Apply talc powder with diaper changes. b. Measles c. Wash the area vigorously with each c. Rabies diaper change. d. Neonatal tetanus d. Decrease the infant’s fluid intake to decrease saturating diapers. 23. May knows that the step in community organizing that involves training of potential 29. Nurse Carla knows that the common cardiac leaders in the community is: anomalies in children with Down Syndrome (tri- a. Integration somy 21) is: b. Community organization a. Atrial septal defect c. Community study b. Pulmonic stenosis d. Core group formation c. Ventricular septal defect d. Endocardial cushion defect 24. Beth a public health nurse takes an active role in community participation. What is the primary 30. Malou was diagnosed with severe preeclampsia goal of community organizing? is now receiving I.V. magnesium sulfate. The a. To educate the people regarding adverse effects associated with magnesium community health problems sulfate is: b. To mobilize the people to resolve a. Anemia community health problems b. Decreased urine output c. To maximize the community’s resources c. Hyperreflexia in dealing with health problems. d. Increased respiratory rate d. To maximize the community’s resources in dealing with health problems. 31. A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. This 25. Tertiary prevention is needed in which stage of type of menstrual pattern is bets defined by: the natural history of disease? a. Menorrhagia a. Pre-pathogenesis b. Metrorrhagia b. Pathogenesis c. Dyspareunia c. Prodromal d. Amenorrhea d. Terminal76
  • 77. 7732. Jannah is admitted to the labor and delivery b. Dehydration and diarrhea unit. The critical laboratory result for this client c. Bradycardia and hypotension would be: d. Petechiae and hematuria a. Oxygen saturation b. Iron binding capacity 38. To evaluate a woman’s understanding about the c. Blood typing use of diaphragm for family planning, Nurse d. Serum Calcium Trish asks her to explain how she will use the appliance. Which response indicates a need for33. Nurse Gina is aware that the most common further health teaching? condition found during the second-trimester of a. “I should check the diaphragm carefully pregnancy is: for holes every time I use it” a. Metabolic alkalosis b. “I may need a different size of b. Respiratory acidosis diaphragm if I gain or lose weight more c. Mastitis than 20 pounds” d. Physiologic anemia c. “The diaphragm must be left in place for atleast 6 hours after intercourse”34. Nurse Lynette is working in the triage area of an d. “I really need to use the diaphragm and emergency department. She sees that several jelly most during the middle of my pediatric clients arrive simultaneously. The client menstrual cycle”. who needs to be treated first is: a. A crying 5 year old child with a 39. Hypoxia is a common complication of laceration on his scalp. laryngotracheobronchitis. Nurse Oliver should b. A 4 year old child with a barking coughs frequently assess a child with and flushed appearance. laryngotracheobronchitis for: c. A 3 year old child with Down syndrome a. Drooling who is pale and asleep in his mother’s b. Muffled voice arms. c. Restlessness d. A 2 year old infant with stridorous d. Low-grade fever breath sounds, sitting up in his mother’s arms and drooling. 40. How should Nurse Michelle guide a child who is blind to walk to the playroom?35. Maureen in her third trimester arrives at the a. Without touching the child, talk emergency room with painless vaginal bleeding. continuously as the child walks down the Which of the following conditions is suspected? hall. a. Placenta previa b. Walk one step ahead, with the child’s b. Abruptio placentae hand on the nurse’s elbow. c. Premature labor c. Walk slightly behind, gently guiding the d. Sexually transmitted disease child forward. d. Walk next to the child, holding the36. A young child named Richard is suspected of child’s hand. having pinworms. The community nurse collects a stool specimen to confirm the diagnosis. The 41. When assessing a newborn diagnosed with nurse should schedule the collection of this ductus arteriosus, Nurse Olivia should expect specimen for: that the child most likely would have an: a. Just before bedtime a. Loud, machinery-like murmur. b. After the child has been bathe b. Bluish color to the lips. c. Any time during the day c. Decreased BP reading in the upper d. Early in the morning extremities d. Increased BP reading in the upper37. In doing a child’s admission assessment, Nurse extremities. Betty should be alert to note which signs or symptoms of chronic lead poisoning? 42. The reason nurse May keeps the neonate in a a. Irritability and seizures neutral thermal environment is that when a
  • 78. newborn becomes too cool, the neonate 47. Barangay Pinoy had an outbreak of German requires: measles. To prevent congenital rubella, what is a. Less oxygen, and the newborn’s the BEST advice that you can give to women in metabolic rate increases. the first trimester of pregnancy in the barangay b. More oxygen, and the newborn’s Pinoy? metabolic rate decreases. a. Advise them on the signs of German c. More oxygen, and the newborn’s measles. metabolic rate increases. b. Avoid crowded places, such as markets d. Less oxygen, and the newborn’s and movie houses. metabolic rate decreases. c. Consult at the health center where rubella vaccine may be given. 43. Before adding potassium to an infant’s I.V. line, d. Consult a physician who may give them Nurse Ron must be sure to assess whether this rubella immunoglobulin. infant has: a. Stable blood pressure 48. Myrna a public health nurse knows that to b. Patant fontanelles determine possible sources of sexually c. Moro’s reflex transmitted infections, the BEST method that d. Voided may be undertaken is: a. Contact tracing 44. Nurse Carla should know that the most common b. Community survey causative factor of dermatitis in infants and c. Mass screening tests younger children is: d. Interview of suspects a. Baby oil b. Baby lotion 49. A 33-year old female client came for c. Laundry detergent consultation at the health center with the chief d. Powder with cornstarch complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. 45. During tube feeding, how far above an infant’s A week after the start of fever, the client noted stomach should the nurse hold the syringe with yellowish discoloration of his sclera. History formula? showed that he waded in flood waters about 2 a. 6 inches weeks before the onset of symptoms. Based on b. 12 inches her history, which disease condition will you c. 18 inches suspect? d. 24 inches a. Hepatitis A b. Hepatitis B 46. In a mothers’ class, Nurse Lhynnete discussed c. Tetanus childhood diseases such as chicken pox. Which d. Leptospirosis of the following statements about chicken pox is correct? 50. Mickey a 3-year old client was brought to the a. The older one gets, the more susceptible health center with the chief complaint of severe he becomes to the complications of diarrhea and the passage of “rice water” stools. chicken pox. The client is most probably suffering from which b. A single attack of chicken pox will condition? prevent future episodes, including a. Giardiasis conditions such as shingles. b. Cholera c. To prevent an outbreak in the c. Amebiasis community, quarantine may be imposed d. Dysentery by health authorities. d. Chicken pox vaccine is best given when 51. The most prevalent form of meningitis among there is an impending outbreak in the children aged 2 months to 3 years is caused by community. which microorganism? a. Hemophilus influenzae b. Morbillivirus78
  • 79. 79 c. Steptococcus pneumoniae d. Use of protective footwear, such as d. Neisseria meningitidis rubber boots52. The student nurse is aware that the 58. Several clients is newly admitted and diagnosed pathognomonic sign of measles is Koplik’s spot with leprosy. Which of the following clients and you may see Koplik’s spot by inspecting the: should be classified as a case of multibacillary a. Nasal mucosa leprosy? b. Buccal mucosa a. 3 skin lesions, negative slit skin smear c. Skin on the abdomen b. 3 skin lesions, positive slit skin smear d. Skin on neck c. 5 skin lesions, negative slit skin smear d. 5 skin lesions, positive slit skin smear53. Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill 59. Nurses are aware that diagnosis of leprosy is when the color of the nailbed that you pressed highly dependent on recognition of symptoms. does not return within how many seconds? Which of the following is an early sign of a. 3 seconds leprosy? b. 6 seconds a. Macular lesions c. 9 seconds b. Inability to close eyelids d. 10 seconds c. Thickened painful nerves d. Sinking of the nosebridge54. In Integrated Management of Childhood Illness, the nurse is aware that the severe conditions 60. Marie brought her 10 month old infant for generally require urgent referral to a hospital. consultation because of fever, started 4 days Which of the following severe conditions DOES prior to consultation. In determining malaria NOT always require urgent referral to a hospital? risk, what will you do? a. Mastoiditis a. Perform a tourniquet test. b. Severe dehydration b. Ask where the family resides. c. Severe pneumonia c. Get a specimen for blood smear. d. Severe febrile disease d. Ask if the fever is present every day.55. Myrna a public health nurse will conduct 61. Susie brought her 4 years old daughter to the outreach immunization in a barangay Masay RHU because of cough and colds. Following the with a population of about 1500. The estimated IMCI assessment guide, which of the following is number of infants in the barangay would be: a danger sign that indicates the need for urgent a. 45 infants referral to a hospital? b. 50 infants a. Inability to drink c. 55 infants b. High grade fever d. 65 infants c. Signs of severe dehydration d. Cough for more than 30 days56. The community nurse is aware that the biological used in Expanded Program on 62. Jimmy a 2-year old child revealed “baggy pants”. Immunization (EPI) should NOT be stored in the As a nurse, using the IMCI guidelines, how will freezer? you manage Jimmy? a. DPT a. Refer the child urgently to a hospital for b. Oral polio vaccine confinement. c. Measles vaccine b. Coordinate with the social worker to d. MMR enroll the child in a feeding program. c. Make a teaching plan for the mother,57. It is the most effective way of controlling focusing on menu planning for her child. schistosomiasis in an endemic area? d. Assess and treat the child for health a. Use of molluscicides problems like infections and intestinal b. Building of foot bridges parasitism. c. Proper use of sanitary toilets
  • 80. 63. Gina is using Oresol in the management of 68. The nurse explains to a breastfeeding mother diarrhea of her 3-year old child. She asked you that breast milk is sufficient for all of the baby’s what to do if her child vomits. As a nurse you will nutrient needs only up to: tell her to: a. 5 months a. Bring the child to the nearest hospital b. 6 months for further assessment. c. 1 year b. Bring the child to the health center for d. 2 years intravenous fluid therapy. c. Bring the child to the health center for 69. Nurse Ron is aware that the gestational age of a assessment by the physician. conceptus that is considered viable (able to live d. Let the child rest for 10 minutes then outside the womb) is: continue giving Oresol more slowly. a. 8 weeks b. 12 weeks 64. Nikki a 5-month old infant was brought by his c. 24 weeks mother to the health center because of diarrhea d. 32 weeks for 4 to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using 70. When teaching parents of a neonate the proper the IMCI guidelines, you will classify this infant in position for the neonate’s sleep, the nurse which category? Patricia stresses the importance of placing the a. No signs of dehydration neonate on his back to reduce the risk of which b. Some dehydration of the following? c. Severe dehydration a. Aspiration d. The data is insufficient. b. Sudden infant death syndrome (SIDS) c. Suffocation 65. Chris a 4-month old infant was brought by her d. Gastroesophageal reflux (GER) mother to the health center because of cough. His respiratory rate is 42/minute. Using the 71. Which finding might be seen in baby James a Integrated Management of Child Illness (IMCI) neonate suspected of having an infection? guidelines of assessment, his breathing is a. Flushed cheeks considered as: b. Increased temperature a. Fast c. Decreased temperature b. Slow d. Increased activity level c. Normal d. Insignificant 72. Baby Jenny who is small-for-gestation is at increased risk during the transitional period for 66. Maylene had just received her 4th dose of which complication? tetanus toxoid. She is aware that her baby will a. Anemia probably due to chronic fetal have protection against tetanus for hyposia a. 1 year b. Hyperthermia due to decreased b. 3 years glycogen stores c. 5 years c. Hyperglycemia due to decreased d. Lifetime glycogen stores d. Polycythemia probably due to chronic 67. Nurse Ron is aware that unused BCG should be fetal hypoxia discarded after how many hours of reconstitution? 73. Marjorie has just given birth at 42 weeks’ a. 2 hours gestation. When the nurse assessing the b. 4 hours neonate, which physical finding is expected? c. 8 hours a. A sleepy, lethargic baby d. At the end of the day b. Lanugo covering the body c. Desquamation of the epidermis d. Vernix caseosa covering the body80
  • 81. 8174. After reviewing the Myrna’s maternal history of b. The parent’s expression of interest magnesium sulfate during labor, which condition about the size of the new born. would nurse Richard anticipate as a potential c. The parents’ indication that they want to problem in the neonate? see the newborn. a. Hypoglycemia d. The parents’ interactions with each b. Jitteriness other. c. Respiratory depression d. Tachycardia 80. Following a precipitous delivery, examination of the clients vagina reveals a fourth-degree75. Which symptom would indicate the Baby laceration. Which of the following would be Alexandra was adapting appropriately to extra- contraindicated when caring for this client? uterine life without difficulty? a. Applying cold to limit edema during the a. Nasal flaring first 12 to 24 hours. b. Light audible grunting b. Instructing the client to use two or more c. Respiratory rate 40 to 60 peripads to cushion the area. breaths/minute c. Instructing the client on the use of sitz d. Respiratory rate 60 to 80 baths if ordered. breaths/minute d. Instructing the client about the importance of perineal (kegel) exercises.76. When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny would include 81. A pregnant woman accompanied by her which information? husband, seeks admission to the labor and a. Apply peroxide to the cord with each delivery area. She states that shes in labor and diaper change says she attended the facility clinic for prenatal b. Cover the cord with petroleum jelly after care. Which question should the nurse Oliver ask bathing her first? c. Keep the cord dry and open to air a. “Do you have any chronic illnesses?” d. Wash the cord with soap and water each b. “Do you have any allergies?” day during a tub bath. c. “What is your expected due date?” d. “Who will be with you during labor?”77. Nurse John is performing an assessment on a neonate. Which of the following findings is 82. A neonate begins to gag and turns a dusky color. considered common in the healthy neonate? What should the nurse do first? a. Simian crease a. Calm the neonate. b. Conjunctival hemorrhage b. Notify the physician. c. Cystic hygroma c. Provide oxygen via face mask as ordered d. Bulging fontanelle d. Aspirate the neonate’s nose and mouth with a bulb syringe.78. Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor. 83. When a client states that her "water broke," Following this procedure, the nurse Hazel checks which of the following actions would be the fetal heart tones for which the following inappropriate for the nurse to do? reasons? a. Observing the pooling of straw-colored a. To determine fetal well-being. fluid. b. To assess for prolapsed cord b. Checking vaginal discharge with nitrazine c. To assess fetal position paper. d. To prepare for an imminent delivery. c. Conducting a bedside ultrasound for an79. Which of the following would be least likely to amniotic fluid index. indicate anticipated bonding behaviors by new d. Observing for flakes of vernix in the parents? vaginal discharge. a. The parents’ willingness to touch and hold the new born. 84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is
  • 82. successfully resuscitated. Within several hours c. Decreased inspiratory capacity she develops respiratory grunting, cyanosis, d. Decreased oxygen consumption tachypnea, nasal flaring, and retractions. Shes diagnosed with respiratory distress syndrome, 90. Emily has gestational diabetes and it is usually intubated, and placed on a ventilator. Which managed by which of the following therapy? nursing action should be included in the babys a. Diet plan of care to prevent retinopathy of b. Long-acting insulin prematurity? c. Oral hypoglycemic a. Cover his eyes while receiving oxygen. d. Oral hypoglycemic drug and insulin b. Keep her body temperature low. c. Monitor partial pressure of oxygen 91. Magnesium sulfate is given to Jemma with (Pao2) levels. preeclampsia to prevent which of the following d. Humidify the oxygen. condition? a. Hemorrhage 85. Which of the following is normal newborn b. Hypertension calorie intake? c. Hypomagnesemia a. 110 to 130 calories per kg. d. Seizure b. 30 to 40 calories per lb of body weight. c. At least 2 ml per feeding 92. Cammile with sickle cell anemia has an increased d. 90 to 100 calories per kg risk for having a sickle cell crisis during pregnancy. Aggressive management of a sickle 86. Nurse John is knowledgeable that usually cell crisis includes which of the following individual twins will grow appropriately and at measures? the same rate as singletons until how many a. Antihypertensive agents weeks? b. Diuretic agents a. 16 to 18 weeks c. I.V. fluids b. 18 to 22 weeks d. Acetaminophen (Tylenol) for pain c. 30 to 32 weeks d. 38 to 40 weeks 93. Which of the following drugs is the antidote for magnesium toxicity? 87. Which of the following classifications applies to a. Calcium gluconate (Kalcinate) monozygotic twins for whom the cleavage of the b. Hydralazine (Apresoline) fertilized ovum occurs more than 13 days after c. Naloxone (Narcan) fertilization? d. Rho (D) immune globulin (RhoGAM) a. conjoined twins b. diamniotic dichorionic twins 94. Marlyn is screened for tuberculosis during her c. diamniotic monochorionic twin first prenatal visit. An intradermal injection of d. monoamniotic monochorionic twins purified protein derivative (PPD) of the tuberculin bacilli is given. She is considered to 88. Tyra experienced painless vaginal bleeding has have a positive test for which of the following just been diagnosed as having a placenta previa. results? Which of the following procedures is usually a. An indurated wheal under 10 mm in performed to diagnose placenta previa? diameter appears in 6 to 12 hours. a. Amniocentesis b. An indurated wheal over 10 mm in b. Digital or speculum examination diameter appears in 48 to 72 hours. c. External fetal monitoring c. A flat circumcised area under 10 mm in d. Ultrasound diameter appears in 6 to 12 hours. d. A flat circumcised area over 10 mm in 89. Nurse Arnold knows that the following changes diameter appears in 48 to 72 hours. in respiratory functioning during pregnancy is considered normal: 95. Dianne, 24 year-old is 27 weeks’ pregnant a. Increased tidal volume arrives at her physician’s office with complaints b. Increased expiratory volume of fever, nausea, vomiting, malaise, unilateral82
  • 83. 83 flank pain, and costovertebral angle tenderness. a. Uterine inversion Which of the following diagnoses is most likely? b. Uterine atony a. Asymptomatic bacteriuria c. Uterine involution b. Bacterial vaginosis d. Uterine discomfort c. Pyelonephritis d. Urinary tract infection (UTI)96. Rh isoimmunization in a pregnant client develops during which of the following conditions? a. Rh-positive maternal blood crosses into fetal blood, stimulating fetal antibodies. b. Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. c. Rh-negative fetal blood crosses into maternal blood, stimulating maternal antibodies. d. Rh-negative maternal blood crosses into fetal blood, stimulating fetal antibodies.97. To promote comfort during labor, the nurse John advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia? a. Lateral position b. Squatting position c. Supine position d. Standing position98. Celeste who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the nurse Lhynnette expects to find: a. Lethargy 2 days after birth. b. Irritability and poor sucking. c. A flattened nose, small eyes, and thin lips. d. Congenital defects such as limb anomalies.99. The uterus returns to the pelvic cavity in which of the following time frames? a. 7th to 9th day postpartum. b. 2 weeks postpartum. c. End of 6th week postpartum. d. When the lochia changes to alba.100. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse whos caring for her should stay alert for:
  • 84. hyperstimulation of the uterus, which could result in injury to the mother and the fetus ifAnswers and Rationale – Community Health Pitocin is not discontinued.Nursing and Care of the Mother and Child 9. Answer: (C) EKG tracings Rationale: A potential side effect of calcium 1. Answer: (A) Inevitable gluconate administration is cardiac arrest. Rationale: An inevitable abortion is termination Continuous monitoring of cardiac activity (EKG) of pregnancy that cannot be prevented. throught administration of calcium gluconate is Moderate to severe bleeding with mild an essential part of care. cramping and cervical dilation would be noted 10. Answer: (D) First low transverse caesarean was in this type of abortion. for breech position. Fetus in this pregnancy is in 2. Answer: (B) History of syphilis a vertex presentation. Rationale: Maternal infections such as syphilis, Rationale: This type of client has no obstetrical toxoplasmosis, and rubella are causes of indication for a caesarean section as she did spontaneous abortion. with her first caesarean delivery. 3. Answer: (C) Monitoring apical pulse 11. Answer: (A) Talk to the mother first and then to Rationale: Nursing care for the client with a the toddler. possible ectopic pregnancy is focused on Rationale: When dealing with a crying toddler, preventing or identifying hypovolemic shock the best approach is to talk to the mother and and controlling pain. An elevated pulse rate is ignore the toddler first. This approach helps the an indicator of shock. toddler get used to the nurse before she 4. Answer: (B) Increased caloric intake attempts any procedures. It also gives the Rationale: Glucose crosses the placenta, but toddler an opportunity to see that the mother insulin does not. High fetal demands for trusts the nurse. glucose, combined with the insulin resistance 12. Answer: (D) Place the infant’s arms in soft caused by hormonal changes in the last half of elbow restraints. pregnancy can result in elevation of maternal Rationale: Soft restraints from the upper arm to blood glucose levels. This increases the the wrist prevent the infant from touching her mother’s demand for insulin and is referred to lip but allow him to hold a favorite item such as as the diabetogenic effect of pregnancy. a blanket. Because they could damage the 5. Answer: (A) Excessive fetal activity. operative site, such as objects as pacifiers, Rationale: The most common signs and suction catheters, and small spoons shouldn’t symptoms of hydatidiform mole includes be placed in a baby’s mouth after cleft repair. A elevated levels of human chorionic baby in a prone position may rub her face on gonadotropin, vaginal bleeding, larger than the sheets and traumatize the operative site. normal uterus for gestational age, failure to The suture line should be cleaned gently to detect fetal heart activity even with sensitive prevent infection, which could interfere with instruments, excessive nausea and vomiting, healing and damage the cosmetic appearance and early development of pregnancy-induced of the repair. hypertension. Fetal activity would not be noted. 13. Answer: (B) Allow the infant to rest before 6. Answer: (B) Absent patellar reflexes feeding. Rationale: Absence of patellar reflexes is an Rationale: Because feeding requires so much indicator of hypermagnesemia, which requires energy, an infant with heart failure should rest administration of calcium gluconate. before feeding. 7. Answer: (C) Presenting part in 2 cm below the 14. Answer: (C) Iron-rich formula only. plane of the ischial spines. Rationale: The infants at age 5 months should Rationale: Fetus at station plus two indicates receive iron-rich formula and that they that the presenting part is 2 cm below the shouldn’t receive solid food, even baby food plane of the ischial spines. until age 6 months. 8. Answer: (A) Contractions every 1 ½ minutes 15. Answer: (D) 10 months lasting 70-80 seconds. Rationale: A 10 month old infant can sit alone Rationale: Contractions every 1 ½ minutes and understands object permanence, so he lasting 70-80 seconds, is indicative of would look for the hidden toy. At age 4 to 684
  • 85. 85 months, infants can’t sit securely alone. At age Rationale: Intrauterine fetal death, abruptio 8 months, infants can sit securely alone but placentae, septic shock, and amniotic fluid cannot understand the permanence of objects. embolism may trigger normal clotting16. Answer: (D) Public health nursing focuses on mechanisms; if clotting factors are depleted, preventive, not curative, services. DIC may occur. Placenta accreta, dysfunctional Rationale: The catchments area in PHN consists labor, and premature rupture of the of a residential community, many of whom are membranes arent associated with DIC. well individuals who have greater need for 27. Answer: (C) 120 to 160 beats/minute preventive rather than curative services. Rationale: A rate of 120 to 160 beats/minute in17. Answer: (B) Efficiency the fetal heart appropriate for filling the heart Rationale: Efficiency is determining whether the with blood and pumping it out to the system. goals were attained at the least possible cost. 28. Answer: (A) Change the diaper more often.18. Answer: (D) Rural Health Unit Rationale: Decreasing the amount of time the Rationale: R.A. 7160 devolved basic health skin comes contact with wet soiled diapers will services to local government units (LGU’s ). The help heal the irritation. public health nurse is an employee of the LGU. 29. Answer: (D) Endocardial cushion defect19. Answer: (A) Mayor Rationale: Endocardial cushion defects are seen Rationale: The local executive serves as the most in children with Down syndrome, chairman of the Municipal Health Board. asplenia, or polysplenia.20. Answer: (A) 1 30. Answer: (B) Decreased urine output Rationale: Each rural health midwife is given a Rationale: Decreased urine output may occur in population assignment of about 5,000. clients receiving I.V. magnesium and should be21. Answer: (B) Health education and community monitored closely to keep urine output at organizing are necessary in providing greater than 30 ml/hour, because magnesium is community health services. Rationale: The excreted through the kidneys and can easily community health nurse develops the health accumulate to toxic levels. capability of people through health education 31. Answer: (A) Menorrhagia and community organizing activities. Rationale: Menorrhagia is an excessive22. Answer: (B) Measles menstrual period. Rationale: Presidential Proclamation No. 4 is on 32. Answer: (C) Blood typing the Ligtas Tigdas Program. Rationale: Blood type would be a critical value23. Answer: (D) Core group formation to have because the risk of blood loss is always Rationale: In core group formation, the nurse is a potential complication during the labor and able to transfer the technology of community delivery process. Approximately 40% of a organizing to the potential or informal woman’s cardiac output is delivered to the community leaders through a training program. uterus, therefore, blood loss can occur quite24. Answer: (D) To maximize the community’s rapidly in the event of uncontrolled bleeding. resources in dealing with health problems. 33. Answer: (D) Physiologic anemia Rationale: Community organizing is a Rationale: Hemoglobin values and hematocrit developmental service, with the goal of decrease during pregnancy as the increase in developing the people’s self-reliance in dealing plasma volume exceeds the increase in red with community health problems. A, B and C blood cell production. are objectives of contributory objectives to this 34. Answer: (D) A 2 year old infant with stridorous goal. breath sounds, sitting up in his mother’s arms25. Answer: (D) Terminal and drooling. Rationale: Tertiary prevention involves Rationale: The infant with the airway rehabilitation, prevention of permanent emergency should be treated first, because of disability and disability limitations appropriate the risk of epiglottitis. for convalescents, the disabled, complicated 35. Answer: (A) Placenta previa cases and the terminally ill (those in the Rationale: Placenta previa with painless vaginal terminal stage of a disease). bleeding.26. Answer: (A) Intrauterine fetal death. 36. Answer: (D) Early in the morning
  • 86. Rationale: Based on the nurse’s knowledge of nurse should withhold the potassium and notify microbiology, the specimen should be collected the physician. early in the morning. The rationale for this 44. Answer: (c) Laundry detergent timing is that, because the female worm lays Rationale: Eczema or dermatitis is an allergic eggs at night around the perineal area, the first skin reaction caused by an offending allergen. bowel movement of the day will yield the best The topical allergen that is the most common results. The specific type of stool specimen causative factor is laundry detergent. used in the diagnosis of pinworms is called the 45. Answer: (A) 6 inches tape test. Rationale: This distance allows for easy flow of 37. Answer: (A) Irritability and seizures the formula by gravity, but the flow will be slow Rationale: Lead poisoning primarily affects the enough not to overload the stomach too CNS, causing increased intracranial pressure. rapidly. This condition results in irritability and changes 46. Answer: (A) The older one gets, the more in level of consciousness, as well as seizure susceptible he becomes to the complications of disorders, hyperactivity, and learning chicken pox. disabilities. Rationale: Chicken pox is usually more severe in 38. Answer: (D) “I really need to use the diaphragm adults than in children. Complications, such as and jelly most during the middle of my pneumonia, are higher in incidence in adults. menstrual cycle”. 47. Answer: (D) Consult a physician who may give Rationale: The woman must understand that, them rubella immunoglobulin. although the “fertile” period is approximately Rationale: Rubella vaccine is made up of mid-cycle, hormonal variations do occur and attenuated German measles viruses. This is can result in early or late ovulation. To be contraindicated in pregnancy. Immune globulin, effective, the diaphragm should be inserted a specific prophylactic against German measles, before every intercourse. may be given to pregnant women. 39. Answer: (C) Restlessness 48. Answer: (A) Contact tracing Rationale: In a child, restlessness is the earliest Rationale: Contact tracing is the most practical sign of hypoxia. Late signs of hypoxia in a child and reliable method of finding possible sources are associated with a change in color, such as of person-to-person transmitted infections, pallor or cyanosis. such as sexually transmitted diseases. 40. Answer: (B) Walk one step ahead, with the 49. Answer: (D) Leptospirosis child’s hand on the nurse’s elbow. Rationale: Leptospirosis is transmitted through Rationale: This procedure is generally contact with the skin or mucous membrane recommended to follow in guiding a person with water or moist soil contaminated with who is blind. urine of infected animals, like rats. 41. Answer: (A) Loud, machinery-like murmur. 50. Answer: (B) Cholera Rationale: A loud, machinery-like murmur is a Rationale: Passage of profuse watery stools is characteristic finding associated with patent the major symptom of cholera. Both amebic ductus arteriosus. and bacillary dysentery are characterized by the 42. Answer: (C) More oxygen, and the newborn’s presence of blood and/or mucus in the stools. metabolic rate increases. Giardiasis is characterized by fat malabsorption Rationale: When cold, the infant requires more and, therefore, steatorrhea. oxygen and there is an increase in metabolic 51. Answer: (A) Hemophilus influenzae rate. Non-shievering thermogenesis is a Rationale: Hemophilus meningitis is unusual complex process that increases the metabolic over the age of 5 years. In developing countries, rate and rate of oxygen consumption, the peak incidence is in children less than 6 therefore, the newborn increase heat months of age. Morbillivirus is the etiology of production. measles. Streptococcus pneumonia and 43. Answer: (D) Voided Neisseria meningitidis may cause meningitis, Rationale: Before administering potassium I.V. but age distribution is not specific in young to any client, the nurse must first check that the children. client’s kidneys are functioning and that the 52. Answer: (B) Buccal mucosa client is voiding. If the client is not voiding, the86
  • 87. 87 Rationale: Koplik’s spot may be seen on the Rationale: A sick child aged 2 months to 5 years mucosa of the mouth or the throat. must be referred urgently to a hospital if53. Answer: (A) 3 seconds he/she has one or more of the following signs: Rationale: Adequate blood supply to the area not able to feed or drink, vomits everything, allows the return of the color of the nailbed convulsions, abnormally sleepy or difficult to within 3 seconds. awaken.54. Answer: (B) Severe dehydration 62. Answer: (A) Refer the child urgently to a Rationale: The order of priority in the hospital for confinement. management of severe dehydration is as Rationale: “Baggy pants” is a sign of severe follows: intravenous fluid therapy, referral to a marasmus. The best management is urgent facility where IV fluids can be initiated within 30 referral to a hospital. minutes, Oresol or nasogastric tube. When the 63. Answer: (D) Let the child rest for 10 minutes foregoing measures are not possible or then continue giving Oresol more slowly. effective, then urgent referral to the hospital is Rationale: If the child vomits persistently, that done. is, he vomits everything that he takes in, he has55. Answer: (A) 45 infants to be referred urgently to a hospital. Otherwise, Rationale: To estimate the number of infants, vomiting is managed by letting the child rest for multiply total population by 3%. 10 minutes and then continuing with Oresol56. Answer: (A) DPT administration. Teach the mother to give Oresol Rationale: DPT is sensitive to freezing. The more slowly. appropriate storage temperature of DPT is 2 to 64. Answer: (B) Some dehydration 8° C only. OPV and measles vaccine are highly Rationale: Using the assessment guidelines of sensitive to heat and require freezing. MMR is IMCI, a child (2 months to 5 years old) with not an immunization in the Expanded Program diarrhea is classified as having SOME on Immunization. DEHYDRATION if he shows 2 or more of the57. Answer: (C) Proper use of sanitary toilets following signs: restless or irritable, sunken Rationale: The ova of the parasite get out of the eyes, the skin goes back slow after a skin pinch. human body together with feces. Cutting the 65. Answer: (C) Normal cycle at this stage is the most effective way of Rationale: In IMCI, a respiratory rate of preventing the spread of the disease to 50/minute or more is fast breathing for an susceptible hosts. infant aged 2 to 12 months.58. Answer: (D) 5 skin lesions, positive slit skin 66. Answer: (A) 1 year smear Rationale: The baby will have passive natural Rationale: A multibacillary leprosy case is one immunity by placental transfer of antibodies. who has a positive slit skin smear and at least 5 The mother will have active artificial immunity skin lesions. lasting for about 10 years. 5 doses will give the59. Answer: (C) Thickened painful nerves mother lifetime protection. Rationale: The lesion of leprosy is not macular. 67. Answer: (B) 4 hours It is characterized by a change in skin color Rationale: While the unused portion of other (either reddish or whitish) and loss of sensation, biologicals in EPI may be given until the end of sweating and hair growth over the lesion. the day, only BCG is discarded 4 hours after Inability to close the eyelids (lagophthalmos) reconstitution. This is why BCG immunization is and sinking of the nosebridge are late scheduled only in the morning. symptoms. 68. Answer: (B) 6 months60. Answer: (B) Ask where the family resides. Rationale: After 6 months, the baby’s nutrient Rationale: Because malaria is endemic, the first needs, especially the baby’s iron requirement, question to determine malaria risk is where the can no longer be provided by mother’s milk client’s family resides. If the area of residence is alone. not a known endemic area, ask if the child had 69. Answer: (C) 24 weeks traveled within the past 6 months, where she Rationale: At approximately 23 to 24 weeks’ was brought and whether she stayed overnight gestation, the lungs are developed enough to in that area. sometimes maintain extrauterine life. The lungs61. Answer: (A) Inability to drink are the most immature system during the
  • 88. gestation period. Medical care for premature Infants aren’t given tub bath but are sponged labor begins much earlier (aggressively at 21 off until the cord falls off. Petroleum jelly weeks’ gestation) prevents the cord from drying and encourages 70. Answer: (B) Sudden infant death syndrome infection. Peroxide could be painful and isn’t (SIDS) recommended. Rationale: Supine positioning is recommended 77. Answer: (B) Conjunctival hemorrhage to reduce the risk of SIDS in infancy. The risk of Rationale: Conjunctival hemorrhages are aspiration is slightly increased with the supine commonly seen in neonates secondary to the position. Suffocation would be less likely with cranial pressure applied during the birth an infant supine than prone and the position process. Bulging fontanelles are a sign of for GER requires the head of the bed to be intracranial pressure. Simian creases are elevated. present in 40% of the neonates with trisomy 21. 71. Answer: (C) Decreased temperature Cystic hygroma is a neck mass that can affect Rationale: Temperature instability, especially the airway. when it results in a low temperature in the 78. Answer: (B) To assess for prolapsed cord neonate, may be a sign of infection. The Rationale: After a client has an amniotomy, the neonate’s color often changes with an infection nurse should assure that the cord isnt process but generally becomes ashen or prolapsed and that the baby tolerated the mottled. The neonate with an infection will procedure well. The most effective way to do usually show a decrease in activity level or this is to check the fetal heart rate. Fetal well- lethargy. being is assessed via a nonstress test. Fetal 72. Answer: (D) Polycythemia probably due to position is determined by vaginal examination. chronic fetal hypoxia Artificial rupture of membranes doesnt Rationale: The small-for-gestation neonate is at indicate an imminent delivery. risk for developing polycythemia during the 79. Answer: (D) The parents’ interactions with each transitional period in an attempt to decrease other. hypoxia. The neonates are also at increased risk Rationale: Parental interaction will provide the for developing hypoglycemia and hypothermia nurse with a good assessment of the stability of due to decreased glycogen stores. the familys home life but it has no indication 73. Answer: (C) Desquamation of the epidermis for parental bonding. Willingness to touch and Rationale: Postdate fetuses lose the vernix hold the newborn, expressing interest about caseosa, and the epidermis may become the newborns size, and indicating a desire to desquamated. These neonates are usually very see the newborn are behaviors indicating alert. Lanugo is missing in the postdate parental bonding. neonate. 80. Answer: (B) Instructing the client to use two or 74. Answer: (C) Respiratory depression more peripads to cushion the area Rationale: Magnesium sulfate crosses the Rationale: Using two or more peripads would placenta and adverse neonatal effects are do little to reduce the pain or promote perineal respiratory depression, hypotonia, and healing. Cold applications, sitz baths, and Kegel bradycardia. The serum blood sugar isn’t exercises are important measures when the affected by magnesium sulfate. The neonate client has a fourth-degree laceration. would be floppy, not jittery. 81. Answer: (C) “What is your expected due date?” 75. Answer: (C) Respiratory rate 40 to 60 Rationale: When obtaining the history of a breaths/minute client who may be in labor, the nurses highest Rationale: A respiratory rate 40 to 60 priority is to determine her current status, breaths/minute is normal for a neonate during particularly her due date, gravidity, and parity. the transitional period. Nasal flaring, Gravidity and parity affect the duration of labor respiratory rate more than 60 breaths/minute, and the potential for labor complications. Later, and audible grunting are signs of respiratory the nurse should ask about chronic illnesses, distress. allergies, and support persons. 76. Answer: (C) Keep the cord dry and open to air 82. Answer: (D) Aspirate the neonate’s nose and Rationale: Keeping the cord dry and open to air mouth with a bulb syringe. helps reduce infection and hastens drying.88
  • 89. 89 Rationale: The nurses first action should be to Rationale: The type of placenta that develops in clear the neonates airway with a bulb syringe. monozygotic twins depends on the time at After the airway is clear and the neonates color which cleavage of the ovum occurs. Cleavage in improves, the nurse should comfort and calm conjoined twins occurs more than 13 days after the neonate. If the problem recurs or the fertilization. Cleavage that occurs less than 3 neonates color doesnt improve readily, the day after fertilization results in diamniotic nurse should notify the physician. dicchorionic twins. Cleavage that occurs Administering oxygen when the airway isnt between days 3 and 8 results in diamniotic clear would be ineffective. monochorionic twins. Cleavage that occurs83. Answer: (C) Conducting a bedside ultrasound between days 8 to 13 result in monoamniotic for an amniotic fluid index. monochorionic twins. Rationale: It isnt within a nurses scope of 88. Answer: (D) Ultrasound practice to perform and interpret a bedside Rationale: Once the mother and the fetus are ultrasound under these conditions and without stabilized, ultrasound evaluation of the specialized training. Observing for pooling of placenta should be done to determine the straw-colored fluid, checking vaginal discharge cause of the bleeding. Amniocentesis is with nitrazine paper, and observing for flakes of contraindicated in placenta previa. A digital or vernix are appropriate assessments for speculum examination shouldn’t be done as determining whether a client has ruptured this may lead to severe bleeding or membranes. hemorrhage. External fetal monitoring won’t84. Answer: (C) Monitor partial pressure of oxygen detect a placenta previa, although it will detect (Pao2) levels. fetal distress, which may result from blood loss Rationale: Monitoring PaO2 levels and reducing or placenta separation. the oxygen concentration to keep PaO2 within 89. Answer: (A) Increased tidal volume normal limits reduces the risk of retinopathy of Rationale: A pregnant client breathes deeper, prematurity in a premature infant receiving which increases the tidal volume of gas moved oxygen. Covering the infants eyes and in and out of the respiratory tract with each humidifying the oxygen dont reduce the risk of breath. The expiratory volume and residual retinopathy of prematurity. Because cooling volume decrease as the pregnancy progresses. increases the risk of acidosis, the infant should The inspiratory capacity increases during be kept warm so that his respiratory distress pregnancy. The increased oxygen consumption isnt aggravated. in the pregnant client is 15% to 20% greater85. Answer: (A) 110 to 130 calories per kg. than in the nonpregnant state. Rationale: Calories per kg is the accepted way 90. Answer: (A) Diet of determined appropriate nutritional intake Rationale: Clients with gestational diabetes are for a newborn. The recommended calorie usually managed by diet alone to control their requirement is 110 to 130 calories per kg of glucose intolerance. Oral hypoglycemic drugs newborn body weight. This level will maintain a are contraindicated in pregnancy. Long-acting consistent blood glucose level and provide insulin usually isn’t needed for blood glucose enough calories for continued growth and control in the client with gestational diabetes. development. 91. Answer: (D) Seizure86. Answer: (C) 30 to 32 weeks Rationale: The anticonvulsant mechanism of Rationale: Individual twins usually grow at the magnesium is believes to depress seizure foci in same rate as singletons until 30 to 32 weeks’ the brain and peripheral neuromuscular gestation, then twins don’t’ gain weight as blockade. Hypomagnesemia isn’t a rapidly as singletons of the same gestational complication of preeclampsia. Antihypertensive age. The placenta can no longer keep pace with drug other than magnesium are preferred for the nutritional requirements of both fetuses sustained hypertension. Magnesium doesn’t after 32 weeks, so there’s some growth help prevent hemorrhage in preeclamptic retardation in twins if they remain in utero at clients. 38 to 40 weeks. 92. Answer: (C) I.V. fluids87. Answer: (A) conjoined twins Rationale: A sickle cell crisis during pregnancy is usually managed by exchange transfusion
  • 90. oxygen, and L.V. Fluids. The client usually needs position promotes comfort by taking advantage a stronger analgesic than acetaminophen to of gravity. The standing position also takes control the pain of a crisis. Antihypertensive advantage of gravity and aligns the fetus with drugs usually aren’t necessary. Diuretic the pelvic angle. wouldn’t be used unless fluid overload resulted. 98. Answer: (B) Irritability and poor sucking. 93. Answer: (A) Calcium gluconate (Kalcinate) Rationale: Neonates of heroin-addicted Rationale: Calcium gluconate is the antidote for mothers are physically dependent on the drug magnesium toxicity. Ten milliliters of 10% and experience withdrawal when the drug is no calcium gluconate is given L.V. push over 3 to 5 longer supplied. Signs of heroin withdrawal minutes. Hydralazine is given for sustained include irritability, poor sucking, and elevated blood pressure in preeclamptic clients. restlessness. Lethargy isnt associated with Rho (D) immune globulin is given to women neonatal heroin addiction. A flattened nose, with Rh-negative blood to prevent antibody small eyes, and thin lips are seen in infants with formation from RH-positive conceptions. fetal alcohol syndrome. Heroin use during Naloxone is used to correct narcotic toxicity. pregnancy hasnt been linked to specific 94. Answer: (B) An indurated wheal over 10 mm in congenital anomalies. diameter appears in 48 to 72 hours. 99. Answer: (A) 7th to 9th day postpartum Rationale: A positive PPD result would be an Rationale: The normal involutional process indurated wheal over 10 mm in diameter that returns the uterus to the pelvic cavity in 7 to 9 appears in 48 to 72 hours. The area must be a days. A significant involutional complication is raised wheal, not a flat circumcised area to be the failure of the uterus to return to the pelvic considered positive. cavity within the prescribed time period. This is 95. Answer: (C) Pyelonephritis known as subinvolution. Rationale The symptoms indicate acute 100. Answer: (B) Uterine atony pyelonephritis, a serious condition in a Rationale: Multiple fetuses, extended labor pregnant client. UTI symptoms include dysuria, stimulation with oxytocin, and traumatic urgency, frequency, and suprapubic delivery commonly are associated with uterine tenderness. Asymptomatic bacteriuria doesn’t atony, which may lead to postpartum cause symptoms. Bacterial vaginosis causes hemorrhage. Uterine inversion may precede or milky white vaginal discharge but no systemic follow delivery and commonly results from symptoms. apparent excessive traction on the umbilical 96. Answer: (B) Rh-positive fetal blood crosses into cord and attempts to deliver the placenta maternal blood, stimulating maternal manually. Uterine involution and some uterine antibodies. discomfort are normal after delivery. Rationale: Rh isoimmunization occurs when Rh- positive fetal blood cells cross into the maternal circulation and stimulate maternal antibody production. In subsequent pregnancies with Rh- positive fetuses, maternal antibodies may cross back into the fetal circulation and destroy the fetal blood cells. 97. Answer: (C) Supine position Rationale: The supine position causes compression of the clients aorta and inferior vena cava by the fetus. This, in turn, inhibits maternal circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other positions promote comfort and aid labor progress. For instance, the lateral, or side-lying, position improves maternal and fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle tension, and eliminates pressure points. The squatting90
  • 91. 91TEST III - Care of Clients with Physiologic and 6. Nurse Monett is caring for a client recoveringPsychosocial Alterations from gastro-intestinal bleeding. The nurse should: 1. Nurse Michelle should know that the drainage is a. Plan care so the client can receive 8 normal 4 days after a sigmoid colostomy when hours of uninterrupted sleep each night. the stool is: b. Monitor vital signs every 2 hours. a. Green liquid c. Make sure that the client takes food and b. Solid formed medications at prescribed intervals. c. Loose, bloody d. Provide milk every 2 to 3 hours. d. Semiformed 7. A male client was on warfarin (Coumadin) before 2. Where would nurse Kristine place the call light admission, and has been receiving heparin I.V. for a male client with a right-sided brain attack for 2 days. The partial thromboplastin time (PTT) and left homonymous hemianopsia? is 68 seconds. What should Nurse Carla do? a. On the client’s right side a. Stop the I.V. infusion of heparin and b. On the client’s left side notify the physician. c. Directly in front of the client b. Continue treatment as ordered. d. Where the client like c. Expect the warfarin to increase the PTT. d. Increase the dosage, because the level is 3. A male client is admitted to the emergency lower than normal. department following an accident. What are the first nursing actions of the nurse? 8. A client undergone ileostomy, when should the a. Check respiration, circulation, drainage appliance be applied to the stoma? neurological response. a. 24 hours later, when edema has b. Align the spine, check pupils, and check subsided. for hemorrhage. b. In the operating room. c. Check respirations, stabilize spine, and c. After the ileostomy begin to function. check circulation. d. When the client is able to begin self-care d. Assess level of consciousness and procedures. circulation. 9. A client undergone spinal anesthetic, it will be 4. In evaluating the effect of nitroglycerin, Nurse important that the nurse immediately position Arthur should know that it reduces preload and the client in: relieves angina by: a. On the side, to prevent obstruction of a. Increasing contractility and slowing airway by tongue. heart rate. b. Flat on back. b. Increasing AV conduction and heart rate. c. On the back, with knees flexed 15 c. Decreasing contractility and oxygen degrees. consumption. d. Flat on the stomach, with the head d. Decreasing venous return through turned to the side. vasodilation. 10. While monitoring a male client several hours 5. Nurse Patricia finds a female client who is post- after a motor vehicle accident, which myocardial infarction (MI) slumped on the side assessment data suggest increasing intracranial rails of the bed and unresponsive to shaking or pressure? shouting. Which is the nurse next action? a. Blood pressure is decreased from a. Call for help and note the time. 160/90 to 110/70. b. Clear the airway b. Pulse is increased from 87 to 95, with an c. Give two sharp thumps to the occasional skipped beat. precordium, and check the pulse. c. The client is oriented when aroused d. Administer two quick blows. from sleep, and goes back to sleep immediately.
  • 92. d. The client refuses dinner because of 16. Nurse John is caring for a male client receiving anorexia. lidocaine I.V. Which factor is the most relevant to administration of this medication? 11. Mrs. Cruz, 80 years old is diagnosed with a. Decrease in arterial oxygen saturation pneumonia. Which of the following symptoms (SaO2) when measured with a pulse may appear first? oximeter. a. Altered mental status and dehydration b. Increase in systemic blood pressure. b. Fever and chills c. Presence of premature ventricular c. Hemoptysis and Dyspnea contractions (PVCs) on a cardiac d. Pleuritic chest pain and cough monitor. d. Increase in intracranial pressure (ICP). 12. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit? 17. Nurse Ron is caring for a male client taking an a. Chest and lower back pain anticoagulant. The nurse should teach the client b. Chills, fever, night sweats, and to: hemoptysis a. Report incidents of diarrhea. c. Fever of more than 104°F (40°C) and b. Avoid foods high in vitamin K nausea c. Use a straight razor when shaving. d. Headache and photophobia d. Take aspirin to pain relief. 13. Mark, a 7-year-old client is brought to the 18. Nurse Lhynnette is preparing a site for the emergency department. He’s tachypneic and insertion of an I.V. catheter. The nurse should afebrile and has a respiratory rate of 36 treat excess hair at the site by: breaths/minute and has a nonproductive cough. a. Leaving the hair intact He recently had a cold. Form this history; the b. Shaving the area client may have which of the following c. Clipping the hair in the area conditions? d. Removing the hair with a depilatory. a. Acute asthma b. Bronchial pneumonia 19. Nurse Michelle is caring for an elderly female c. Chronic obstructive pulmonary disease with osteoporosis. When teaching the client, the (COPD) nurse should include information about which d. Emphysema major complication: a. Bone fracture 14. Marichu was given morphine sulfate for pain. b. Loss of estrogen She is sleeping and her respiratory rate is 4 c. Negative calcium balance breaths/minute. If action isn’t taken quickly, she d. Dowager’s hump might have which of the following reactions? a. Asthma attack 20. Nurse Len is teaching a group of women to b. Respiratory arrest perform BSE. The nurse should explain that the c. Seizure purpose of performing the examination is to d. Wake up on his own discover: a. Cancerous lumps 15. A 77-year-old male client is admitted for elective b. Areas of thickness or fullness knee surgery. Physical examination reveals c. Changes from previous examinations. shallow respirations but no sign of respiratory d. Fibrocystic masses distress. Which of the following is a normal physiologic change related to aging? 21. When caring for a female client who is being a. Increased elastic recoil of the lungs treated for hyperthyroidism, it is important to: b. Increased number of functional a. Provide extra blankets and clothing to capillaries in the alveoli keep the client warm. c. Decreased residual volume b. Monitor the client for signs of d. Decreased vital capacity restlessness, sweating, and excessive92
  • 93. 93 weight loss during thyroid replacement During routine assessment, the nurse notices therapy. Cheyne- Strokes respirations. Cheyne-strokes c. Balance the client’s periods of activity respirations are: and rest. a. A progressively deeper breaths followed d. Encourage the client to be active to by shallower breaths with apneic prevent constipation. periods. b. Rapid, deep breathing with abrupt22. Nurse Kris is teaching a client with history of pauses between each breath. atherosclerosis. To decrease the risk of c. Rapid, deep breathing and irregular atherosclerosis, the nurse should encourage the breathing without pauses. client to: d. Shallow breathing with an increased a. Avoid focusing on his weight. respiratory rate. b. Increase his activity level. c. Follow a regular diet. 28. Nurse Bea is assessing a male client with heart d. Continue leading a high-stress lifestyle. failure. The breath sounds commonly auscultated in clients with heart failure are:23. Nurse Greta is working on a surgical floor. Nurse a. Tracheal Greta must logroll a client following a: b. Fine crackles a. Laminectomy c. Coarse crackles b. Thoracotomy d. Friction rubs c. Hemorrhoidectomy d. Cystectomy. 29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing24. A 55-year old client underwent cataract removal and breath sounds aren’t audible. The reason for with intraocular lens implant. Nurse Oliver is this change is that: giving the client discharge instructions. These a. The attack is over. instructions should include which of the b. The airways are so swollen that no air following? cannot get through. a. Avoid lifting objects weighing more than c. The swelling has decreased. 5 lb (2.25 kg). d. Crackles have replaced wheezes. b. Lie on your abdomen when in bed c. Keep rooms brightly lit. 30. Mike with epilepsy is having a seizure. During d. Avoiding straining during bowel the active seizure phase, the nurse should: movement or bending at the waist. a. Place the client on his back remove dangerous objects, and insert a bite25. George should be taught about testicular block. examinations during: b. Place the client on his side, remove a. when sexual activity starts dangerous objects, and insert a bite b. After age 69 block. c. After age 40 c. Place the client o his back, remove d. Before age 20. dangerous objects, and hold down his26. A male client undergone a colon resection. While arms. turning him, wound dehiscence with d. Place the client on his side, remove evisceration occurs. Nurse Trish first response is dangerous objects, and protect his head. to: a. Call the physician 31. After insertion of a cheat tube for a b. Place a saline-soaked sterile dressing on pneumothorax, a client becomes hypotensive the wound. with neck vein distention, tracheal shift, absent c. Take a blood pressure and pulse. breath sounds, and diaphoresis. Nurse Amanda d. Pull the dehiscence closed. suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the27. Nurse Audrey is caring for a client who has nurse check for? suffered a severe cerebrovascular accident. a. Infection of the lung.
  • 94. b. Kinked or obstructed chest tube tuberculosis (TB). Which of the following clients c. Excessive water in the water-seal entering the clinic today most likely to have TB? chamber a. A 16-year-old female high school d. Excessive chest tube drainage student b. A 33-year-old day-care worker 32. Nurse Maureen is talking to a male client; the c. A 43-yesr-old homeless man with a client begins choking on his lunch. He’s coughing history of alcoholism forcefully. The nurse should: d. A 54-year-old businessman a. Stand him up and perform the abdominal thrust maneuver from 37. Virgie with a positive Mantoux test result will be behind. sent for a chest X-ray. The nurse is aware that b. Lay him down, straddle him, and which of the following reasons this is done? perform the abdominal thrust a. To confirm the diagnosis maneuver. b. To determine if a repeat skin test is c. Leave him to get assistance needed d. Stay with him but not intervene at this c. To determine the extent of lesions time. d. To determine if this is a primary or secondary infection 33. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful 38. Kennedy with acute asthma showing inspiratory to the nurse for planning care? and expiratory wheezes and a decreased forced a. General health for the last 10 years. expiratory volume should be treated with which b. Current health promotion activities. of the following classes of medication right c. Family history of diseases. away? d. Marital status. a. Beta-adrenergic blockers b. Bronchodilators 34. When performing oral care on a comatose client, c. Inhaled steroids Nurse Krina should: d. Oral steroids a. Apply lemon glycerin to the client’s lips at least every 2 hours. 39. Mr. Vasquez 56-year-old client with a 40-year b. Brush the teeth with client lying supine. history of smoking one to two packs of cigarettes c. Place the client in a side lying position, per day has a chronic cough producing thick with the head of the bed lowered. sputum, peripheral edema and cyanotic nail d. Clean the client’s mouth with hydrogen beds. Based on this information, he most likely peroxide. has which of the following conditions? a. Adult respiratory distress syndrome 35. A 77-year-old male client is admitted with a (ARDS) diagnosis of dehydration and change in mental b. Asthma status. He’s being hydrated with L.V. fluids. c. Chronic obstructive bronchitis When the nurse takes his vital signs, she notes d. Emphysema he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest Situation: Francis, age 46 is admitted to the hospital with pain. The nurse suspects this client may have diagnosis of Chronic Lymphocytic Leukemia. which of the following conditions? a. Adult respiratory distress syndrome 40. The treatment for patients with leukemia is bone (ARDS) marrow transplantation. Which statement about b. Myocardial infarction (MI) bone marrow transplantation is not correct? c. Pneumonia a. The patient is under local anesthesia d. Tuberculosis during the procedure b. The aspirated bone marrow is mixed 36. Nurse Oliver is working in an outpatient clinic. with heparin. He has been alerted that there is an outbreak of c. The aspiration site is the posterior or anterior iliac crest.94
  • 95. 95 d. The recipient receives pressure of 126/76 mm Hg, and a cyclophosphamide (Cytoxan) for 4 respiratory rate of 22 breaths/ minute. consecutive days before the procedure. b. The 89-year-old client with end-stage41. After several days of admission, Francis becomes right-sided heart failure, blood pressure disoriented and complains of frequent of 78/50 mm Hg, and a “do not headaches. The nurse in-charge first action resuscitate” order would be: c. The 62-year-old client who was admitted a. Call the physician 1 day ago with thrombophlebitis and is b. Document the patient’s status in his receiving L.V. heparin charts. d. The 75-year-old client who was admitted c. Prepare oxygen treatment 1 hour ago with new-onset atrial d. Raise the side rails fibrillation and is receiving L.V. dilitiazem (Cardizem)42. During routine care, Francis asks the nurse, “How can I be anemic if this disease causes 46. Honey, a 23-year old client complains of increased my white blood cell production?” The substernal chest pain and states that her heart nurse in-charge best response would be that the feels like “it’s racing out of the chest”. She increased number of white blood cells (WBC) is: reports no history of cardiac disorders. The a. Crowd red blood cells nurse attaches her to a cardiac monitor and b. Are not responsible for the anemia. notes sinus tachycardia with a rate of c. Uses nutrients from other cells 136beats/minutes. Breath sounds are clear and d. Have an abnormally short life span of the respiratory rate is 26 breaths/minutes. cells. Which of the following drugs should the nurse question the client about using?43. Diagnostic assessment of Francis would probably a. Barbiturates not reveal: b. Opioids a. Predominance of lymhoblasts c. Cocaine b. Leukocytosis d. Benzodiazepines c. Abnormal blast cells in the bone marrow d. Elevated thrombocyte counts 47. A 51-year-old female client tells the nurse in- charge that she has found a painless lump in her44. Robert, a 57-year-old client with acute arterial right breast during her monthly self- occlusion of the left leg undergoes an examination. Which assessment finding would emergency embolectomy. Six hours later, the strongly suggest that this clients lump is nurse isn’t able to obtain pulses in his left foot cancerous? using Doppler ultrasound. The nurse a. Eversion of the right nipple and mobile immediately notifies the physician, and asks her mass to prepare the client for surgery. As the nurse b. Nonmobile mass with irregular edges enters the client’s room to prepare him, he c. Mobile mass that is soft and easily states that he won’t have any more surgery. delineated Which of the following is the best initial d. Nonpalpable right axillary lymph nodes response by the nurse? a. Explain the risks of not having the 48. A 35-year-old client with vaginal cancer asks the surgery nurse, "What is the usual treatment for this type b. Notifying the physician immediately of cancer?" Which treatment should the nurse c. Notifying the nursing supervisor name? d. Recording the client’s refusal in the a. Surgery nurses’ notes b. Chemotherapy c. Radiation45. During the endorsement, which of the following d. Immunotherapy clients should the on-duty nurse assess first? a. The 58-year-old client who was admitted 49. Cristina undergoes a biopsy of a suspicious 2 days ago with heart failure, blood lesion. The biopsy report classifies the lesion
  • 96. according to the TNM staging system as follows: a. prostate-specific antigen, which is used TIS, N0, M0. What does this classification mean? to screen for prostate cancer. a. No evidence of primary tumor, no b. protein serum antigen, which is used to abnormal regional lymph nodes, and no determine protein levels. evidence of distant metastasis c. pneumococcal strep antigen, which is a b. Carcinoma in situ, no abnormal regional bacteria that causes pneumonia. lymph nodes, and no evidence of distant d. Papanicolaou-specific antigen, which is metastasis used to screen for cervical cancer. c. Cant assess tumor or regional lymph nodes and no evidence of metastasis 54. What is the most important postoperative d. Carcinoma in situ, no demonstrable instruction that nurse Kate must give a client metastasis of the regional lymph nodes, who has just returned from the operating room and ascending degrees of distant after receiving a subarachnoid block? metastasis a. "Avoid drinking liquids until the gag reflex returns." 50. Lydia undergoes a laryngectomy to treat b. "Avoid eating milk products for 24 laryngeal cancer. When teaching the client how hours." to care for the neck stoma, the nurse should c. "Notify a nurse if you experience blood include which instruction? in your urine." a. "Keep the stoma uncovered." d. "Remain supine for the time specified by b. "Keep the stoma dry." the physician." c. "Have a family member perform stoma care initially until you get used to the 55. A male client suspected of having colorectal procedure." cancer will require which diagnostic study to d. "Keep the stoma moist." confirm the diagnosis? a. Stool Hematest 51. A 37-year-old client with uterine cancer asks the b. Carcinoembryonic antigen (CEA) nurse, "Which is the most common type of c. Sigmoidoscopy cancer in women?" The nurse replies that its d. Abdominal computed tomography (CT) breast cancer. Which type of cancer causes the scan most deaths in women? a. Breast cancer 56. During a breast examination, which finding most b. Lung cancer strongly suggests that the Luz has breast cancer? c. Brain cancer a. Slight asymmetry of the breasts. d. Colon and rectal cancer b. A fixed nodular mass with dimpling of the overlying skin 52. Antonio with lung cancer develops Horners c. Bloody discharge from the nipple syndrome when the tumor invades the ribs and d. Multiple firm, round, freely movable affects the sympathetic nerve ganglia. When masses that change with the menstrual assessing for signs and symptoms of this cycle syndrome, the nurse should note: a. miosis, partial eyelid ptosis, and 57. A female client with cancer is being evaluated anhidrosis on the affected side of the for possible metastasis. Which of the following is face. one of the most common metastasis sites for b. chest pain, dyspnea, cough, weight loss, cancer cells? and fever. a. Liver c. arm and shoulder pain and atrophy of b. Colon arm and hand muscles, both on the c. Reproductive tract affected side. d. White blood cells (WBCs) d. hoarseness and dysphagia. 58. Nurse Mandy is preparing a client for magnetic 53. Vic asks the nurse what PSA is. The nurse should resonance imaging (MRI) to confirm or rule out a reply that it stands for:96
  • 97. 97 spinal cord lesion. During the MRI scan, which of 63. A 76-year-old male client had a thromboembolic the following would pose a threat to the client? right stroke; his left arm is swollen. Which of the a. The client lies still. following conditions may cause swelling after a b. The client asks questions. stroke? c. The client hears thumping sounds. a. Elbow contracture secondary to d. The client wears a watch and wedding spasticity band. b. Loss of muscle contraction decreasing venous return59. Nurse Cecile is teaching a female client about c. Deep vein thrombosis (DVT) due to preventing osteoporosis. Which of the following immobility of the ipsilateral side teaching points is correct? d. Hypoalbuminemia due to protein a. Obtaining an X-ray of the bones every 3 escaping from an inflamed glomerulus years is recommended to detect bone loss. 64. Heberden’s nodes are a common sign of b. To avoid fractures, the client should osteoarthritis. Which of the following statement avoid strenuous exercise. is correct about this deformity? c. The recommended daily allowance of a. It appears only in men calcium may be found in a wide variety b. It appears on the distal interphalangeal of foods. joint d. Obtaining the recommended daily c. It appears on the proximal allowance of calcium requires taking a interphalangeal joint calcium supplement. d. It appears on the dorsolateral aspect of the interphalangeal joint.60. Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for 65. Which of the following statements explains the contraindications for this procedure. Which main difference between rheumatoid arthritis finding is a contraindication? and osteoarthritis? a. Joint pain a. Osteoarthritis is gender-specific, b. Joint deformity rheumatoid arthritis isn’t c. Joint flexion of less than 50% b. Osteoarthritis is a localized disease d. Joint stiffness rheumatoid arthritis is systemic c. Osteoarthritis is a systemic disease,61. Mr. Rodriguez is admitted with severe pain in rheumatoid arthritis is localized the knees. Which form of arthritis is d. Osteoarthritis has dislocations and characterized by urate deposits and joint pain, subluxations, rheumatoid arthritis usually in the feet and legs, and occurs primarily doesn’t in men over age 30? a. Septic arthritis 66. Mrs. Cruz uses a cane for assistance in walking. b. Traumatic arthritis Which of the following statements is true about c. Intermittent arthritis a cane or other assistive devices? d. Gouty arthritis a. A walker is a better choice than a cane. b. The cane should be used on the affected62. A heparin infusion at 1,500 unit/hour is ordered side for a 64-year-old client with stroke in evolution. c. The cane should be used on the The infusion contains 25,000 units of heparin in unaffected side 500 ml of saline solution. How many milliliters d. A client with osteoarthritis should be per hour should be given? encouraged to ambulate without the a. 15 ml/hour cane b. 30 ml/hour c. 45 ml/hour 67. A male client with type 1 diabetes is scheduled d. 50 ml/hour to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:
  • 98. a. 9 U regular insulin and 21 U neutral c. Restricting fluids protamine Hagedorn (NPH). d. Administering glucose-containing I.V. b. 21 U regular insulin and 9 U NPH. fluids as ordered c. 10 U regular insulin and 20 U NPH. d. 20 U regular insulin and 10 U NPH. 73. A female client tells nurse Nikki that she has been working hard for the last 3 months to 68. Nurse Len should expect to administer which control her type 2 diabetes mellitus with diet medication to a client with gout? and exercise. To determine the effectiveness of a. aspirin the clients efforts, the nurse should check: b. furosemide (Lasix) a. urine glucose level. c. colchicines b. fasting blood glucose level. d. calcium gluconate (Kalcinate) c. serum fructosamine level. d. glycosylated hemoglobin level. 69. Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. 74. Nurse Trinity administered neutral protamine This diagnosis indicates that the clients Hagedorn (NPH) insulin to a diabetic client at 7 hypertension is caused by excessive hormone a.m. At what time would the nurse expect the secretion from which of the following glands? client to be most at risk for a hypoglycemic a. Adrenal cortex reaction? b. Pancreas a. 10:00 am c. Adrenal medulla b. Noon d. Parathyroid c. 4:00 pm d. 10:00 pm 70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wet-to-dry dressing 75. The adrenal cortex is responsible for producing change every shift, and blood glucose which substances? monitoring before meals and bedtime. Why are a. Glucocorticoids and androgens wet-to-dry dressings used for this client? b. Catecholamines and epinephrine a. They contain exudate and provide a c. Mineralocorticoids and catecholamines moist wound environment. d. Norepinephrine and epinephrine b. They protect the wound from mechanical trauma and promote 76. On the third day after a partial thyroidectomy, healing. Proserfina exhibits muscle twitching and c. They debride the wound and promote hyperirritability of the nervous system. When healing by secondary intention. questioned, the client reports numbness and d. They prevent the entrance of tingling of the mouth and fingertips. Suspecting microorganisms and minimize wound a life-threatening electrolyte disturbance, the discomfort. nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows 71. Nurse Zeny is caring for a client in acute thyroid surgery? addisonian crisis. Which laboratory data would a. Hypocalcemia the nurse expect to find? b. Hyponatremia a. Hyperkalemia c. Hyperkalemia b. Reduced blood urea nitrogen (BUN) d. Hypermagnesemia c. Hypernatremia d. Hyperglycemia 77. Which laboratory test value is elevated in clients who smoke and cant be used as a general 72. A client is admitted for treatment of the indicator of cancer? syndrome of inappropriate antidiuretic hormone a. Acid phosphatase level (SIADH). Which nursing intervention is b. Serum calcitonin level appropriate? c. Alkaline phosphatase level a. Infusing I.V. fluids rapidly as ordered d. Carcinoembryonic antigen level b. Encouraging increased oral intake98
  • 99. 9978. Francis with anemia has been admitted to the c. Administer the antidote for penicillin, as medical-surgical unit. Which assessment findings prescribed, and continue to monitor the are characteristic of iron-deficiency anemia? clients vital signs. a. Nights sweats, weight loss, and diarrhea d. Insert an indwelling urinary catheter and b. Dyspnea, tachycardia, and pallor begin to infuse I.V. fluids as ordered. c. Nausea, vomiting, and anorexia d. Itching, rash, and jaundice 83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation.79. In teaching a female client who is HIV-positive When teaching the client about aspirin, the about pregnancy, the nurse would know more nurse discusses adverse reactions to prolonged teaching is necessary when the client says: aspirin therapy. These include: a. The baby can get the virus from my a. weight gain. placenta." b. fine motor tremors. b. "Im planning on starting on birth control c. respiratory acidosis. pills." d. bilateral hearing loss. c. "Not everyone who has the virus gives birth to a baby who has the virus." 84. A 23-year-old client is diagnosed with human d. "Ill need to have a C-section if I become immunodeficiency virus (HIV). After recovering pregnant and have a baby." from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible80. When preparing Judy with acquired about HIV and acquired immunodeficiency immunodeficiency syndrome (AIDS) for syndrome (AIDS). When teaching the client discharge to the home, the nurse should be sure about the immune system, the nurse states that to include which instruction? adaptive immunity is provided by which type of a. "Put on disposable gloves before white blood cell? bathing." a. Neutrophil b. "Sterilize all plates and utensils in boiling b. Basophil water." c. Monocyte c. "Avoid sharing such articles as d. Lymphocyte toothbrushes and razors." d. "Avoid eating foods from serving dishes 85. In an individual with Sjögrens syndrome, nursing shared by other family members." care should focus on: a. moisture replacement.81. Nurse Marie is caring for a 32-year-old client b. electrolyte balance. admitted with pernicious anemia. Which set of c. nutritional supplementation. findings should the nurse expect when assessing d. arrhythmia management. the client? a. Pallor, bradycardia, and reduced pulse 86. During chemotherapy for lymphocytic leukemia, pressure Mathew develops abdominal pain, fever, and b. Pallor, tachycardia, and a sore tongue "horse barn" smelling diarrhea. It would be most c. Sore tongue, dyspnea, and weight gain important for the nurse to advise the physician d. Angina, double vision, and anorexia to order: a. enzyme-linked immunosuppressant82. After receiving a dose of penicillin, a client assay (ELISA) test. develops dyspnea and hypotension. Nurse b. electrolyte panel and hemogram. Celestina suspects the client is experiencing c. stool for Clostridium difficile test. anaphylactic shock. What should the nurse do d. flat plate X-ray of the abdomen. first? a. Page an anesthesiologist immediately 87. A male client seeks medical evaluation for and prepare to intubate the client. fatigue, night sweats, and a 20-lb weight loss in 6 b. Administer epinephrine, as prescribed, weeks. To confirm that the client has been and prepare to intubate the client if infected with the human immunodeficiency virus necessary. (HIV), the nurse expects the physician to order:
  • 100. a. E-rosette immunofluorescence. d. A client with rheumatoid arthritis who b. quantification of T-lymphocytes. states, “I am having trouble sleeping.” c. enzyme-linked immunosorbent assay (ELISA). 92. Nurse Sarah is caring for clients on the surgical d. Western blot test with ELISA. floor and has just received report from the previous shift. Which of the following clients 88. A complete blood count is commonly performed should the nurse see first? before a Joe goes into surgery. What does this a. A 35-year-old admitted three hours ago test seek to identify? with a gunshot wound; 1.5 cm area of a. Potential hepatic dysfunction indicated dark drainage noted on the dressing. by decreased blood urea nitrogen (BUN) b. A 43-year-old who had a mastectomy and creatinine levels two days ago; 23 ml of serosanguinous b. Low levels of urine constituents normally fluid noted in the Jackson-Pratt drain. excreted in the urine c. A 59-year-old with a collapsed lung due c. Abnormally low hematocrit (HCT) and to an accident; no drainage noted in the hemoglobin (Hb) levels previous eight hours. d. Electrolyte imbalance that could affect d. A 62-year-old who had an abdominal- the bloods ability to coagulate properly perineal resection three days ago; client complaints of chills. 89. While monitoring a client for the development of disseminated intravascular coagulation (DIC), 93. Nurse Eve is caring for a client who had a the nurse should take note of what assessment thyroidectomy 12 hours ago for treatment of parameters? Grave’s disease. The nurse would be most a. Platelet count, prothrombin time, and concerned if which of the following was partial thromboplastin time observed? b. Platelet count, blood glucose levels, and a. Blood pressure 138/82, respirations 16, white blood cell (WBC) count oral temperature 99 degrees Fahrenheit. c. Thrombin time, calcium levels, and b. The client supports his head and neck potassium levels when turning his head to the right. d. Fibrinogen level, WBC, and platelet c. The client spontaneously flexes his wrist count when the blood pressure is obtained. d. The client is drowsy and complains of 90. When taking a dietary history from a newly sore throat. admitted female client, Nurse Len should remember that which of the following foods is a 94. Julius is admitted with complaints of severe pain common allergen? in the lower right quadrant of the abdomen. To a. Bread assist with pain relief, the nurse should take b. Carrots which of the following actions? c. Orange a. Encourage the client to change positions d. Strawberries frequently in bed. b. Administer Demerol 50 mg IM q 4 hours 91. Nurse John is caring for clients in the outpatient and PRN. clinic. Which of the following phone calls should c. Apply warmth to the abdomen with a the nurse return first? heating pad. a. A client with hepatitis A who states, “My d. Use comfort measures and pillows to arms and legs are itching.” position the client. b. A client with cast on the right leg who states, “I have a funny feeling in my right 95. Nurse Tina prepares a client for peritoneal leg.” dialysis. Which of the following actions should c. A client with osteomyelitis of the spine the nurse take first? who states, “I am so nauseous that I a. Assess for a bruit and a thrill. can’t eat.” b. Warm the dialysate solution. c. Position the client on the left side.100
  • 101. 101 d. Insert a Foley catheter takes small steps while balancing on the walker.96. Nurse Jannah teaches an elderly client with d. The client slides the walker 18 inches right-sided weakness how to use cane. Which of forward, then takes small steps while the following behaviors, if demonstrated by the holding onto the walker for balance. client to the nurse, indicates that the teaching was effective? 99. Nurse Deric is supervising a group of elderly a. The client holds the cane with his right clients in a residential home setting. The nurse hand, moves the can forward followed knows that the elderly are at greater risk of by the right leg, and then moves the left developing sensory deprivation for what reason? leg. a. Increased sensitivity to the side effects b. The client holds the cane with his right of medications. hand, moves the cane forward followed b. Decreased visual, auditory, and by his left leg, and then moves the right gustatory abilities. leg. c. Isolation from their families and familiar c. The client holds the cane with his left surroundings. hand, moves the cane forward followed d. Decrease musculoskeletal function and by the right leg, and then moves the left mobility. leg. d. The client holds the cane with his left 100. A male client with emphysema becomes hand, moves the cane forward followed restless and confused. What step should by his left leg, and then moves the right nurse Jasmine take next? leg. a. Encourage the client to perform pursed lip breathing.97. An elderly client is admitted to the nursing home b. Check the client’s temperature. setting. The client is occasionally confused and c. Assess the client’s potassium level. her gait is often unsteady. Which of the d. Increase the client’s oxygen flow rate. following actions, if taken by the nurse, is most appropriate? a. Ask the woman’s family to provide personal items such as photos or mementos. b. Select a room with a bed by the door so the woman can look down the hall. c. Suggest the woman eat her meals in the room with her roommate. d. Encourage the woman to ambulate in the halls twice a day.98. Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective? a. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker. b. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward. c. The client supports his weight on the walker while advancing it forward, then
  • 102. digestive enzymes and highly irritating to the skin. Protection of the skin from the effects ofAnswers and Rationale – Care of Clients with these enzymes is begun at once. Skin exposedPhysiologic and Psychosocial Alterations to these enzymes even for a short time becomes reddened, painful, and excoriated. 1. Answer: (C) Loose, bloody 9. Answer: (B) Flat on back. Rationale: Normal bowel function and soft- Rationale: To avoid the complication of a formed stool usually do not occur until around painful spinal headache that can last for the seventh day following surgery. The stool several days, the client is kept in flat in a consistency is related to how much water is supine position for approximately 4 to 12 being absorbed. hours postoperatively. Headaches are 2. Answer: (A) On the client’s right side believed to be causes by the seepage of Rationale: The client has left visual field cerebral spinal fluid from the puncture site. By blindness. The client will see only from the keeping the client flat, cerebral spinal fluid right side. pressures are equalized, which avoids trauma 3. Answer: (C) Check respirations, stabilize spine, to the neurons. and check circulation 10. Answer: (C) The client is oriented when Rationale: Checking the airway would be aroused from sleep, and goes back to sleep priority, and a neck injury should be immediately. suspected. Rationale: This finding suggest that the level 4. Answer: (D) Decreasing venous return through of consciousness is decreasing. vasodilation. 11. Answer: (A) Altered mental status and Rationale: The significant effect of dehydration nitroglycerin is vasodilation and decreased Rationale: Fever, chills, hemortysis, dyspnea, venous return, so the heart does not have to cough, and pleuritic chest pain are the work hard. common symptoms of pneumonia, but elderly 5. Answer: (A) Call for help and note the time. clients may first appear with only an altered Rationale: Having established, by stimulating lentil status and dehydration due to a blunted the client, that the client is unconscious rather immune response. than sleep, the nurse should immediately call 12. Answer: (B) Chills, fever, night sweats, and for help. This may be done by dialing the hemoptysis operator from the client’s phone and giving Rationale: Typical signs and symptoms are the hospital code for cardiac arrest and the chills, fever, night sweats, and hemoptysis. client’s room number to the operator, of if the Chest pain may be present from coughing, but phone is not available, by pulling the isn’t usual. Clients with TB typically have low- emergency call button. Noting the time is grade fevers, not higher than 102°F (38.9°C). important baseline information for cardiac Nausea, headache, and photophobia aren’t arrest procedure usual TB symptoms. 6. Answer: (C) Make sure that the client takes 13. Answer:(A) Acute asthma food and medications at prescribed intervals. Rationale: Based on the client’s history and Rationale: Food and drug therapy will prevent symptoms, acute asthma is the most likely the accumulation of hydrochloric acid, or will diagnosis. He’s unlikely to have bronchial neutralize and buffer the acid that does pneumonia without a productive cough and accumulate. fever and he’s too young to have developed 7. Answer: (B) Continue treatment as ordered. (COPD) and emphysema. Rationale: The effects of heparin are 14. Answer: (B) Respiratory arrest monitored by the PTT is normally 30 to 45 Rationale: Narcotics can cause respiratory seconds; the therapeutic level is 1.5 to 2 times arrest if given in large quantities. It’s unlikely the normal level. the client will have asthma attack or a seizure 8. Answer: (B) In the operating room. or wake up on his own. Rationale: The stoma drainage bag is applied 15. Answer: (D) Decreased vital capacity in the operating room. Drainage from the Rationale: Reduction in vital capacity is a ileostomy contains secretions that are rich in normal physiologic change includes decreased102
  • 103. 103 elastic recoil of the lungs, fewer functional activity and rest. Many clients with capillaries in the alveoli, and an increased in hyperthyroidism are hyperactive and complain residual volume. of feeling very warm.16. Answer: (C) Presence of premature ventricular 22. Answer: (B) Increase his activity level. contractions (PVCs) on a cardiac monitor. Rationale: The client should be encouraged to Rationale: Lidocaine drips are commonly used increase his activity level. aintaining an ideal to treat clients whose arrhythmias haven’t weight; following a low-cholesterol, low been controlled with oral medication and who sodium diet; and avoiding stress are all are having PVCs that are visible on the cardiac important factors in decreasing the risk of monitor. SaO2, blood pressure, and ICP are atherosclerosis. important factors but aren’t as significant as 23. Answer: (A) Laminectomy PVCs in the situation. Rationale: The client who has had spinal17. Answer: (B) Avoid foods high in vitamin K surgery, such as laminectomy, must be log Rationale: The client should avoid consuming rolled to keep the spinal column straight when large amounts of vitamin K because vitamin K turning. Thoracotomy and cystectomy may can interfere with anticoagulation. The client turn themselves or may be assisted into a may need to report diarrhea, but isn’t effect comfortable position. Under normal of taking an anticoagulant. An electric razor- circumstances, hemorrhoidectomy is an not a straight razor-should be used to prevent outpatient procedure, and the client may cuts that cause bleeding. Aspirin may increase resume normal activities immediately after the risk of bleeding; acetaminophen should be surgery. used to pain relief. 24. Answer: (D) Avoiding straining during bowel18. Answer: (C) Clipping the hair in the area movement or bending at the waist. Rationale: Hair can be a source of infection Rationale: The client should avoid straining, and should be removed by clipping. Shaving lifting heavy objects, and coughing harshly the area can cause skin abrasions and because these activities increase intraocular depilatories can irritate the skin. pressure. Typically, the client is instructed to19. Answer: (A) Bone fracture avoid lifting objects weighing more than 15 lb Rationale: Bone fracture is a major (7kg) – not 5lb. instruct the client when lying complication of osteoporosis that results in bed to lie on either the side or back. The when loss of calcium and phosphate increased client should avoid bright light by wearing the fragility of bones. Estrogen deficiencies sunglasses. result from menopause-not osteoporosis. 25. Answer: (D) Before age 20. Calcium and vitamin D supplements may be Rationale: Testicular cancer commonly occurs used to support normal bone metabolism, But in men between ages 20 and 30. A male client a negative calcium balance isn’t a should be taught how to perform testicular complication of osteoporosis. Dowager’s self- examination before age 20, preferably hump results from bone fractures. It develops when he enters his teens. when repeated vertebral fractures increase 26. Answer: (B) Place a saline-soaked sterile spinal curvature. dressing on the wound.20. Answer: (C) Changes from previous Rationale: The nurse should first place saline- examinations. soaked sterile dressings on the open wound to Rationale: Women are instructed to examine prevent tissue drying and possible infection. themselves to discover changes that have Then the nurse should call the physician and occurred in the breast. Only a physician can take the client’s vital signs. The dehiscence diagnose lumps that are cancerous, areas of needs to be surgically closed, so the nurse thickness or fullness that signal the presence should never try to close it. of a malignancy, or masses that are fibrocystic 27. Answer: (A) A progressively deeper breaths as opposed to malignant. followed by shallower breaths with apneic21. Answer: (C) Balance the client’s periods of periods. activity and rest. Rationale: Cheyne-Strokes respirations are Rationale: A client with hyperthyroidism breaths that become progressively deeper needs to be encouraged to balance periods of fallowed by shallower respirations with
  • 104. apneas periods. Biot’s respirations are rapid, 33. Answer: (B) Current health promotion deep breathing with abrupt pauses between activities each breath, and equal depth between each Rationale: Recognizing an individual’s positive breath. Kussmaul’s respirationa are rapid, health measures is very useful. General health deep breathing without pauses. Tachypnea is in the previous 10 years is important, shallow breathing with increased respiratory however, the current activities of an 84 year rate. old client are most significant in planning care. 28. Answer: (B) Fine crackles Family history of disease for a client in later Rationale: Fine crackles are caused by fluid in years is of minor significance. Marital status the alveoli and commonly occur in clients with information may be important for discharge heart failure. Tracheal breath sounds are planning but is not as significant for auscultated over the trachea. Coarse crackles addressing the immediate medical problem. are caused by secretion accumulation in the 34. Answer: (C) Place the client in a side lying airways. Friction rubs occur with pleural position, with the head of the bed lowered. inflammation. Rationale: The client should be positioned in a 29. Answer: (B) The airways are so swollen that no side-lying position with the head of the bed air cannot get through lowered to prevent aspiration. A small amount Rationale: During an acute attack, wheezing of toothpaste should be used and the mouth may stop and breath sounds become swabbed or suctioned to remove pooled inaudible because the airways are so swollen secretions. Lemon glycerin can be drying if that air can’t get through. If the attack is over used for extended periods. Brushing the teeth and swelling has decreased, there would be with the client lying supine may lead to no more wheezing and less emergent concern. aspiration. Hydrogen peroxide is caustic to Crackles do not replace wheezes during an tissues and should not be used. acute asthma attack. 35. Answer: (C) Pneumonia 30. Answer: (D) Place the client on his side, Rationale: Fever productive cough and remove dangerous objects, and protect his pleuritic chest pain are common signs and head. symptoms of pneumonia. The client with Rationale: During the active seizure phase, ARDS has dyspnea and hypoxia with initiate precautions by placing the client on his worsening hypoxia over time, if not treated side, removing dangerous objects, and aggressively. Pleuritic chest pain varies with protecting his head from injury. A bite block respiration, unlike the constant chest pain should never be inserted during the active during an MI; so this client most likely isn’t seizure phase. Insertion can break the teeth having an MI. the client with TB typically has a and lead to aspiration. cough producing blood-tinged sputum. A 31. Answer: (B) Kinked or obstructed chest tube sputum culture should be obtained to confirm Rationales: Kinking and blockage of the chest the nurse’s suspicions. tube is a common cause of a tension 36. Answer: (C) A 43-yesr-old homeless man with pneumothorax. Infection and excessive a history of alcoholism drainage won’t cause a tension Rationale: Clients who are economically pneumothorax. Excessive water won’t affect disadvantaged, malnourished, and have the chest tube drainage. reduced immunity, such as a client with a 32. Answer: (D) Stay with him but not intervene at history of alcoholism, are at extremely high this time. risk for developing TB. A high school student, Rationale: If the client is coughing, he should day- care worker, and businessman probably be able to dislodge the object or cause a have a much low risk of contracting TB. complete obstruction. If complete obstruction 37. Answer: (C ) To determine the extent of occurs, the nurse should perform the lesions abdominal thrust maneuver with the client Rationale: If the lesions are large enough, the standing. If the client is unconscious, she chest X-ray will show their presence in the should lay him down. A nurse should never lungs. Sputum culture confirms the diagnosis. leave a choking client alone. There can be false-positive and false-negative104
  • 105. 105 skin test results. A chest X-ray can’t determine fibrillation and is receiving L.V. dilitiazem if this is a primary or secondary infection. (Cardizem)38. Answer: (B) Bronchodilators Rationale: The client with atrial fibrillation has Rationale: Bronchodilators are the first line of the greatest potential to become unstable and treatment for asthma because broncho- is on L.V. medication that requires close constriction is the cause of reduced airflow. monitoring. After assessing this client, the Beta- adrenergic blockers aren’t used to treat nurse should assess the client with asthma and can cause broncho- constriction. thrombophlebitis who is receiving a heparin Inhaled oral steroids may be given to reduce infusion, and then the 58- year-old client the inflammation but aren’t used for admitted 2 days ago with heart failure (his emergency relief. signs and symptoms are resolving and don’t39. Answer: (C) Chronic obstructive bronchitis require immediate attention). The lowest Rationale: Because of this extensive smoking priority is the 89-year-old with end-stage history and symptoms the client most likely right-sided heart failure, who requires time- has chronic obstructive bronchitis. Client with consuming supportive measures. ARDS have acute symptoms of hypoxia and 46. Answer: (C) Cocaine typically need large amounts of oxygen. Rationale: Because of the client’s age and Clients with asthma and emphysema tend not negative medical history, the nurse should to have chronic cough or peripheral edema. question her about cocaine use. Cocaine40. Answer: (A) The patient is under local increases myocardial oxygen consumption and anesthesia during the procedure Rationale: can cause coronary artery spasm, leading to Before the procedure, the patient is tachycardia, ventricular fibrillation, myocardial administered with drugs that would help to ischemia, and myocardial infarction. prevent infection and rejection of the Barbiturate overdose may trigger respiratory transplanted cells such as antibiotics, depression and slow pulse. Opioids can cause cytotoxic, and corticosteroids. During the marked respiratory depression, while transplant, the patient is placed under general benzodiazepines can cause drowsiness and anesthesia. confusion.41. Answer: (D) Raise the side rails 47. Answer: (B) Nonmobile mass with irregular Rationale: A patient who is disoriented is at edges risk of falling out of bed. The initial action of Rationale: Breast cancer tumors are fixed, the nurse should be raising the side rails to hard, and poorly delineated with irregular ensure patients safety. edges. A mobile mass that is soft and easily42. Answer: (A) Crowd red blood cells delineated is most often a fluid-filled benign Rationale: The excessive production of white cyst. Axillary lymph nodes may or may not be blood cells crowd out red blood cells palpable on initial detection of a cancerous production which causes anemia to occur. mass. Nipple retraction — not eversion —43. Answer: (B) Leukocytosis may be a sign of cancer. Rationale: Chronic Lymphocytic leukemia (CLL) 48. Answer: (C) Radiation is characterized by increased production of Rationale: The usual treatment for vaginal leukocytes and lymphocytes resulting in cancer is external or intravaginal radiation leukocytosis, and proliferation of these cells therapy. Less often, surgery is performed. within the bone marrow, spleen and liver. Chemotherapy typically is prescribed only if44. Answer: (A) Explain the risks of not having the vaginal cancer is diagnosed in an early stage, surgery which is rare. Immunotherapy isnt used to Rationale: The best initial response is to treat vaginal cancer. explain the risks of not having the surgery. If 49. Answer: (B) Carcinoma in situ, no abnormal the client understands the risks but still regional lymph nodes, and no evidence of refuses the nurse should notify the physician distant metastasis and the nurse supervisor and then record the Rationale: TIS, N0, M0 denotes carcinoma in client’s refusal in the nurses’ notes. situ, no abnormal regional lymph nodes, and45. Answer: (D) The 75-year-old client who was no evidence of distant metastasis. No admitted 1 hour ago with new-onset atrial evidence of primary tumor, no abnormal
  • 106. regional lymph nodes, and no evidence of 54. Answer: (D) "Remain supine for the time distant metastasis is classified as T0, N0, M0. If specified by the physician." Rationale: The the tumor and regional lymph nodes cant be nurse should instruct the client to remain assessed and no evidence of metastasis exists, supine for the time specified by the physician. the lesion is classified as TX, NX, M0. A Local anesthetics used in a subarachnoid block progressive increase in tumor size, no dont alter the gag reflex. No interactions demonstrable metastasis of the regional between local anesthetics and food occur. lymph nodes, and ascending degrees of Local anesthetics dont cause hematuria. distant metastasis is classified as T1, T2, T3, or 55. Answer: (C) Sigmoidoscopy T4; N0; and M1, M2, or M3. Rationale: Used to visualize the lower GI tract, 50. Answer: (D) "Keep the stoma moist." sigmoidoscopy and proctoscopy aid in the Rationale: The nurse should instruct the client detection of two-thirds of all colorectal to keep the stoma moist, such as by applying a cancers. Stool Hematest detects blood, which thin layer of petroleum jelly around the edges, is a sign of colorectal cancer; however, the because a dry stoma may become irritated. test doesnt confirm the diagnosis. CEA may The nurse should recommend placing a stoma be elevated in colorectal cancer but isnt bib over the stoma to filter and warm air considered a confirming test. An abdominal CT before it enters the stoma. The client should scan is used to stage the presence of begin performing stoma care without colorectal cancer. assistance as soon as possible to gain 56. Answer: (B) A fixed nodular mass with independence in self-care activities. dimpling of the overlying skin 51. Answer: (B) Lung cancer Rationale: A fixed nodular mass with dimpling Rationale: Lung cancer is the most deadly type of the overlying skin is common during late of cancer in both women and men. Breast stages of breast cancer. Many women have cancer ranks second in women, followed (in slightly asymmetrical breasts. Bloody nipple descending order) by colon and rectal cancer, discharge is a sign of intraductal papilloma, a pancreatic cancer, ovarian cancer, uterine benign condition. Multiple firm, round, freely cancer, lymphoma, leukemia, liver cancer, movable masses that change with the brain cancer, stomach cancer, and multiple menstrual cycle indicate fibrocystic breasts, a myeloma. benign condition. 52. Answer: (A) miosis, partial eyelid ptosis, and 57. Answer: (A) Liver anhidrosis on the affected side of the face. Rationale: The liver is one of the five most Rationale: Horners syndrome, which occurs common cancer metastasis sites. The others when a lung tumor invades the ribs and are the lymph nodes, lung, bone, and brain. affects the sympathetic nerve ganglia, is The colon, reproductive tract, and WBCs are characterized by miosis, partial eyelid ptosis, occasional metastasis sites. and anhidrosis on the affected side of the 58. Answer: (D) The client wears a watch and face. Chest pain, dyspnea, cough, weight loss, wedding band. and fever are associated with pleural tumors. Rationale: During an MRI, the client should Arm and shoulder pain and atrophy of the arm wear no metal objects, such as jewelry, and hand muscles on the affected side suggest because the strong magnetic field can pull on Pancoasts tumor, a lung tumor involving the them, causing injury to the client and (if they first thoracic and eighth cervical nerves within fly off) to others. The client must lie still the brachial plexus. Hoarseness in a client during the MRI but can talk to those with lung cancer suggests that the tumor has performing the test by way of the microphone extended to the recurrent laryngeal nerve; inside the scanner tunnel. The client should dysphagia suggests that the lung tumor is hear thumping sounds, which are caused by compressing the esophagus. the sound waves thumping on the magnetic 53. 53. Answer: (A) prostate-specific antigen, field. which is used to screen for prostate cancer. 59. Answer: (C) The recommended daily Rationale: PSA stands for prostate-specific allowance of calcium may be found in a wide antigen, which is used to screen for prostate variety of foods. cancer. The other answers are incorrect.106
  • 107. 107 Rationale: Premenopausal women require more likely to occur in the lower extremities. 1,000 mg of calcium per day. Postmenopausal A stroke isn’t linked to protein loss. women require 1,500 mg per day. Its often, 64. Answer: (B) It appears on the distal though not always, possible to get the interphalangeal joint recommended daily requirement in the foods Rationale: Heberden’s nodes appear on the we eat. Supplements are available but not distal interphalageal joint on both men and always necessary. Osteoporosis doesnt show women. Bouchard’s node appears on the up on ordinary X-rays until 30% of the bone dorsolateral aspect of the proximal loss has occurred. Bone densitometry can interphalangeal joint. detect bone loss of 3% or less. This test is 65. Answer: (B) Osteoarthritis is a localized sometimes recommended routinely for disease rheumatoid arthritis is systemic women over 35 who are at risk. Strenuous Rationale: Osteoarthritis is a localized disease, exercise wont cause fractures. rheumatoid arthritis is systemic. Osteoarthritis60. Answer: (C) Joint flexion of less than 50% isn’t gender-specific, but rheumatoid arthritis Rationale: Arthroscopy is contraindicated in is. Clients have dislocations and subluxations clients with joint flexion of less than 50% in both disorders. because of technical problems in inserting the 66. Answer: (C) The cane should be used on the instrument into the joint to see it clearly. unaffected side Other contraindications for this procedure Rationale: A cane should be used on the include skin and wound infections. Joint pain unaffected side. A client with osteoarthritis may be an indication, not a contraindication, should be encouraged to ambulate with a for arthroscopy. Joint deformity and joint cane, walker, or other assistive device as stiffness arent contraindications for this needed; their use takes weight and stress off procedure. joints.61. Answer: (D) Gouty arthritis 67. Answer: (A) a. 9 U regular insulin and 21 U Rationale: Gouty arthritis, a metabolic disease, neutral protamine Hagedorn (NPH). is characterized by urate deposits and pain in Rationale: A 70/30 insulin preparation is 70% the joints, especially those in the feet and NPH and 30% regular insulin. Therefore, a legs. Urate deposits dont occur in septic or correct substitution requires mixing 21 U of traumatic arthritis. Septic arthritis results from NPH and 9 U of regular insulin. The other bacterial invasion of a joint and leads to choices are incorrect dosages for the inflammation of the synovial lining. Traumatic prescribed insulin. arthritis results from blunt trauma to a joint or 68. Answer: (C) colchicines ligament. Intermittent arthritis is a rare, Rationale: A disease characterized by joint benign condition marked by regular, recurrent inflammation (especially in the great toe), joint effusions, especially in the knees. gout is caused by urate crystal deposits in the62. Answer: (B) 30 ml/hou joints. The physician prescribes colchicine to Rationale: An infusion prepared with 25,000 reduce these deposits and thus ease joint units of heparin in 500 ml of saline solution inflammation. Although aspirin is used to yields 50 units of heparin per milliliter of reduce joint inflammation and pain in clients solution. The equation is set up as 50 units with osteoarthritis and rheumatoid arthritis, it times X (the unknown quantity) equals 1,500 isnt indicated for gout because it has no units/hour, X equals 30 ml/hour. effect on urate crystal formation. Furosemide,63. Answer: (B) Loss of muscle contraction a diuretic, doesnt relieve gout. Calcium decreasing venous return gluconate is used to reverse a negative Rationale: In clients with hemiplegia or calcium balance and relieve muscle cramps, hemiparesis loss of muscle contraction not to treat gout. decreases venous return and may cause 69. Answer: (A) Adrenal cortex swelling of the affected extremity. Rationale: Excessive secretion of aldosterone Contractures, or bony calcifications may occur in the adrenal cortex is responsible for the with a stroke, but don’t appear with swelling. clients hypertension. This hormone acts on DVT may develop in clients with a stroke but is the renal tubule, where it promotes reabsorption of sodium and excretion of
  • 108. potassium and hydrogen ions. The pancreas is at greatest risk for hypoglycemia from 3 mainly secretes hormones involved in fuel p.m. to 7 p.m. metabolism. The adrenal medulla secretes the 75. Answer: (A) Glucocorticoids and androgens catecholamines — epinephrine and Rationale: The adrenal glands have two norepinephrine. The parathyroids secrete divisions, the cortex and medulla. The cortex parathyroid hormone. produces three types of hormones: 70. Answer: (C) They debride the wound and glucocorticoids, mineralocorticoids, and promote healing by secondary intention androgens. The medulla produces Rationale: For this client, wet-to-dry dressings catecholamines— epinephrine and are most appropriate because they clean the norepinephrine. foot ulcer by debriding exudate and necrotic 76. Answer: (A) Hypocalcemia tissue, thus promoting healing by secondary Rationale: Hypocalcemia may follow thyroid intention. Moist, transparent dressings surgery if the parathyroid glands were contain exudate and provide a moist wound removed accidentally. Signs and symptoms of environment. Hydrocolloid dressings prevent hypocalcemia may be delayed for up to 7 days the entrance of microorganisms and minimize after surgery. Thyroid surgery doesnt directly wound discomfort. Dry sterile dressings cause serum sodium, potassium, or protect the wound from mechanical trauma magnesium abnormalities. Hyponatremia may and promote healing. occur if the client inadvertently received too 71. Answer: (A) Hyperkalemia much fluid; however, this can happen to any Rationale: In adrenal insufficiency, the client surgical client receiving I.V. fluid therapy, not has hyperkalemia due to reduced aldosterone just one recovering from thyroid surgery. secretion. BUN increases as the glomerular Hyperkalemia and hypermagnesemia usually filtration rate is reduced. Hyponatremia is are associated with reduced renal excretion of caused by reduced aldosterone secretion. potassium and magnesium, not thyroid Reduced cortisol secretion leads to impaired surgery. glyconeogenesis and a reduction of glycogen 77. Answer: (D) Carcinoembryonic antigen level in the liver and muscle, causing hypoglycemia. Rationale: In clients who smoke, the level of 72. Answer: (C) Restricting fluids carcinoembryonic antigen is elevated. Rationale: To reduce water retention in a Therefore, it cant be used as a general client with the SIADH, the nurse should indicator of cancer. However, it is helpful in restrict fluids. Administering fluids by any monitoring cancer treatment because the route would further increase the clients level usually falls to normal within 1 month if already heightened fluid load. treatment is successful. An elevated acid 73. Answer: (D) glycosylated hemoglobin level. phosphatase level may indicate prostate Rationale: Because some of the glucose in the cancer. An elevated alkaline phosphatase level bloodstream attaches to some of the may reflect bone metastasis. An elevated hemoglobin and stays attached during the serum calcitonin level usually signals thyroid 120-day life span of red blood cells, cancer. glycosylated hemoglobin levels provide 78. Answer: (B) Dyspnea, tachycardia, and pallor information about blood glucose levels during Rationale: Signs of iron-deficiency anemia the previous 3 months. Fasting blood glucose include dyspnea, tachycardia, and pallor as and urine glucose levels only give information well as fatigue, listlessness, irritability, and about glucose levels at the point in time when headache. Night sweats, weight loss, and they were obtained. Serum fructosamine diarrhea may signal acquired levels provide information about blood immunodeficiency syndrome (AIDS). Nausea, glucose control over the past 2 to 3 weeks. vomiting, and anorexia may be signs of 74. Answer: (C) 4:00 pm hepatitis B. Itching, rash, and jaundice may Rationale: NPH is an intermediate-acting result from an allergic or hemolytic reaction. insulin that peaks 8 to 12 hours after 79. Answer: (D) "Ill need to have a C-section if I administration. Because the nurse become pregnant and have a baby." administered NPH insulin at 7 a.m., the client Rationale: The human immunodeficiency virus (HIV) is transmitted from mother to child via108
  • 109. 109 the transplacental route, but a Cesarean therapy is discontinued. Aspirin doesnt lead section delivery isnt necessary when the to weight gain or fine motor tremors. Large or mother is HIV-positive. The use of birth toxic salicylate doses may cause respiratory control will prevent the conception of a child alkalosis, not respiratory acidosis. who might have HIV. Its true that a mother 84. Answer: (D) Lymphocyte whos HIV positive can give birth to a baby Rationale: The lymphocyte provides adaptive whos HIV negative. immunity — recognition of a foreign antigen80. Answer: (C) "Avoid sharing such articles as and formation of memory cells against the toothbrushes and razors." antigen. Adaptive immunity is mediated by B Rationale: The human immunodeficiency virus and T lymphocytes and can be acquired (HIV), which causes AIDS, is most actively or passively. The neutrophil is crucial concentrated in the blood. For this reason, the to phagocytosis. The basophil plays an client shouldnt share personal articles that important role in the release of inflammatory may be blood-contaminated, such as mediators. The monocyte functions in toothbrushes and razors, with other family phagocytosis and monokine production. members. HIV isnt transmitted by bathing or 85. Answer: (A) moisture replacement. by eating from plates, utensils, or serving Rationale: Sjogrens syndrome is an dishes used by a person with AIDS. autoimmune disorder leading to progressive81. Answer: (B) Pallor, tachycardia, and a sore loss of lubrication of the skin, GI tract, ears, tongue nose, and vagina. Moisture replacement is the Rationale: Pallor, tachycardia, and a sore mainstay of therapy. Though malnutrition and tongue are all characteristic findings in electrolyte imbalance may occur as a result of pernicious anemia. Other clinical Sjogrens syndromes effect on the GI tract, it manifestations include anorexia; weight loss; a isnt the predominant problem. Arrhythmias smooth, beefy red tongue; a wide pulse arent a problem associated with Sjogrens pressure; palpitations; angina; weakness; syndrome. fatigue; and paresthesia of the hands and feet. 86. Answer: (C) stool for Clostridium difficile test. Bradycardia, reduced pulse pressure, weight Rationale: Immunosuppressed clients — for gain, and double vision arent characteristic example, clients receiving chemotherapy, — findings in pernicious anemia. are at risk for infection with C. difficile, which82. Answer: (B) Administer epinephrine, as causes "horse barn" smelling diarrhea. prescribed, and prepare to intubate the client Successful treatment begins with an accurate if necessary. diagnosis, which includes a stool test. The Rationale: To reverse anaphylactic shock, the ELISA test is diagnostic for human nurse first should administer epinephrine, a immunodeficiency virus (HIV) and isnt potent bronchodilator as prescribed. The indicated in this case. An electrolyte panel and physician is likely to order additional hemogram may be useful in the overall medications, such as antihistamines and evaluation of a client but arent diagnostic for corticosteroids; if these medications dont specific causes of diarrhea. A flat plate of the relieve the respiratory compromise associated abdomen may provide useful information with anaphylaxis, the nurse should prepare to about bowel function but isnt indicated in the intubate the client. No antidote for penicillin case of "horse barn" smelling diarrhea. exists; however, the nurse should continue to 87. Answer: (D) Western blot test with ELISA. monitor the clients vital signs. A client who Rationale: HIV infection is detected by remains hypotensive may need fluid analyzing blood for antibodies to HIV, which resuscitation and fluid intake and output form approximately 2 to 12 weeks after monitoring; however, administering exposure to HIV and denote infection. The epinephrine is the first priority. Western blot test — electrophoresis of83. Answer: (D) bilateral hearing loss. antibody proteins — is more than 98% Rationale: Prolonged use of aspirin and other accurate in detecting HIV antibodies when salicylates sometimes causes bilateral hearing used in conjunction with the ELISA. It isnt loss of 30 to 40 decibels. Usually, this adverse specific when used alone. E-rosette effect resolves within 2 weeks after the immunofluorescence is used to detect viruses
  • 110. in general; it doesnt confirm HIV infection. Rationale: Using comfort measures and Quantification of T-lymphocytes is a useful pillows to position the client is a non- monitoring test but isnt diagnostic for HIV. pharmacological methods of pain relief. The ELISA test detects HIV antibody particles 95. Answer: (B) Warm the dialysate solution. but may yield inaccurate results; a positive Rationale: Cold dialysate increases discomfort. ELISA result must be confirmed by the The solution should be warmed to body Western blot test. temperature in warmer or heating pad; don’t 88. Answer: (C) Abnormally low hematocrit (HCT) use microwave oven. and hemoglobin (Hb) levels 96. Answer: (C) The client holds the cane with his Rationale: Low preoperative HCT and Hb left hand, moves the cane forward followed levels indicate the client may require a blood by the right leg, and then moves the left leg. transfusion before surgery. If the HCT and Hb Rationale: The cane acts as a support and aids levels decrease during surgery because of in weight bearing for the weaker right leg. blood loss, the potential need for a 97. Answer: (A) Ask the woman’s family to transfusion increases. Possible renal failure is provide personal items such as photos or indicated by elevated BUN or creatinine levels. mementos. Urine constituents arent found in the blood. Rationale: Photos and mementos provide Coagulation is determined by the presence of visual stimulation to reduce sensory appropriate clotting factors, not electrolytes. deprivation. 89. Answer: (A) Platelet count, prothrombin time, 98. Answer: (B) The client lifts the walker, moves and partial thromboplastin time it forward 10 inches, and then takes several Rationale: The diagnosis of DIC is based on the small steps forward. results of laboratory studies of prothrombin Rationale: A walker needs to be picked up, time, platelet count, thrombin time, partial placed down on all legs. thromboplastin time, and fibrinogen level as 99. Answer: (C) Isolation from their families and well as client history and other assessment familiar surroundings. factors. Blood glucose levels, WBC count, Rationale: Gradual loss of sight, hearing, and calcium levels, and potassium levels arent taste interferes with normal functioning. used to confirm a diagnosis of DIC. 100. Answer: (A) Encourage the client to perform 90. Answer: (D) Strawberries pursed lip breathing. Rationale: Common food allergens include Rationale: Purse lip breathing prevents the berries, peanuts, Brazil nuts, cashews, collapse of lung unit and helps client control shellfish, and eggs. Bread, carrots, and rate and depth of breathing. oranges rarely cause allergic reactions. 91. Answer: (B) A client with cast on the right leg who states, “I have a funny feeling in my right leg.” Rationale: It may indicate neurovascular compromise, requires immediate assessment. 92. Answer: (D) A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills. Rationale: The client is at risk for peritonitis; should be assessed for further symptoms and infection. 93. Answer: (C) The client spontaneously flexes his wrist when the blood pressure is obtained. Rationale: Carpal spasms indicate hypocalcemia. 94. Answer: (D) Use comfort measures and pillows to position the client.110
  • 111. 111TEST IV - Care of Clients with Physiologic and b. Decrease fluid intake at meal times.Psychosocial Alterations c. Avoid foods that in the past caused flatus. 1. Randy has undergone kidney transplant, what d. Adhere to a bland diet prior to social assessment would prompt Nurse Katrina to events. suspect organ rejection? a. Sudden weight loss 7. Nurse Ron begins to teach a male client how to b. Polyuria perform colostomy irrigations. The nurse would c. Hypertension evaluate that the instructions were understood d. Shock when the client states, “I should: a. Lie on my left side while instilling the 2. The immediate objective of nursing care for an irrigating solution.” overweight, mildly hypertensive male client with b. Keep the irrigating container less than ureteral colic and hematuria is to decrease: 18 inches above the stoma.” a. Pain c. Instill a minimum of 1200 ml of irrigating b. Weight solution to stimulate evacuation of the c. Hematuria bowel.” d. Hypertension d. Insert the irrigating catheter deeper into the stoma if cramping occurs during the 3. Matilda, with hyperthyroidism is to receive procedure.” Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware 8. Patrick is in the oliguric phase of acute tubular that this medication is given to: necrosis and is experiencing fluid and electrolyte a. Decrease the total basal metabolic rate. imbalances. The client is somewhat confused b. Maintain the function of the parathyroid and complains of nausea and muscle weakness. glands. As part of the prescribed therapy to correct this c. Block the formation of thyroxine by the electrolyte imbalance, the nurse would expect thyroid gland. to: d. Decrease the size and vascularity of the a. Administer Kayexalate thyroid gland. b. Restrict foods high in protein c. Increase oral intake of cheese and milk. 4. Ricardo, was diagnosed with type I diabetes. The d. Administer large amounts of normal nurse is aware that acute hypoglycemia also can saline via I.V. develop in the client who is diagnosed with: a. Liver disease 9. Mario has burn injury. After Forty48 hours, the b. Hypertension physician orders for Mario 2 liters of IV fluid to c. Type 2 diabetes be administered q12 h. The drop factor of the d. Hyperthyroidism tubing is 10 gtt/ml. The nurse should set the flow to provide: 5. Tracy is receiving combination chemotherapy for a. 18 gtt/min treatment of metastatic carcinoma. Nurse Ruby b. 28 gtt/min should monitor the client for the systemic side c. 32 gtt/min effect of: d. 36 gtt/min a. Ascites b. Nystagmus 10. Terence suffered from burn injury. Using the rule c. Leukopenia of nines, which has the largest percent of burns? d. Polycythemia a. Face and neck b. Right upper arm and penis 6. Norma, with recent colostomy expresses c. Right thigh and penis concern about the inability to control the d. Upper trunk passage of gas. Nurse Oliver should suggest that the client plan to: 11. Herbert, a 45 year old construction engineer is a. Eliminate foods high in cellulose. brought to the hospital unconscious after falling
  • 112. from a 2-story building. When assessing the d. Only ice chips and cold liquids will be client, the nurse would be most concerned if the allowed initially. assessment revealed: a. Reactive pupils 16. Nurse Tristan is caring for a male client in acute b. A depressed fontanel renal failure. The nurse should expect hypertonic c. Bleeding from ears glucose, insulin infusions, and sodium d. An elevated temperature bicarbonate to be used to treat: a. hypernatremia. 12. Nurse Sherry is teaching male client regarding b. hypokalemia. his permanent artificial pacemaker. Which c. hyperkalemia. information given by the nurse shows her d. hypercalcemia. knowledge deficit about the artificial cardiac pacemaker? 17. Ms. X has just been diagnosed with condylomata a. take the pulse rate once a day, in the acuminata (genital warts). What information is morning upon awakening appropriate to tell this client? b. May be allowed to use electrical a. This condition puts her at a higher risk appliances for cervical cancer; therefore, she should c. Have regular follow up care have a Papanicolaou (Pap) smear d. May engage in contact sports annually. b. The most common treatment is 13. The nurse is ware that the most relevant metronidazole (Flagyl), which should knowledge about oxygen administration to a eradicate the problem within 7 to 10 male client with COPD is days. a. Oxygen at 1-2L/min is given to maintain c. The potential for transmission to her the hypoxic stimulus for breathing. sexual partner will be eliminated if b. Hypoxia stimulates the central condoms are used every time they have chemoreceptors in the medulla that sexual intercourse. makes the client breath. d. The human papillomavirus (HPV), which c. Oxygen is administered best using a non- causes condylomata acuminata, cant be rebreathing mask transmitted during oral sex. d. Blood gases are monitored using a pulse oximeter. 18. Maritess was recently diagnosed with a genitourinary problem and is being examined in 14. Tonny has undergoes a left thoracotomy and a the emergency department. When palpating her partial pneumonectomy. Chest tubes are kidneys, the nurse should keep which anatomical inserted, and one-bottle water-seal drainage is fact in mind? instituted in the operating room. In the a. The left kidney usually is slightly higher postanesthesia care unit Tonny is placed in than the right one. Fowlers position on either his right side or on b. The kidneys are situated just above the his back. The nurse is aware that this position: adrenal glands. a. Reduce incisional pain. c. The average kidney is approximately 5 b. Facilitate ventilation of the left lung. cm (2") long and 2 to 3 cm (¾" to 1-1/8") c. Equalize pressure in the pleural space. wide. d. Increase venous return d. The kidneys lie between the 10th and 12th thoracic vertebrae. 15. Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the 19. Jestoni with chronic renal failure (CRF) is nurses highest priority of information would be: admitted to the urology unit. The nurse is aware a. Food and fluids will be withheld for at that the diagnostic test are consistent with CRF if least 2 hours. the result is: b. Warm saline gargles will be done q 2h. a. Increased pH with decreased hydrogen c. Coughing and deep-breathing exercises ions. will be done q2h.112
  • 113. 113 b. Increased serum levels of potassium, b. Palpate the abdomen. magnesium, and calcium. c. Change the clients position. c. Blood urea nitrogen (BUN) 100 mg/dl d. Insert a rectal tube. and serum creatinine 6.5 mg/ dl. d. Uric acid analysis 3.5 mg/dl and 24. Wilfredo with a recent history of rectal bleeding phenolsulfonphthalein (PSP) excretion is being prepared for a colonoscopy. How should 75%. the nurse Patricia position the client for this test initially?20. Katrina has an abnormal result on a a. Lying on the right side with legs straight Papanicolaou test. After admitting that she read b. Lying on the left side with knees bent her chart while the nurse was out of the room, c. Prone with the torso elevated Katrina asks what dysplasia means. Which d. Bent over with hands touching the floor definition should the nurse provide? a. Presence of completely undifferentiated 25. A male client with inflammatory bowel disease tumor cells that dont resemble cells of undergoes an ileostomy. On the first day after the tissues of their origin. surgery, Nurse Oliver notes that the clients b. Increase in the number of normal cells in stoma appears dusky. How should the nurse a normal arrangement in a tissue or an interpret this finding? organ. a. Blood supply to the stoma has been c. Replacement of one type of fully interrupted. differentiated cell by another in tissues b. This is a normal finding 1 day after where the second type normally isnt surgery. found. c. The ostomy bag should be adjusted. d. Alteration in the size, shape, and d. An intestinal obstruction has occurred. organization of differentiated cells. 26. Anthony suffers burns on the legs, which nursing21. During a routine checkup, Nurse Mariane intervention helps prevent contractures? assesses a male client with acquired a. Applying knee splints immunodeficiency syndrome (AIDS) for signs and b. Elevating the foot of the bed symptoms of cancer. What is the most common c. Hyperextending the clients palms AIDS-related cancer? d. Performing shoulder range-of-motion a. Squamous cell carcinoma exercises b. Multiple myeloma c. Leukemia 27. Nurse Ron is assessing a client admitted with d. Kaposis sarcoma second- and third-degree burns on the face, arms, and chest. Which finding indicates a22. Ricardo is scheduled for a prostatectomy, and potential problem? the anesthesiologist plans to use a spinal a. Partial pressure of arterial oxygen (subarachnoid) block during surgery. In the (PaO2) value of 80 mm Hg. operating room, the nurse positions the client b. Urine output of 20 ml/hour. according to the anesthesiologists instructions. c. White pulmonary secretions. Why does the client require special positioning d. Rectal temperature of 100.6° F (38° C). for this type of anesthesia? a. To prevent confusion 28. Mr. Mendoza who has suffered a b. To prevent seizures cerebrovascular accident (CVA) is too weak to c. To prevent cerebrospinal fluid (CSF) move on his own. To help the client avoid leakage pressure ulcers, Nurse Celia should: d. To prevent cardiac arrhythmias a. Turn him frequently. b. Perform passive range-of-motion (ROM)23. A male client had a nephrectomy 2 days ago and exercises. is now complaining of abdominal pressure and c. Reduce the clients fluid intake. nausea. The first nursing action should be to: d. Encourage the client to use a footboard. a. Auscultate bowel sounds.
  • 114. 29. Nurse Maria plans to administer dexamethasone 34. A 37-year-old male client was admitted to the cream to a female client who has dermatitis over coronary care unit (CCU) 2 days ago with an the anterior chest. How should the nurse apply acute myocardial infarction. Which of the this topical agent? following actions would breach the client a. With a circular motion, to enhance confidentiality? absorption. a. The CCU nurse gives a verbal report to b. With an upward motion, to increase the nurse on the telemetry unit before blood supply to the affected area transferring the client to that unit c. In long, even, outward, and downward b. The CCU nurse notifies the on-call strokes in the direction of hair growth physician about a change in the client’s d. In long, even, outward, and upward condition strokes in the direction opposite hair c. The emergency department nurse calls growth up the latest electrocardiogram results to check the client’s progress. 30. Nurse Kate is aware that one of the following d. At the client’s request, the CCU nurse classes of medication protects the ischemic updates the client’s wife on his condition myocardium by blocking catecholamines and sympathetic nerve stimulation is: 35. A male client arriving in the emergency a. Beta -adrenergic blockers department is receiving cardiopulmonary b. Calcium channel blocker resuscitation from paramedics who are giving c. Narcotics ventilations through an endotracheal (ET) tube d. Nitrates that they placed in the client’s home. During a pause in compressions, the cardiac monitor 31. A male client has jugular distention. On what shows narrow QRS complexes and a heart rate position should the nurse place the head of the of beats/minute with a palpable pulse. Which of bed to obtain the most accurate reading of the following actions should the nurse take first? jugular vein distention? a. Start an L.V. line and administer a. High Fowler’s amiodarone (Cardarone), 300 mg L.V. b. Raised 10 degrees over 10 minutes. c. Raised 30 degrees b. Check endotracheal tube placement. d. Supine position c. Obtain an arterial blood gas (ABG) sample. 32. The nurse is aware that one of the following d. Administer atropine, 1 mg L.V. classes of medications maximizes cardiac performance in clients with heart failure by 36. After cardiac surgery, a client’s blood pressure increasing ventricular contractility? measures 126/80 mm Hg. Nurse Katrina a. Beta-adrenergic blockers determines that mean arterial pressure (MAP) is b. Calcium channel blocker which of the following? c. Diuretics a. 46 mm Hg d. Inotropic agents b. 80 mm Hg c. 95 mm Hg 33. A male client has a reduced serum high-density d. 90 mm Hg lipoprotein (HDL) level and an elevated low- density lipoprotein (LDL) level. Which of the 37. A female client arrives at the emergency following dietary modifications is not department with chest and stomach pain and a appropriate for this client? report of black tarry stool for several months. a. Fiber intake of 25 to 30 g daily Which of the following order should the nurse b. Less than 30% of calories from fat Oliver anticipate? c. Cholesterol intake of less than 300 mg a. Cardiac monitor, oxygen, creatine kinase daily and lactate dehydrogenase levels d. Less than 10% of calories from saturated b. Prothrombin time, partial fat thromboplastin time, fibrinogen and fibrin split product values.114
  • 115. 115 c. Electrocardiogram, complete blood 43. The nurse is aware that the following symptom count, testing for occult blood, is most commonly an early indication of stage 1 comprehensive serum metabolic panel. Hodgkin’s disease? d. Electroencephalogram, alkaline a. Pericarditis phosphatase and aspartate b. Night sweat aminotransferase levels, basic serum c. Splenomegaly metabolic panel d. Persistent hypothermia38. Macario had coronary artery bypass graft (CABG) 44. Francis with leukemia has neutropenia. Which of surgery 3 days ago. Which of the following the following functions must frequently conditions is suspected by the nurse when a assessed? decrease in platelet count from 230,000 ul to a. Blood pressure 5,000 ul is noted? b. Bowel sounds a. Pancytopenia c. Heart sounds b. Idiopathic thrombocytopemic purpura d. Breath sounds (ITP) c. Disseminated intravascular coagulation 45. The nurse knows that neurologic complications (DIC) of multiple myeloma (MM) usually involve which d. Heparin-associated thrombosis and of the following body system? thrombocytopenia (HATT) a. Brain b. Muscle spasm39. Which of the following drugs would be ordered c. Renal dysfunction by the physician to improve the platelet count in d. Myocardial irritability a male client with idiopathic thrombocytopenic purpura (ITP)? 46. Nurse Patricia is aware that the average length a. Acetylsalicylic acid (ASA) of time from human immunodeficiency virus b. Corticosteroids (HIV) infection to the development of acquired c. Methotrezate immunodeficiency syndrome (AIDS)? d. Vitamin K a. Less than 5 years b. 5 to 7 years40. A female client is scheduled to receive a heart c. 10 years valve replacement with a porcine valve. Which d. More than 10 years of the following types of transplant is this? a. Allogeneic 47. An 18-year-old male client admitted with heat b. Autologous stroke begins to show signs of disseminated c. Syngeneic intravascular coagulation (DIC). Which of the d. Xenogeneic following laboratory findings is most consistent with DIC?41. Marco falls off his bicycle and injuries his ankle. a. Low platelet count Which of the following actions shows the initial b. Elevated fibrinogen levels response to the injury in the extrinsic pathway? c. Low levels of fibrin degradation products a. Release of Calcium d. Reduced prothrombin time b. Release of tissue thromboplastin c. Conversion of factors XII to factor XIIa 48. Mario comes to the clinic complaining of fever, d. Conversion of factor VIII to factor VIIIa drenching night sweats, and unexplained weight42. Instructions for a client with systemic lupus loss over the past 3 months. Physical erythematosus (SLE) would include information examination reveals a single enlarged about which of the following blood dyscrasias? supraclavicular lymph node. Which of the a. Dressler’s syndrome following is the most probable diagnosis? b. Polycythemia a. Influenza c. Essential thrombocytopenia b. Sickle cell anemia d. Von Willebrand’s disease c. Leukemia d. Hodgkin’s disease
  • 116. red and swollen, when the IV is touched Stacy 49. A male client with a gunshot wound requires an shouts in pain. The first nursing action to take is: emergency blood transfusion. His blood type is a. Notify the physician AB negative. Which blood type would be the b. Flush the IV line with saline solution safest for him to receive? c. Immediately discontinue the infusion a. AB Rh-positive d. Apply an ice pack to the site, followed by b. A Rh-positive warm compress. c. A Rh-negative d. O Rh-positive 54. The term “blue bloater” refers to a male client which of the following conditions?Situation: Stacy is diagnosed with acute lymphoid a. Adult respiratory distress syndromeleukemia (ALL) and beginning chemotherapy. (ARDS) b. Asthma 50. Stacy is discharged from the hospital following c. Chronic obstructive bronchitis her chemotherapy treatments. Which statement d. Emphysema of Stacy’s mother indicated that she understands when she will contact the physician? 55. The term “pink puffer” refers to the female a. “I should contact the physician if Stacy client with which of the following conditions? has difficulty in sleeping”. a. Adult respiratory distress syndrome b. “I will call my doctor if Stacy has (ARDS) persistent vomiting and diarrhea”. b. Asthma c. “My physician should be called if Stacy is c. Chronic obstructive bronchitis irritable and unhappy”. d. Emphysema d. “Should Stacy have continued hair loss, I need to call the doctor”. 56. Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An 51. Stacy’s mother states to the nurse that it is hard arterial blood gas value is obtained. Nurse Oliver to see Stacy with no hair. The best response for would expect the paco2 to be which of the the nurse is: following values? a. “Stacy looks very nice wearing a hat”. a. 15 mm Hg b. “You should not worry about her hair, b. 30 mm Hg just be glad that she is alive”. c. 40 mm Hg c. “Yes it is upsetting. But try to cover up d. 80 mm Hg your feelings when you are with her or else she may be upset”. 57. Timothy’s arterial blood gas (ABG) results are as d. “This is only temporary; Stacy will re- follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm grow new hair in 3-6 months, but may Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result be different in texture”. represents which of the following conditions? a. Metabolic acidosis 52. Stacy has beginning stomatitis. To promote oral b. Metabolic alkalosis hygiene and comfort, the nurse in-charge c. Respiratory acidosis should: d. Respiratory alkalosis a. Provide frequent mouthwash with normal saline. 58. Norma has started a new drug for hypertension. b. Apply viscous Lidocaine to oral ulcers as Thirty minutes after she takes the drug, she needed. develops chest tightness and becomes short of c. Use lemon glycerine swabs every 2 breath and tachypneic. She has a decreased level hours. of consciousness. These signs indicate which of d. Rinse mouth with Hydrogen Peroxide. the following conditions? a. Asthma attack 53. During the administration of chemotherapy b. Pulmonary embolism agents, Nurse Oliver observed that the IV site is c. Respiratory failure d. Rheumatoid arthritis116
  • 117. 117 decreased RBC count, decreased WBCSituation: Mr. Gonzales was admitted to the hospital count.with ascites and jaundice. To rule out cirrhosis of the d. Intermitted lower back pain, decreasedliver: blood pressure, decreased RBC count, increased WBC count. 59. Which laboratory test indicates liver cirrhosis? a. Decreased red blood cell count 64. After undergoing a cardiac catheterization, Tracy b. Decreased serum acid phosphate level has a large puddle of blood under his buttocks. c. Elevated white blood cell count Which of the following steps should the nurse d. Elevated serum aminotransferase take first? a. Call for help. 60. 60.The biopsy of Mr. Gonzales confirms the b. Obtain vital signs diagnosis of cirrhosis. Mr. Gonzales is at c. Ask the client to “lift up” increased risk for excessive bleeding primarily d. Apply gloves and assess the groin site because of: a. Impaired clotting mechanism 65. Which of the following treatment is a suitable b. Varix formation surgical intervention for a client with unstable c. Inadequate nutrition angina? d. Trauma of invasive procedure a. Cardiac catheterization b. Echocardiogram 61. Mr. Gonzales develops hepatic encephalopathy. c. Nitroglycerin Which clinical manifestation is most common d. Percutaneous transluminal coronary with this condition? angioplasty (PTCA) a. Increased urine output b. Altered level of consciousness 66. The nurse is aware that the following terms used c. Decreased tendon reflex to describe reduced cardiac output and d. Hypotension perfusion impairment due to ineffective pumping of the heart is: 62. When Mr. Gonzales regained consciousness, the a. Anaphylactic shock physician orders 50 ml of Lactose p.o. every 2 b. Cardiogenic shock hours. Mr. Gozales develops diarrhea. The nurse c. Distributive shock best action would be: d. Myocardial infarction (MI) a. “I’ll see if your physician is in the hospital”. 67. A client with hypertension asks the nurse which b. “Maybe you’re reacting to the drug; I factors can cause blood pressure to drop to will withhold the next dose”. normal levels? c. “I’ll lower the dosage as ordered so the a. Kidneys’ excretion to sodium only. drug causes only 2 to 4 stools a day”. b. Kidneys’ retention of sodium and water d. “Frequently, bowel movements are c. Kidneys’ excretion of sodium and water needed to reduce sodium level”. d. Kidneys’ retention of sodium and excretion of water 63. Which of the following groups of symptoms indicates a ruptured abdominal aortic 68. Nurse Rose is aware that the statement that aneurysm? best explains why furosemide (Lasix) is a. Lower back pain, increased blood administered to treat hypertension is: pressure, decreased red blood cell (RBC) a. It dilates peripheral blood vessels. count, increased white blood (WBC) b. It decreases sympathetic count. cardioacceleration. b. Severe lower back pain, decreased blood c. It inhibits the angiotensin-coverting pressure, decreased RBC count, enzymes increased WBC count. d. It inhibits reabsorption of sodium and c. Severe lower back pain, decreased blood water in the loop of Henle. pressure, decreased RBC count,
  • 118. 69. Nurse Nikki knows that laboratory results 73. JP has been diagnosed with gout and wants to supports the diagnosis of systemic lupus know why colchicine is used in the treatment of erythematosus (SLE) is: gout. Which of the following actions of a. Elavated serum complement level colchicines explains why it’s effective for gout? b. Thrombocytosis, elevated sedimentation a. Replaces estrogen rate b. Decreases infection c. Pancytopenia, elevated antinuclear c. Decreases inflammation antibody (ANA) titer d. Decreases bone demineralization d. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels 74. Norma asks for information about osteoarthritis. Which of the following statements about 70. Arnold, a 19-year-old client with a mild osteoarthritis is correct? concussion is discharged from the emergency a. Osteoarthritis is rarely debilitating department. Before discharge, he complains of a b. Osteoarthritis is a rare form of arthritis headache. When offered acetaminophen, his c. Osteoarthritis is the most common form mother tells the nurse the headache is severe of arthritis and she would like her son to have something d. Osteoarthritis afflicts people over 60 stronger. Which of the following responses by the nurse is appropriate? 75. Ruby is receiving thyroid replacement therapy a. “Your son had a mild concussion, develops the flu and forgets to take her thyroid acetaminophen is strong enough.” replacement medicine. The nurse understands b. “Aspirin is avoided because of the that skipping this medication will put the client danger of Reye’s syndrome in children or at risk for developing which of the following life- young adults.” threatening complications? c. “Narcotics are avoided after a head a. Exophthalmos injury because they may hide a b. Thyroid storm worsening condition.” c. Myxedema coma d. Stronger medications may lead to d. Tibial myxedema vomiting, which increases the intracarnial pressure (ICP).” 76. Nurse Sugar is assessing a client with Cushings 71. When evaluating an arterial blood gas from a syndrome. Which observation should the nurse male client with a subdural hematoma, the report to the physician immediately? nurse notes the Paco2 is 30 mm Hg. Which of a. Pitting edema of the legs the following responses best describes the b. An irregular apical pulse result? c. Dry mucous membranes a. Appropriate; lowering carbon dioxide d. Frequent urination (CO2) reduces intracranial pressure (ICP) b. Emergent; the client is poorly 77. Cyrill with severe head trauma sustained in a car oxygenated accident is admitted to the intensive care unit. c. Normal Thirty-six hours later, the clients urine output d. Significant; the client has alveolar suddenly rises above 200 ml/hour, leading the hypoventilation nurse to suspect diabetes insipidus. Which laboratory findings support the nurses suspicion 72. When prioritizing care, which of the following of diabetes insipidus? clients should the nurse Olivia assess first? a. Above-normal urine and serum a. A 17-year-old client’s 24-hours osmolality levels postappendectomy b. Below-normal urine and serum b. A 33-year-old client with a recent osmolality levels diagnosis of Guillain-Barre syndrome c. Above-normal urine osmolality level, c. A 50-year-old client 3 days below-normal serum osmolality level postmyocardial infarction d. Below-normal urine osmolality level, d. A 50-year-old client with diverticulitis above-normal serum osmolality level118
  • 119. 11978. Jomari is diagnosed with hyperosmolar d. Low corticotropin and low cortisol levels hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When 82. A male client is scheduled for a transsphenoidal preparing the client for discharge and home hypophysectomy to remove a pituitary tumor. management, which of the following statements Preoperatively, the nurse should assess for indicates that the client understands her potential complications by doing which of the condition and how to control it? following? a. "I can avoid getting sick by not becoming a. Testing for ketones in the urine dehydrated and by paying attention to b. Testing urine specific gravity my need to urinate, drink, or eat more c. Checking temperature every 4 hours than usual." d. Performing capillary glucose testing b. "If I experience trembling, weakness, every 4 hours and headache, I should drink a glass of soda that contains sugar." 83. Capillary glucose monitoring is being performed c. "I will have to monitor my blood glucose every 4 hours for a client diagnosed with level closely and notify the physician if diabetic ketoacidosis. Insulin is administered its constantly elevated." using a scale of regular insulin according to d. "If I begin to feel especially hungry and glucose results. At 2 p.m., the client has a thirsty, Ill eat a snack high in capillary glucose level of 250 mg/dl for which he carbohydrates." receives 8 U of regular insulin. Nurse Mariner should expect the doses:79. A 66-year-old client has been complaining of a. onset to be at 2 p.m. and its peak to be sleeping more, increased urination, anorexia, at 3 p.m. weakness, irritability, depression, and bone pain b. onset to be at 2:15 p.m. and its peak to that interferes with her going outdoors. Based be at 3 p.m. on these assessment findings, the nurse would c. onset to be at 2:30 p.m. and its peak to suspect which of the following disorders? be at 4 p.m. a. Diabetes mellitus d. onset to be at 4 p.m. and its peak to be b. Diabetes insipidus at 6 p.m. c. Hypoparathyroidism d. Hyperparathyroidism 84. The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic80. Nurse Lourdes is teaching a client recovering signs and symptoms of this disorder. Which test from addisonian crisis about the need to take result would confirm the diagnosis? fludrocortisone acetate and hydrocortisone at a. No increase in the thyroid-stimulating home. Which statement by the client indicates hormone (TSH) level after 30 minutes an understanding of the instructions? during the TSH stimulation test a. "Ill take my hydrocortisone in the late b. A decreased TSH level afternoon, before dinner." c. An increase in the TSH level after 30 b. "Ill take all of my hydrocortisone in the minutes during the TSH stimulation test morning, right after I wake up." d. Below-normal levels of serum c. "Ill take two-thirds of the dose when I triiodothyronine (T3) and serum wake up and one-third in the late thyroxine (T4) as detected by afternoon." radioimmunoassay d. "Ill take the entire dose at bedtime." 85. Rico with diabetes mellitus must learn how to81. Which of the following laboratory test results self-administer insulin. The physician has would suggest to the nurse Len that a client has prescribed 10 U of U-100 regular insulin and 35 a corticotropin-secreting pituitary adenoma? U of U-100 isophane insulin suspension (NPH) to a. High corticotropin and low cortisol levels be taken before breakfast. When teaching the b. Low corticotropin and high cortisol levels client how to select and rotate insulin injection c. High corticotropin and high cortisol sites, the nurse should provide which levels instruction?
  • 120. a. "Inject insulin into healthy tissue with a. Adult respiratory distress syndrome large blood vessels and nerves." (ARDS) b. "Rotate injection sites within the same b. Atelectasis anatomic region, not among different c. Bronchitis regions." d. Pneumonia c. "Administer insulin into areas of scar tissue or hypotrophy whenever 91. A 67-year-old client develops acute shortness of possible." breath and progressive hypoxia requiring right d. "Administer insulin into sites above femur. The hypoxia was probably caused by muscles that you plan to exercise heavily which of the following conditions? later that day." a. Asthma attack b. Atelectasis 86. Nurse Sarah expects to note an elevated serum c. Bronchitis glucose level in a client with hyperosmolar d. Fat embolism hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse 92. A client with shortness of breath has decreased anticipate? to absent breath sounds on the right side, from a. Elevated serum acetone level the apex to the base. Which of the following b. Serum ketone bodies conditions would best explain this? c. Serum alkalosis a. Acute asthma d. Below-normal serum potassium level b. Chronic bronchitis c. Pneumonia 87. For a client with Graves disease, which nursing d. Spontaneous pneumothorax intervention promotes comfort? a. Restricting intake of oral fluids 93. A 62-year-old male client was in a motor vehicle b. Placing extra blankets on the clients bed accident as an unrestrained driver. He’s now in c. Limiting intake of high-carbohydrate the emergency department complaining of foods difficulty of breathing and chest pain. On d. Maintaining room temperature in the auscultation of his lung field, no breath sounds low-normal range are present in the upper lobe. This client may have which of the following conditions? 88. Patrick is treated in the emergency department a. Bronchitis for a Colles fracture sustained during a fall. b. Pneumonia What is a Colles fracture? c. Pneumothorax a. Fracture of the distal radius d. Tuberculosis (TB) b. Fracture of the olecranon c. Fracture of the humerus 94. If a client requires a pneumonectomy, what fills d. Fracture of the carpal scaphoid the area of the thoracic cavity? a. The space remains filled with air only 89. Cleo is diagnosed with osteoporosis. Which b. The surgeon fills the space with a gel electrolytes are involved in the development of c. Serous fluids fills the space and this disorder? consolidates the region a. Calcium and sodium d. The tissue from the other lung grows b. Calcium and phosphorous over to the other side c. Phosphorous and potassium d. Potassium and sodium 95. Hemoptysis may be present in the client with a pulmonary embolism because of which of the 90. Johnny a firefighter was involved in following reasons? extinguishing a house fire and is being treated to a. Alveolar damage in the infracted area smoke inhalation. He develops severe hypoxia b. Involvement of major blood vessels in 48 hours after the incident, requiring intubation the occluded area and mechanical ventilation. He most likely has c. Loss of lung parenchyma developed which of the following conditions? d. Loss of lung tissue120
  • 121. 121 c. “Every four hours I should remove the96. Aldo with a massive pulmonary embolism will stockings for a half hour.” have an arterial blood gas analysis performed to d. “I should put on the stockings before determine the extent of hypoxia. The acid-base getting out of bed in the morning.” disorder that may be present is? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis97. After a motor vehicle accident, Armand an 22- year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling? a. Air leak b. Adequate suction c. Inadequate suction d. Kinked chest tube98. Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute? a. 18 b. 21 c. 35 d. 4099. Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child? a. 1.2 ml b. 2.4 ml c. 3.5 ml d. 4.2 ml100. Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful? a. “I will wear the stockings until the physician tells me to remove them.” b. “I should wear the stockings even when I am sleep.”
  • 122. Answers and Rationale – Care of Clients with 10. Answer: (D) Upper trunkPhysiologic and Psychosocial Alterations Rationale: The percentage designated for each burned part of the body using the 1. Answer: (C) Hypertension rule of nines: Head and neck 9%; Right Rationale: Hypertension, along with fever, upper extremity 9%; Left upper extremity and tenderness over the grafted kidney, 9%; Anterior trunk 18%; Posterior trunk reflects acute rejection. 18%; Right lower extremity 18%; Left 2. Answer: (A) Pain lower extremity 18%; Perineum 1%. Rationale: Sharp, severe pain (renal colic) 11. Answer: (C) Bleeding from ears radiating toward the genitalia and thigh is Rationale: The nurse needs to perform a caused by uretheral distention and thorough assessment that could indicate smooth muscle spasm; relief form pain is alterations in cerebral function, increased the priority. intracranial pressures, fractures and 3. Answer: (D) Decrease the size and bleeding. Bleeding from the ears occurs vascularity of the thyroid gland. only with basal skull fractures that can Rationale: Lugol’s solution provides easily contribute to increased intracranial iodine, which aids in decreasing the pressure and brain herniation. vascularity of the thyroid gland, which 12. Answer: (D) may engage in contact sports limits the risk of hemorrhage when Rationale: The client should be advised by surgery is performed. the nurse to avoid contact sports. This will 4. Answer: (A) Liver Disease prevent trauma to the area of the Rationale: The client with liver disease has pacemaker generator. a decreased ability to metabolize 13. Answer: (A) Oxygen at 1-2L/min is given to carbohydrates because of a decreased maintain the hypoxic stimulus for ability to form glycogen (glycogenesis) and breathing. to form glucose from glycogen. Rationale: COPD causes a chronic CO2 5. Answer: (C) Leukopenia retention that renders the medulla Rationale: Leukopenia, a reduction in insensitive to the CO2 stimulation for WBCs, is a systemic effect of breathing. The hypoxic state of the client chemotherapy as a result of then becomes the stimulus for breathing. myelosuppression. Giving the client oxygen in low 6. Answer: (C) Avoid foods that in the past concentrations will maintain the client’s caused flatus. hypoxic drive. Rationale: Foods that bothered a person 14. Answer: (B) Facilitate ventilation of the preoperatively will continue to do so after left lung. a colostomy. Rationale: Since only a partial 7. Answer: (B) Keep the irrigating container pneumonectomy is done, there is a need less than 18 inches above the stoma.” to promote expansion of this remaining Rationale: This height permits the solution Left lung by positioning the client on the to flow slowly with little force so that opposite unoperated side. excessive peristalsis is not immediately 15. Answer: (A) Food and fluids will be precipitated. withheld for at least 2 hours. 8. Answer: (A) Administer Kayexalate Rationale: Prior to bronchoscopy, the Rationale: Kayexalate,a potassium doctors sprays the back of the throat with exchange resin, permits sodium to be anesthetic to minimize the gag reflex and exchanged for potassium in the intestine, thus facilitate the insertion of the reducing the serum potassium level. bronchoscope. Giving the client food and 9. Answer:(B) 28 gtt/min drink after the procedure without Rationale: This is the correct flow rate; checking on the return of the gag reflex multiply the amount to be infused (2000 can cause the client to aspirate. The gag ml) by the drop factor (10) and divide the reflex usually returns after two hours. result by the amount of time in minutes 16. Answer: (C) hyperkalemia. (12 hours x 60 minutes)122
  • 123. 123 Rationale: Hyperkalemia is a common increases serum levels of potassium, complication of acute renal failure. Its magnesium, and phosphorous, and life-threatening if immediate action isnt decreases serum levels of calcium. A uric taken to reverse it. The administration of acid analysis of 3.5 mg/dl falls within the glucose and regular insulin, with sodium normal range of 2.7 to 7.7 mg/dl; PSP bicarbonate if necessary, can temporarily excretion of 75% also falls with the normal prevent cardiac arrest by moving range of 60% to 75%. potassium into the cells and temporarily 20. Answer: (D) Alteration in the size, shape, reducing serum potassium levels. and organization of differentiated cells Hypernatremia, hypokalemia, and Rationale: Dysplasia refers to an alteration hypercalcemia dont usually occur with in the size, shape, and organization of acute renal failure and arent treated with differentiated cells. The presence of glucose, insulin, or sodium bicarbonate. completely undifferentiated tumor cells17. Answer: (A) This condition puts her at a that dont resemble cells of the tissues of higher risk for cervical cancer; therefore, their origin is called anaplasia. An increase she should have a Papanicolaou (Pap) in the number of normal cells in a normal smear annually. arrangement in a tissue or an organ is Rationale: Women with condylomata called hyperplasia. Replacement of one acuminata are at risk for cancer of the type of fully differentiated cell by another cervix and vulva. Yearly Pap smears are in tissues where the second type normally very important for early detection. isnt found is called metaplasia. Because condylomata acuminata is a 21. Answer: (D) Kaposis sarcoma virus, there is no permanent cure. Rationale: Kaposis sarcoma is the most Because condylomata acuminata can common cancer associated with AIDS. occur on the vulva, a condom wont Squamous cell carcinoma, multiple protect sexual partners. HPV can be myeloma, and leukemia may occur in transmitted to other parts of the body, anyone and arent associated specifically such as the mouth, oropharynx, and with AIDS. larynx. 22. Answer: (C) To prevent cerebrospinal fluid18. Answer: (A) The left kidney usually is (CSF) leakage slightly higher than the right one. Rationale: The client receiving a Rationale: The left kidney usually is subarachnoid block requires special slightly higher than the right one. An positioning to prevent CSF leakage and adrenal gland lies atop each kidney. The headache and to ensure proper anesthetic average kidney measures approximately distribution. Proper positioning doesnt 11 cm (4-3/8") long, 5 to 5.8 cm (2" to help prevent confusion, seizures, or 2¼") wide, and 2.5 cm (1") thick. The cardiac arrhythmias. kidneys are located retroperitoneally, in 23. Answer: (A) Auscultate bowel sounds. the posterior aspect of the abdomen, on Rationale: If abdominal distention is either side of the vertebral column. They accompanied by nausea, the nurse must lie between the 12th thoracic and 3rd first auscultate bowel sounds. If bowel lumbar vertebrae. sounds are absent, the nurse should19. Answer: (C) Blood urea nitrogen (BUN) suspect gastric or small intestine dilation 100 mg/dl and serum creatinine 6.5mg/dl. and these findings must be reported to Rationale: The normal BUN level ranges 8 the physician. Palpation should be to 23 mg/dl; the normal serum creatinine avoided postoperatively with abdominal level ranges from 0.7 to 1.5 mg/dl. The distention. If peristalsis is absent, test results in option C are abnormally changing positions and inserting a rectal elevated, reflecting CRF and the kidneys tube wont relieve the clients discomfort. decreased ability to remove nonprotein 24. Answer: (B) Lying on the left side with nitrogen waste from the blood. CRF knees bent causes decreased pH and increased Rationale: For a colonoscopy, the nurse hydrogen ions — not vice versa. CRF also initially should position the client on the
  • 124. left side with knees bent. Placing the capillaries become occluded, reducing client on the right side with legs straight, circulation and oxygenation of the tissues prone with the torso elevated, or bent and resulting in cell death and ulcer over with hands touching the floor formation. During passive ROM exercises, wouldnt allow proper visualization of the the nurse moves each joint through its large intestine. range of movement, which improves joint 25. Answer: (A) Blood supply to the stoma has mobility and circulation to the affected been interrupted area but doesnt prevent pressure ulcers. Rationale: An ileostomy stoma forms as Adequate hydration is necessary to the ileum is brought through the maintain healthy skin and ensure tissue abdominal wall to the surface skin, repair. A footboard prevents plantar creating an artificial opening for waste flexion and footdrop by maintaining the elimination. The stoma should appear foot in a dorsiflexed position. cherry red, indicating adequate arterial 29. Answer: (C) In long, even, outward, and perfusion. A dusky stoma suggests downward strokes in the direction of hair decreased perfusion, which may result growth from interruption of the stomas blood Rationale: When applying a topical agent, supply and may lead to tissue damage or the nurse should begin at the midline and necrosis. A dusky stoma isnt a normal use long, even, outward, and downward finding. Adjusting the ostomy bag strokes in the direction of hair growth. wouldnt affect stoma color, which This application pattern reduces the risk depends on blood supply to the area. An of follicle irritation and skin inflammation. intestinal obstruction also wouldnt 30. Answer: (A) Beta -adrenergic blockers change stoma color. Rationale: Beta-adrenergic blockers work 26. Answer: (A) Applying knee splints by blocking beta receptors in the Rationale: Applying knee splints prevents myocardium, reducing the response to leg contractures by holding the joints in a catecholamines and sympathetic nerve position of function. Elevating the foot of stimulation. They protect the the bed cant prevent contractures myocardium, helping to reduce the risk of because this action doesnt hold the joints another infraction by decreasing in a position of function. Hyperextending a myocardial oxygen demand. Calcium body part for an extended time is channel blockers reduce the workload of inappropriate because it can cause the heart by decreasing the heart rate. contractures. Performing shoulder range- Narcotics reduce myocardial oxygen of-motion exercises can prevent demand, promote vasodilation, and contractures in the shoulders, but not in decrease anxiety. Nitrates reduce the legs. myocardial oxygen consumption bt 27. Answer: (B) Urine output of 20 ml/hour. decreasing left ventricular end diastolic Rationale: A urine output of less than 40 pressure (preload) and systemic vascular ml/hour in a client with burns indicates a resistance (afterload). fluid volume deficit. This clients PaO2 31. Answer: (C) Raised 30 degrees value falls within the normal range (80 to Rationale: Jugular venous pressure is 100 mm Hg). White pulmonary secretions measured with a centimeter ruler to also are normal. The clients rectal obtain the vertical distance between the temperature isnt significantly elevated sternal angle and the point of highest and probably results from the fluid pulsation with the head of the bed volume deficit. inclined between 15 to 30 degrees. 28. Answer: (A) Turn him frequently. Increased pressure can’t be seen when Rationale: The most important the client is supine or when the head of intervention to prevent pressure ulcers is the bed is raised 10 degrees because the frequent position changes, which relieve point that marks the pressure level is pressure on the skin and underlying above the jaw (therefore, not visible). In tissues. If pressure isnt relieved,124
  • 125. 125 high Fowler’s position, the veins would be ventricular fibrillation and atrial flutter – barely discernible above the clavicle. not symptomatic bradycardia.32. Answer: (D) Inotropic agents 36. Answer: (C) 95 mm Hg Rationale: Inotropic agents are Rationale: Use the following formula to administered to increase the force of the calculate MAP heart’s contractions, thereby increasing MAP = systolic + 2 (diastolic) ventricular contractility and ultimately 3 increasing cardiac output. Beta-adrenergic MAP=126 mm Hg + 2 (80 mm Hg) blockers and calcium channel blockers 3 decrease the heart rate and ultimately MAP=286 mm HG decreased the workload of the heart. 3 Diuretics are administered to decrease the MAP=95 mm Hg overall vascular volume, also decreasing 37. Answer: (C) Electrocardiogram, complete the workload of the heart. blood count, testing for occult blood,33. Answer: (B) Less than 30% of calories from comprehensive serum metabolic panel. fat Rationale: An electrocardiogram evaluates Rationale: A client with low serum HDL the complaints of chest pain, laboratory and high serum LDL levels should get less tests determines anemia, and the stool than 30% of daily calories from fat. The test for occult blood determines blood in other modifications are appropriate for the stool. Cardiac monitoring, oxygen, and this client. creatine kinase and lactate34. Answer: (C) The emergency department dehydrogenase levels are appropriate for nurse calls up the latest electrocardiogram a cardiac primary problem. A basic results to check the client’s progress metabolic panel and alkaline phosphatase Rationale: The emergency department and aspartate aminotransferase levels nurse is no longer directly involved with assess liver function. Prothrombin time, the client’s care and thus has no legal partial thromboplastin time, fibrinogen right to information about his present and fibrin split products are measured to condition. Anyone directly involved in his verify bleeding dyscrasias; an care (such as the telemetry nurse and the electroencephalogram evaluates brain on-call physician) has the right to electrical activity. information about his condition. Because 38. Answer: (D) Heparin-associated the client requested that the nurse update thrombosis and thrombocytopenia (HATT) his wife on his condition, doing so doesn’t Rationale: HATT may occur after CABG breach confidentiality. surgery due to heparin use during surgery.35. Answer: (B) Check endotracheal tube Although DIC and ITP cause platelet placement. aggregation and bleeding, neither is Rationale: ET tube placement should be common in a client after revascularization confirmed as soon as the client arrives in surgery. Pancytopenia is a reduction in all the emergency department. Once the blood cells. airways is secured, oxygenation and 39. Answer: (B) Corticosteroids ventilation should be confirmed using an Rationale: Corticosteroid therapy can end-tidal carbon dioxide monitor and decrease antibody production and pulse oximetry. Next, the nurse should phagocytosis of the antibody-coated make sure L.V. access is established. If the platelets, retaining more functioning client experiences symptomatic platelets. Methotrexate can cause bradycardia, atropine is administered as thrombocytopenia. Vitamin K is used to ordered 0.5 to 1 mg every 3 to 5 minutes treat an excessive anticoagulate state to a total of 3 mg. Then the nurse should from warfarin overload, and ASA try to find the cause of the client’s arrest decreases platelet aggregation. by obtaining an ABG sample. Amiodarone 40. Answer: (D) Xenogeneic is indicated for ventricular tachycardia, Rationale: An xenogeneic transplant is between is between human and another
  • 126. species. A syngeneic transplant is between options, which reflect parts of the nervous identical twins, allogeneic transplant is system, aren’t usually affected by MM. between two humans, and autologous is a 46. Answer: (C) 10 years transplant from the same individual. Rationale: Epidermiologic studies show 41. Answer: (B) the average time from initial contact with Rationale: Tissue thromboplastin is HIV to the development of AIDS is 10 released when damaged tissue comes in years. contact with clotting factors. Calcium is 47. Answer: (A) Low platelet count released to assist the conversion of Rationale: In DIC, platelets and clotting factors X to Xa. Conversion of factors XII to