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Nursing question practice case Nursing question practice case Document Transcript

  • Nursing Board Practice Test CompilationContentsNURSING PRACTICE I: FOUNDATION OF NURSINGPRACTICE..........................................................................4NURSING PRACTICE II.....................................................15NURSING PRACTICE III....................................................26NURSING PRACTICE IV....................................................36NURSING PRACTICE V.....................................................46TEST I - Foundation of Professional Nursing Practice ....56Answers and Rationale – Foundation of ProfessionalNursing Practice.........................................................66TEST II - Community Health Nursing and Care of theMother and Child...........................................................74Answers and Rationale – Community Health Nursingand Care of the Mother and Child .............................84TEST III - Care of Clients with Physiologic andPsychosocial Alterations ................................................91Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................102TEST IV - Care of Clients with Physiologic andPsychosocial Alterations ..............................................111Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................122TEST V - Care of Clients with Physiologic and PsychosocialAlterations....................................................................133Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................144PART III PRACTICE TEST I FOUNDATION OF NURSING.153ANSWERS AND RATIONALE – FOUNDATION OFNURSING ..................................................................158PRACTICE TEST II Maternal and Child Health...............162ANSWERS AND RATIONALE – MATERNAL AND CHILDHEALTH.....................................................................167MEDICAL SURGICAL NURSING .....................................173ANSWERS AND RATIONALE – MEDICAL SURGICALNURSING ..................................................................178PSYCHIATRIC NURSING ................................................180ANSWERS AND RATIONALE – PSYCHIATRIC NURSING.................................................................................185FOUNDATION OF PROFESSIONAL NURSING PRACTICE188ANSWER KEY - FOUNDATION OF PROFESSIONALNURSING PRACTICE..................................................199COMMUNITY HEALTH NURSING AND CARE OF THEMOTHER AND CHILD....................................................200ANSWER KEY: COMMUNITY HEALTH NURSING ANDCARE OF THE MOTHER AND CHILD..........................211Comprehensive Exam 1................................................213CARE OF CLIENTS WITH PHYSIOLOGIC ANDPSYCHOSOCIAL ALTERATIONS......................................222ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGICAND PSYCHOSOCIAL ALTERATIONS .........................234Nursing Practice Test V ................................................235Nursing Practice Test V ................................................245TEST I - Foundation of Professional Nursing Practice..255Answers and Rationale – Foundation of ProfessionalNursing Practice.......................................................265TEST II - Community Health Nursing and Care of theMother and Child.........................................................273Answers and Rationale – Community Health Nursingand Care of the Mother and Child ...........................283TEST III - Care of Clients with Physiologic andPsychosocial Alterations ..............................................290Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................301TEST IV - Care of Clients with Physiologic andPsychosocial Alterations ..............................................310Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................321TEST V - Care of Clients with Physiologic and PsychosocialAlterations....................................................................332Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations ................343PART III.........................................................................352PRACTICE TEST I FOUNDATION OF NURSING ..............352ANSWERS AND RATIONALE – FOUNDATION OFNURSING ..................................................................357PRACTICE TEST II Maternal and Child Health...............361
  • 2ANSWERS AND RATIONALE – MATERNAL AND CHILDHEALTH.....................................................................366MEDICAL SURGICAL NURSING .....................................372ANSWERS AND RATIONALE – MEDICAL SURGICALNURSING ..................................................................377PSYCHIATRIC NURSING ................................................379ANSWERS AND RATIONALE – PSYCHIATRIC NURSING.................................................................................384FUNDAMENTALS OF NURSING PART 1 ........................387FUNDAMENTALS OF NURSING PART 2 ........................392ANSWERS and RATIONALES for FUNDAMENTALS OFNURSING PART 2......................................................397FUNDAMENTALS OF NURSING PART 3 ........................401ANSWERS and RATIONALES for FUNDAMENTALS OFNURSING PART 3......................................................405MATERNITY NURSING Part 1........................................409ANSWERS and RATIONALES for MATERNITY NURSINGPart 1........................................................................418MATERNITY NURSING Part 2........................................428Answer for maternity part 2 ....................................433PEDIATRIC NURSING ....................................................434ANSWERS and RATIONALES for PEDIATRIC NURSING.................................................................................439COMMUNITY HEALTH NURSING Part 1........................444COMMUNITY HEALTH NURSING Part 2........................454MEDICAL SURGICAL NURSING Part 1...........................475ANSWERS and RATIONALES for MEDICAL SURGICALNURSING Part 1........................................................479MEDICAL SURGICAL NURSING Part 2...........................481MEDICAL SURGICAL NURSING Part 2.......................485ANSWERS and RATIONALES for MEDICAL SURGICALNURSING Part 2........................................................489MEDICAL SURGICAL NURSING Part 3...........................491ANSWERS and RATIONALES for MEDICAL SURGICALNURSING Part 3........................................................495PSYCHIATRIC NURSING Part 1......................................497ANSWERS and RATIONALES for PSYCHIATRIC NURSINGPart 1........................................................................502PSYCHIATRIC NURSING Part 2......................................504ANSWERS and RATIONALES for PSYCHIATRIC NURSINGPart 2........................................................................509PSYCHIATRIC NURSING Part 3......................................512ANSWERS and RATIONALES for PSYCHIATRIC NURSINGPart 3........................................................................516PROFESSIONAL ADJUSTMENT......................................519LEADERSHIP and MANAGEMENT.................................522NURSING RESEARCH Part 1..........................................532NURSING RESEARCH Part 2..........................................542Nursing Research Suggested Answer Key................546
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  • 4NURSING PRACTICE I: FOUNDATION OF NURSINGPRACTICESITUATION: Nursing is a profession. The nurse shouldhave a background on the theories and foundation ofnursing as it influenced what is nursing today.1. Nursing is the protection, promotion andoptimization of health and abilities, preventionof illness and injury, alleviation of sufferingthrough the diagnosis and treatment of humanresponse and advocacy in the care of theindividuals, families, communities and thepopulation. This is the most accepted definitionof nursing as defined by the:a. PNAb. ANAc. Nightingaled. Henderson2. Advancement in Nursing leads to thedevelopment of the Expanded Career Roles.Which of the following is NOT an expandedcareer role for nurses?a. Nurse practitionerb. Nurse Researcherc. Clinical nurse specialistd. Nurse anaesthesiologist3. The Board of Nursing regulated the Nursingprofession in the Philippines and is responsiblefor the maintenance of the quality of nursing inthe country. Powers and duties of the board ofnursing are the following, EXCEPT:a. Issue, suspend, revoke certificates ofregistrationb. Issue subpoena duces tecum, adtestificandumc. Open and close colleges of nursingd. Supervise and regulate the practice ofnursing4. A nursing student or a beginning staff nurse whohas not yet experienced enough real situationsto make judgments about them is in what stageof Nursing Expertise?a. Noviceb. Newbiec. Advanced Beginnerd. Competent5. Benner’s “Proficient” nurse level is differentfrom the other levels in nursing expertise in thecontext of having:a. the ability to organize and plan activitiesb. having attained an advanced level ofeducationc. a holistic understanding and perceptionof the clientd. intuitive and analytic ability in newsituationsSITUATION: The nurse has been asked to administer aninjection via Z TRACK technique. Questions 6 to 10 referto this.6. The nurse prepares an IM injection for an adultclient using the Z track technique. 4 ml ofmedication is to be administered to the client.Which of the following site will you choose?a. Deltoidb. Rectus femorisc. Ventrogluteald. Vastus lateralis7. In infants 1 year old and below, which of thefollowing is the site of choice for intramuscularInjection?a. Deltoidb. Rectus femorisc. Ventrogluteald. Vastus lateralis8. In order to decrease discomfort in Z trackadministration, which of the following isapplicable?a. Pierce the skin quickly and smoothly ata 90 degree angleb. Inject the medication steadily at around10 minutes per millilitrec. Pull back the plunger and aspirate for 1minute to make sure that the needle didnot hit a blood vesseld. Pierce the skin slowly and carefully at a90 degree angle9. After injection using the Z track technique, thenurse should know that she needs to wait for afew seconds before withdrawing the needle andthis is to allow the medication to disperse intothe muscle tissue, thus decreasing the client’sdiscomfort. How many seconds should the nursewait before withdrawing the needle?a. 2 seconds
  • 5b. 5 secondsc. 10 secondsd. 15 seconds10. The rationale in using the Z track technique in anintramuscular injection is:a. It decreases the leakage of discolouringand irritating medication into thesubcutaneous tissuesb. It will allow a faster absorption of themedicationc. The Z track technique prevent irritationof the muscled. It is much more convenient for the nurseSITUATION: A Client was rushed to the emergency roomand you are his attending nurse. You are performing avital sign assessment.11. All of the following are correct methods inassessment of the blood pressure EXCEPT:a. Take the blood pressure reading on botharms for comparisonb. Listen to and identify the phases ofKorotkoff’s soundc. Pump the cuff to around 50 mmHgabove the point where the pulse isobliteratedd. Observe procedures for infection control12. You attached a pulse oximeter to the client. Youknow that the purpose is to:a. Determine if the client’s hemoglobinlevel is low and if he needs bloodtransfusionb. Check level of client’s tissue perfusionc. Measure the efficacy of the client’s anti-hypertensive medicationsd. Detect oxygen saturation of arterialblood before symptoms of hypoxemiadevelops13. After a few hours in the Emergency Room, Theclient is admitted to the ward with an order ofhourly monitoring of blood pressure. The nursefinds that the cuff is too narrow and this willcause the blood pressure reading to be:a. inconsistentb. low systolic and high diastolicc. higher than what the reading should bed. lower than what the reading should be14. Through the client’s health history, you gatherthat the patient smokes and drinks coffee. Whentaking the blood pressure of a client whorecently smoked or drank coffee, how longshould the nurse wait before taking the client’sblood pressure for accurate reading?a. 15 minutesb. 30 minutesc. 1 hourd. 5 minutes15. While the client has pulse oximeter on hisfingertip, you notice that the sunlight is shiningon the area where the oximeter is. Your actionwill be to:a. Set and turn on the alarm of theoximeterb. Do nothing since there is no identifiedproblemc. Cover the fingertip sensor with a towelor bedsheetd. Change the location of the sensor everyfour hours16. The nurse finds it necessary to recheck the bloodpressure reading. In case of such re assessment,the nurse should wait for a period of:a. 15 secondsb. 1 to 2 minutesc. 30 minutesd. 15 minutes17. If the arm is said to be elevated when taking theblood pressure, it will create a:a. False high readingb. False low readingc. True false readingd. Indeterminate18. You are to assessed the temperature of theclient the next morning and found out that heate ice cream. How many minutes should youwait before assessing the client’s oraltemperature?a. 10 minutesb. 20 minutesc. 30 minutesd. 15 minutes19. When auscultating the client’s blood pressurethe nurse hears the following: From 150 mmHgto 130 mmHg: Silence, Then: a thumping soundcontinuing down to 100 mmHg; muffled soundcontinuing down to 80 mmHg and then silence.
  • 6What is the client’s blood pressure?a. 130/80b. 150/100c. 100/80d. 150/10020. In a client with a previous blood pressure of130/80 4 hours ago, how long will it take torelease the blood pressure cuff to obtain anaccurate reading?a. 10-20 secondsb. 30-45 secondsc. 1-1.5 minutesd. 3-3.5 minutesSituation: Oral care is an important part of hygienicpractices and promoting client comfort.21. An elderly client, 84 years old, is unconscious.Assessment of the mouth reveals excessivedryness and presence of sores. Which of thefollowing is BEST to use for oral care?a. lemon glycerineb. Mineral oilc. hydrogen peroxided. Normal saline solution22. When performing oral care to an unconsciousclient, which of the following is a specialconsideration to prevent aspiration of fluids intothe lungs?a. Put the client on a sidelying positionwith head of bed loweredb. Keep the client dry by placing towelunder the chinc. Wash hands and observes appropriateinfection controld. Clean mouth with oral swabs in a carefuland an orderly progression23. The advantages of oral care for a client includeall of the following, EXCEPT:a. decreases bacteria in the mouth andteethb. reduces need to use commercialmouthwash which irritate the buccalmucosac. improves client’s appearance and self-confidenced. improves appetite and taste of food24. A possible problem while providing oral care tounconscious clients is the risk of fluid aspirationto lungs. This can be avoided by:a. Cleaning teeth and mouth with cottonswabs soaked with mouthwash to avoidrinsing the buccal cavityb. swabbing the inside of the cheeks andlips, tongue and gums with dry cottonswabsc. use fingers wrapped with wet cottonwashcloth to rub inside the cheeks,tongue, lips and umsd. suctioning as needed while cleaning thebuccal cavity25. Your client has difficulty of breathing and ismouth breathing most of the time. This causesdryness of the mouth with unpleasant odor. Oralhygiene is recommended for the client and inaddition, you will keep the mouth moistened byusing:a. salt solutionb. petroleum jellyc. waterd. mentholated ointmentSituation – Ensuring safety before, during and after adiagnostic procedure is an important responsibility ofthe nurse.26. To help Fernan better tolerate thebronchoscopy, you should instruct him topractice which of the following prior to theprocedure?a. Clenching his fist every 2 minutesb. Breathing in and out through the nosewith his mouth openc. Tensing the shoulder muscles while lyingon his backd. Holding his breath periodically for 30seconds27. Following a bronchoscopy, which of thefollowing complains to Fernan should be notedas a possible complication:a. Nausea and vomitingb. Shortness of breath and laryngealstridorc. Blood tinged sputum and coughingd. Sore throat and hoarseness28. Immediately after bronchoscopy, you instructedFernan to:a. Exercise the neck musclesb. Refrain from coughing and talking
  • 7c. Breathe deeplyd. Clear his throat29. Thoracentesis may be performed for cytologicstudy of pleural fluid. As a nurse your mostimportant function during the procedure is to:a. Keep the sterile equipment fromcontaminationb. Assist the physicianc. Open and close the three-way stopcockd. Observe the patient’s vital signs30. Right after thoracentesis, which of the followingis most appropriate intervention?a. Instruct the patient not to cough or deepbreathe for two hoursb. Observe for symptoms of tightness ofchest or bleedingc. Place an ice pack to the puncture sited. Remove the dressing to check forbleedingSituation: Knowledge of the acid-base disturbance andthe functions of the electrolytes is necessary todetermine appropriate intervention and nursing actions.31. A client with diabetes milletus has a bloodglucose level of 644 mg/dL. The nurse interpretsthat this client is at most risk for thedevelopment of which type of acid-baseimbalance?a. Respiratory acidosisb. Respiratory alkalosisc. Metabolic acidosisd. Metabolic alkalosis32. In a client in the health care clinic, arterial bloodgas analysis gives the following results: pH 7.48,PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L.The nurse interprets that the client has whichacid base disturbance?a. Respiratory acidosisb. Metabolic acidosisc. Respiratory alkalosisd. Metabolic alkalosis33. A client has an order for ABG analysis on radialartery specimens. The nurse ensures that whichof the following has been performed or testedbefore the ABG specimens are drawn?a. Guthrie testb. Romberg’s testc. Allen’s testd. Weber’s test34. A nurse is reviewing the arterial blood gas valuesof a client and notes that the ph is 7.31, Pco2 is50 mmHg, and the bicarbonate is 27 mEq/L. Thenurse concludes that which acid basedisturbance is present in this client?a. Respiratory acidosisb. Metabolic acidosisc. Respiratory alkalosisd. Metabolic alkalosis35. Allen’s test checks the patency of the:a. Ulnar arteryb. Carotid arteryc. Radial arteryd. Brachial arterySituation 6: Eileen, 45 years old is admitted to thehospital with a diagnosis of renal calculi. She isexperiencing severe flank pain, nauseated and with atemperature of 39 0C.36. Given the above assessment data, the mostimmediate goal of the nurse would be which ofthe following?a. Prevent urinary complicationb. maintains fluid and electrolytesc. Alleviate paind. Alleviating nausea37. After IVP a renal stone was confirmed, a leftnephrectomy was done. Her post-operativeorder includes “daily urine specimen to be sentto the laboratory”. Eileen has a foley catheterattached to a urinary drainage system. How willyou collect the urine specimen?a. remove urine from drainage tube withsterile needle and syringe and emptyurine from the syringe into thespecimen containerb. empty a sample urine from thecollecting bag into the specimencontainerc. Disconnect the drainage tube from theindwelling catheter and allow urine toflow from catheter into the specimencontainer.d. Disconnect the drainage from thecollecting bag and allow the urine toflow from the catheter into thespecimen container.
  • 838. Where would the nurse tape Eileen’s indwellingcatheter in order to reduce urethral irritation?a. to the patient’s inner thighb. to the patient’ buttocksc. to the patient’s lower thighd. to the patient lower abdomen39. Which of the following menu is appropriate forone with low sodium diet?a. instant noodles, fresh fruits and ice teab. ham and cheese sandwich, fresh fruitsand vegetablesc. white chicken sandwich, vegetablesalad and tead. canned soup, potato salad, and diet soda40. How will you prevent ascending infection toEileen who has an indwelling catheter?a. see to it that the drainage tubingtouches the level of the urineb. change he catheter every eight hoursc. see to it that the drainage tubing doesnot touch the level of the urined. clean catheter may be used sinceurethral meatus is not a sterile areaSituation: Hormones are secreted by the various glandsin the body. Basic knowledge of the endocrine system isnecessary.41. Somatocrinin or the Growth hormone releasinghormone is secreted by the:a. Hypothalamusb. Posterior pituitary glandc. Anterior pituitary glandd. Thyroid gland42. All of the following are secreted by the anteriorpituitary gland except:a. Somatotropin/Growth hormoneb. Thyroid stimulating hormonec. Follicle stimulating hormoned. Gonadotropin hormone releasinghormone43. All of the following hormones are hormonessecreted by the Posterior pituitary gland except:a. Vasopressinb. Anti-diuretic hormonec. Oxytocind. Growth hormone44. Calcitonin, a hormone necessary for calciumregulation is secreted in the:a. Thyroid glandb. Parathyroid glandc. Hypothalamusd. Anterior pituitary gland45. While Parathormone, a hormone that negatesthe effect of calcitonin is secreted by the:a. Thyroid glandb. Parathyroid glandc. Hypothalamusd. Anterior pituitary glandSituation: The staff nurse supervisor requests all the staffnurses to “brainstorm” and learn ways to instructdiabetic clients on self-administration of insulin. Shewants to ensure that there are nurses available daily todo health education classes.46. The plan of the nurse supervisor is an example ofa. in service education processb. efficient management of humanresourcesc. increasing human resourcesd. primary prevention47. When Mrs. Guevarra, a nurse, delegates aspectsof the clients care to the nurse-aide who is anunlicensed staff, Mrs. Guevarraa. makes the assignment to teach the staffmemberb. is assigning the responsibility to theaide but not the accountability forthose tasksc. does not have to supervise or evaluatethe aided. most know how to perform taskdelegated48. Connie, the new nurse, appears tired andsluggish and lacks the enthusiasm she had sixweeks ago when she started the job. The nursesupervisor shoulda. empathize with the nurse and listen toherb. tell her to take the day offc. discuss how she is adjusting to her newjobd. ask about her family life49. Process of formal negotiations of workingconditions between a group of registered nursesand employer is
  • 9a. grievanceb. arbitrationc. collective bargainingd. strike50. You are attending a certification oncardiopulmonary resuscitation (CPR) offered andrequired by the hospital employing you. This isa. professional course towards creditsb. in-service educationc. advance trainingd. continuing educationSituation: As a nurse, you are aware that properdocumentation in the patient chart is your responsibility.51. Which of the following is not a legally bindingdocument but nevertheless very important inthe care of all patients in any health caresetting?a. Bill of rights as provided in the Philippineconstitutionb. Scope of nursing practice as defined byRA 9173c. Board of nursing resolution adopting thecode of ethicsd. Patient’s bill of rights52. A nurse gives a wrong medication to the client.Another nurse employed by the same hospital asa risk manager will expect to receive which ofthe following communication?a. Incident reportb. Nursing kardexc. Oral reportd. Complain report53. Performing a procedure on a client in theabsence of an informed consent can lead towhich of the following charges?a. Fraudb. Harassmentc. Assault and batteryd. Breach of confidentiality54. Which of the following is the essence ofinformed consent?a. It should have a durable power ofattorneyb. It should have coverage from aninsurance companyc. It should respect the client’s freedomfrom coerciond. It should disclose previous diagnosis,prognosis and alternative treatmentsavailable for the client55. Delegation is the process of assigning tasks thatcan be performed by a subordinate. The RNshould always be accountable and should notlose his accountability. Which of the following isa role included in delegation?a. The RN must supervise all delegatedtasksb. After a task has been delegated, it is nolonger a responsibility of the RNc. The RN is responsible and accountablefor the delegated task in adjunct withthe delegated. Follow up with a delegated task isnecessary only if the assistive personnelis not trustworthySituation: When creating your lesson plan forcerebrovascular disease or STROKE. It is important toinclude the risk factors of stroke.56. The most important risk factor is:a. Cigarette smokingb. binge drinkingc. Hypertensiond. heredity57. Part of your lesson plan is to talk about etiologyor cause of stroke. The types of stroke based oncause are the following EXCEPT:a. Embolic strokeb. diabetic strokec. Hemorrhagic stroked. thrombotic stroke58. Hemmorhagic stroke occurs suddenly usuallywhen the person is active. All are causes ofhemorrhage, EXCEPT:a. phlebitisb. damage to blood vesselc. traumad. aneurysm59. The nurse emphasizes that intravenous drugabuse carries a high risk of stroke. Which drug isclosely linked to this?a. Amphetaminesb. shabuc. Cocained. Demerol
  • 1060. A participant in the STROKE class asks what is arisk factor of stroke. Your best response is:a. “More red blood cells thicken bloodand make clots more possible.”b. “Increased RBC count is linked to highcholesterol.”c. “More red blood cell increaseshemoglobin content.”d. “High RBC count increases bloodpressure.”Situation: Recognition of normal values is vital inassessment of clients with various disorders.61. A nurse is reviewing the laboratory test resultsfor a client with a diagnosis of severedehydration. The nurse would expect thehematocrit level for this client to be which of thefollowing?a. 60%b. 47%c. 45%d. 32%62. A nurse is reviewing the electrolyte results of anassigned client and notes that the potassiumlevel is 5.6 mEq/L. Which of the following wouldthe nurse expect to note on the ECG as a resultof this laboratory value?a. ST depressionb. Prominent U wavec. Inverted T waved. Tall peaked T waves63. A nurse is reviewing the electrolyte results of anassigned client and notes that the potassiumlevel is 3.2 mEq/L. Which of the following wouldthe nurse expect to note on the ECG as a resultof this laboratory value?a. U wavesb. Elevated T wavesc. Absent P wavesd. Elevated ST Segment64. Dorothy underwent diagnostic test and theresult of the blood examination are back. Onreviewing the result the nurse notices which ofthe following as abnormal finding?a. Neutrophils 60%b. White blood cells (WBC) 9000/mmc. Erythrocyte sedimentation rate (ESR) is39 mm/hrd. Iron 75 mg/100 ml65. Which of the following laboratory test resultindicate presence of an infectious process?a. Erythrocyte sedimentation rate (ESR) 12mm/hrb. White blood cells (WBC) 18,000/mm3c. Iron 90 g/100mld. Neutrophils 67%Situation: Pleural effusion is the accumulation of fluid inthe pleural space. Questions 66 to 70 refer to this.66. Which of the following is a finding that the nursewill be able to assess in a client with Pleuraleffusion?a. Reduced or absent breath sound at thebase of the lungs, dyspnea, tachpyneaand shortness of breathb. Hypoxemia, hypercapnea andrespiratory acidosisc. Noisy respiration, crackles, stridor andwheezingd. Tracheal deviation towards the affectedside, increased fremitus and loud breathsounds67. Thoracentesis is performed to the client witheffusion. The nurse knows that the removal offluid should be slow. Rapid removal of fluid inthoracentesis might cause:a. Pneumothoraxb. Cardiovascular collapsec. Pleurisy or Pleuritisd. Hypertension68. 3 Days after thoracentesis, the client againexhibited respiratory distress. The nurse willknow that pleural effusion has reoccurred whenshe noticed a sharp stabbing pain duringinspiration. The physician ordered a closed tubethoracotomy for the client. The nurse knowsthat the primary function of the chest tube is to:a. Restore positive intrathoracic pressureb. Restore negative intrathoracic pressurec. To visualize the intrathoracic contentd. As a method of air administration viaventilator69. The chest tube is functioning properly if:a. There is an oscillationb. There is no bubbling in the drainagebottle
  • 11c. There is a continuous bubbling in thewaterseald. The suction control bottle has acontinuous bubbling70. In a client with pleural effusion, the nurse isinstructing appropriate breathing technique.Which of the following is included in theteaching?a. Breath normallyb. Hold the breath after each inspirationfor 1 full minutec. Practice abdominal breathingd. Inhale slowly and hold the breath for 3to 5 seconds after each inhalationSITUATION: Health care delivery system affects thehealth status of every filipino. As a Nurse, Knowledge ofthis system is expected to ensure quality of life.71. When should rehabilitation commence?a. The day before dischargeb. When the patient desiresc. Upon admissiond. 24 hours after discharge72. What exemplified the preventive and promotiveprograms in the hospital?a. Hospital as a center to prevent andcontrol infectionb. Program for smokersc. Program for alcoholics and drug addictsd. Hospital Wellness Center73. Which makes nursing dynamic?a. Every patient is a unique physical,emotional, social and spiritual beingb. The patient participate in the overallnursing care planc. Nursing practice is expanding in the lightof modern developments that takesplaced. The health status of the patient isconstantly changing and the nurse mustbe cognizant and responsive to thesechanges74. Prevention is an important responsibility of thenurse in:a. Hospitalsb. Communityc. Workplaced. All of the above75. This form of Health Insurance providescomprehensive prepaid health services toenrollees for a fixed periodic payment.a. Health Maintenance Organizationb. Medicarec. Philippine Health Insurance Actd. Hospital Maintenance OrganizationSituation: Nursing ethics is an important part of thenursing profession. As the ethical situation arises, so isthe need to have an accurate and ethical decisionmaking.76. The purpose of having a nurses’ code of ethics is:a. Delineate the scope and areas of nursingpracticeb. identify nursing action recommended forspecific health care situationsc. To help the public understandprofessional conduct expected ofnursesd. To define the roles and functions of thehealth care givers, nurses, clients77. The principles that govern right and properconduct of a person regarding life, biology andthe health professionals is referred to as:a. Moralityb. Religionc. Valuesd. Bioethics78. A subjective feeling about what is right or wrongis said to be:a. Moralityb. Religionc. Valuesd. Bioethics79. Values are said to be the enduring believe abouta worth of a person, ideas and belief. If Valuesare going to be a part of a research, this iscategorized under:a. Qualitativeb. Experimentalc. Quantitatived. Non Experimental80. The most important nursing responsibility whereethical situations emerge in patient care is to:a. Act only when advised that the action isethically sound
  • 12b. Not takes sides, remain neutral and fairc. Assume that ethical questions are theresponsibility of the health teamd. Be accountable for his or her ownactions81. Why is there an ethical dilemma?a. the choices involved do not appear to beclearly right or wrongb. a client’s legal right co-exist with thenurse’s professional obligationc. decisions has to be made based onsocietal norms.d. decisions has to be mad quickly, oftenunder stressful conditions82. According to the code of ethics, which of thefollowing is the primary responsibility of thenurse?a. Assist towards peaceful deathb. Health is a fundamental rightc. Promotion of health, prevention ofillness, alleviation of suffering andrestoration of healthd. Preservation of health at all cost83. Which of the following is TRUE about the Codeof Ethics of Filipino Nurses, except:a. The Philippine Nurses Association forbeing the accredited professionalorganization was given the privilege toformulate a Code of Ethics for Nurseswhich the Board of Nursingpromulgatedb. Code for Nurses was first formulated in1982 published in the Proceedings of theThird Annual Convention of the PNAHouse of Delegatesc. The present code utilized the Code ofGood Governance for the Professions inthe Philippinesd. Certificates of Registration of registerednurses may be revoked or suspended forviolations of any provisions of the Codeof Ethics.84. Violation of the code of ethics might equate tothe revocation of the nursing license. Whorevokes the license?a. PRCb. PNAc. DOHd. BON85. Based on the Code of Ethics for Filipino Nurses,what is regarded as the hallmark of nursingresponsibility and accountability?a. Human rights of clients, regardless ofcreed and genderb. The privilege of being a registeredprofessional nursec. Health, being a fundamental right ofevery individuald. Accurate documentation of actions andoutcomesSituation: As a profession, nursing is dynamic and itspractice is directed by various theoretical models. Todemonstrate caring behaviour, the nurse applies variousnursing models in providing quality nursing care.86. When you clean the bedside unit and regularlyattend to the personal hygiene of the patient aswell as in washing your hands before and after aprocedure and in between patients, you indentto facilitate the body’s reparative processes.Which of the following nursing theory are youapplying in the above nursing action?a. Hildegard Peplaub. Dorothea Oremc. Virginia Hendersond. Florence Nightingale87. A communication skill is one of the importantcompetencies expected of a nurse. Interpersonalprocess is viewed as human to humanrelationship. This statement is an application ofwhose nursing model?a. Joyce Travelbeeb. Martha Rogersc. Callista Royd. Imogene King88. The statement “the health status of an individualis constantly changing and the nurse must becognizant and responsive to these changes” bestexplains which of the following facts aboutnursing?a. Dynamicb. Client centredc. Holisticd. Art89. Virginia Henderson professes that the goal ofnursing is to work interdependently with otherhealth care working in assisting the patient to
  • 13gain independence as quickly as possible. Whichof the following nursing actions bestdemonstrates this theory in taking care of a 94year old client with dementia who is totallyimmobile?a. Feeds the patient, brushes his teeth,gives the sponge bathb. Supervise the watcher in renderingpatient his morning carec. Put the patient in semi fowler’s position,set the over bed table so the patient caneat by himself, brush his teeth andsponge himselfd. Assist the patient to turn to his sides andallow him to brush and feed himself onlywhen he feels ready90. In the self-care deficit theory by Dorothea Orem,nursing care becomes necessary when a patientis unable to fulfil his physiological, psychologicaland social needs. A pregnant client needingprenatal check-up is classified as:a. Wholly compensatoryb. Supportive Educativec. Partially compensatoryd. Non compensatorySituation: Documentation and reporting are just asimportant as providing patient care, As such, the nursemust be factual and accurate to ensure qualitydocumentation and reporting.91. Health care reports have different purposes. Theavailability of patients’ record to all health teammembers demonstrates which of the followingpurposes:a. Legal documentationb. Researchc. Educationd. Vehicle for communication92. When a nurse commits medication error, sheshould accurately document client’s responseand her corresponding action. This is veryimportant for which of the following purposes:a. Researchb. Legal documentationc. Nursing Auditd. Vehicle for communication93. POMR has been widely used in many teachinghospitals. One of its unique features is SOAPIEcharting. The P in SOAPIE charting shouldinclude:a. Prescription of the doctor to thepatient’s illnessb. Plan of care for patientc. Patient’s perception of one’s illnessd. Nursing problem and Nursing diagnosis94. The medical records that are organized intoseparate section from doctors or nurses hasmore disadvantages than advantages. This isclassified as what type of recording?a. POMRb. Modified POMRc. SOAPIEd. SOMR95. Which of the following is the advantage of SOMRor Traditional recording?a. Increases efficiency in data gatheringb. Reinforces the use of the nursingprocessc. The caregiver can easily locate propersection for making charting entriesd. Enhances effective communicationamong health care team membersSituation: June is a 24 year old client with symptoms ofdyspnea, absent breath sounds on the right lung andchest x ray revealed pleural effusion. The physician willperform thoracentesis.96. Thoracentesis is useful in treating all of thefollowing pulmonary disorders except:a. Hemothoraxb. Hydrothoraxc. Tuberculosisd. Empyema97. Which of the following psychological preparationis not relevant for him?a. Telling him that the gauge of the needleand anesthesia to be usedb. Telling him to keep still during theprocedure to facilitate the insertion ofthe needle in the correct placec. Allow June to express his feelings andconcernsd. Physician’s explanation on the purposeof the procedure and how it will be done98. Before thoracentesis, the legal consideration youmust check is:a. Consent is signed by the client
  • 14b. Medicine preparation is correctc. Position of the client is correctd. Consent is signed by relative andphysician99. As a nurse, you know that the position for Junebefore thoracentesis is:a. Orthopneicb. Low fowlersc. Knee-chestd. Sidelying position on the affected side100. Which of the following anaesthetics drug is usedfor thoracentesis?a. Procaine 2%b. Demerol 75 mgc. Valium 250 mgd. Phenobartbital 50 mg
  • 15NURSING PRACTICE IISituation: Mariah is a 31 year old lawyer who has beenmarried for 6 months. She consults you for guidance inrelation with her menstrual cycle and her desire to getpregnant.1. She wants to know the length of her menstrualcycle. Her previous menstrual period is October22 to 26. Her LMB is November 21. Which of thefollowing number of days will be your correctresponse?A. 29B. 28C. 30D. 312. You advised her to observe and record the signsof Ovulation. Which of the following signs willshe likely note down?1. A 1 degree Fahrenheit rise in basal bodytemperature2. Cervical mucus becomes copious andclear3. One pound increase in weight4. MittelschmerzA. 1, 2, 4B. 1, 2, 3C. 2, 3, 4D. 1, 3, 43. You instruct Mariah to keep record of her basaltemperature every day, which of the followinginstructions is incorrect?A. If coitus has occurred; this should bereflected in the chartB. It is best to have coitus on the eveningfollowing a drop in BBT to becomepregnantC. Temperature should be takenimmediately after waking and beforegetting out of bedD. BBT is lowest during the secretoryphase4. She reports an increase in BBT on December 16.Which hormone brings about this change in herBBT?A. EstrogenB. GonadotropineC. ProgesteroneD. Follicle stimulating hormone5. The following month, Mariah suspects she ispregnant. Her urine is positive for Humanchorionic gonadotrophin. Which structureproduces Hcg?A. Pituitary glandB. Trophoblastic cells of the embryoC. Uterine deciduasD. Ovarian folliclesSituation: Mariah came back and she is now pregnant.6. At 5 month gestation, which of the followingfetal development would probably be achieve?A. Fetal movement are felt by MariahB. Vernix caseosa covers the entire bodyC. Viable if delivered within this periodD. Braxton hicks contractions are observed7. The nurse palpates the abdomen of Mariah.Now At 5 month gestation, What level of theabdomen can the fundic height be palpated?A. Symphysis pubisB. Midpoint between the umbilicus and thexiphoid processC. Midpoint between the symphysis pubisand the umbilicusD. Umbilicus8. She worries about her small breasts, thinkingthat she probably will not be able to breastfeedher baby. Which of the following responses ofthe nurse is correct?A. “The size of your breast will not affectyour lactation”B. “You can switch to bottle feeding”C. “You can try to have exercise to increasethe size of your breast”D. “Manual expression of milk is possible”9. She tells the nurse that she does not take milkregularly. She claims that she does not want togain too much weight during her pregnancy.Which of the following nursing diagnosis is apriority?A. Potential self-esteem disturbancerelated to physiologic changes inpregnancyB. Ineffective individual coping related tophysiologic changes in pregnancyC. Fear related to the effects of pregnancyD. Knowledge deficit regarding nutritional
  • 16requirements of pregnancies related tolack of information sources10. Which of the following interventions will likelyensure compliance of Mariah?A. Incorporate her food preferences thatare adequately nutritious in her mealplanB. Consistently counsel toward optimumnutritional intakeC. Respect her right to reject dietaryinformation if she choosesD. Inform her of the adverse effects ofinadequate nutrition to her fetusSituation: Susan is a patient in the clinic where you work.She is inquiring about pregnancy.11. Susan tells you she is worried because shedevelops breasts later than most of her friends.Breast development is termed as:A. AdrenarcheB. ThelarcheC. MamarcheD. Menarche12. Kevin, Susan’s husband tells you that he isconsidering vasectomy After the birth of theirnew child. Vasectomy involves the incision ofwhich organ?A. The testesB. The epididymisC. The vas deferensD. The scrotum13. On examination, Susan has been found of havinga cystocele. A cystocele is:A. A sebaceous cyst arising from the vulvarfoldB. Protrusion of intestines into the vaginaC. Prolapse of the uterus into the vaginaD. Herniation of the bladder into thevaginal wall14. Susan typically has menstrual cycle of 34 days.She told you she had coitus on days 8, 10, 15 and20 of her menstrual cycle. Which is the day onwhich she is most likely to conceive?A. 8thdayB. Day 15C. 10thdayD. Day 2015. While talking with Susan, 2 new patients arrivedand they are covered with large towels and thenurse noticed that there are many cameramanand news people outside of the OPD. Uponassessment the nurse noticed that both of themare still nude and the male client’s penis is stillinside the female client’s vagina and the maleclient said that “I can’t pull it”. Vaginismus wasyour first impression. You know that Thepsychological cause of Vaginismus is related to:A. The male client inserted the penis toodeeply that it stimulates vaginal closureB. The penis was too large that is why thevagina triggered its defense to attemptto close itC. The vagina does not want to bepenetratedD. It is due to learning patterns of thefemale client where she views sex asbad or sinfulSituation: Overpopulation is one problem in thePhilippines that causes economic drain. Most Filipinosare against in legalizing abortion. As a nurse, Mastery ofcontraception is needed to contribute to the society andeconomic growth.16. Supposed that Dana, 17 years old, tells you shewants to use fertility awareness method ofcontraception. How will she determine herfertile days?A. She will notice that she feels hot, as ifshe has an elevated temperature.B. She should assess whether her cervicalmucus is thin, copious, clear andwatery.C. She should monitor her emotions forsudden anger or cryingD. She should assess whether her breastsfeel sensitive to cool air17. Dana chooses to use COC as her family planningmethod. What is the danger sign of COC youwould ask her to report?A. A stuffy or runny noseB. Slight weight gainC. Arthritis like symptomsD. Migraine headache18. Dana asks about subcutaneous implants and sheasks, how long will these implants be effective.Your best answer is:A. One month
  • 17B. Five yearsC. Twelve monthsD. 10 years19. Dana asks about female condoms. Which of thefollowing is true with regards to femalecondoms?A. The hormone the condom releasesmight cause mild weight gainB. She should insert the condom beforeany penile penetrationC. She should coat the condom withspermicide before useD. Female condoms, unlike male condoms,are reusable20. Dana has asked about GIFT procedure. Whatmakes her a good candidate for GIFT?A. She has patent fallopian tubes, sofertilized ova can be implanted on themB. She is RH negative, a necessarystipulation to rule out RH incompatibilityC. She has normal uterus, so the sperm canbe injected through the cervix into itD. Her husband is taking sildenafil, so allsperms will be motileSituation: Nurse Lorena is a Family Planning andInfertility Nurse Specialist and currently attends toFAMILY PLANNING CLIENTS AND INFERTILE COUPLES.The following conditions pertain to meeting the nursingneeds of this particular population group.21. Dina, 17 years old, asks you how a tubal ligationprevents pregnancy. Which would be the bestanswer?A. Prostaglandins released from the cutfallopian tubes can kill spermB. Sperm cannot enter the uterus becausethe cervical entrance is blocked.C. Sperm can no longer reach the ova,because the fallopian tubes are blockedD. The ovary no longer releases ova asthere is nowhere for them to go.22. The Dators are a couple undergoing testing forinfertility. Infertility is said to exist when:A. A woman has no uterusB. A woman has no childrenC. A couple has been trying to conceive for1 yearD. A couple has wanted a child for 6months23. Another client named Lilia is diagnosed as havingendometriosis. This condition interferes withfertility because:A. Endometrial implants can block thefallopian tubesB. The uterine cervix becomes inflamedand swollenC. The ovaries stop producing adequateestrogenD. Pressure on the pituitary leads todecreased FSH levels24. Lilia is scheduled to have ahysterosalphingogram. Which of the followinginstructions would you give her regarding thisprocedure?A. She will not be able to conceive for 3months after the procedureB. The sonogram of the uterus will revealany tumors presentC. Many women experience mild bleedingas an after effectD. She may feel some cramping when thedye is inserted25. Lilia’s cousin on the other hand, knowing nurseLorena’s specialization asks what artificialinsemination by donor entails. Which would beyour best answer if you were Nurse Lorena?A. Donor sperm are introduced vaginallyinto the uterus or cervixB. Donor sperm are injected intra-abdominally into each ovaryC. Artificial sperm are injected vaginally totest tubal patencyD. The husband’s sperm is administeredintravenously weeklySituation: You are assigned to take care of a group ofpatients across the lifespan.26. Pain in the elder persons requires carefulassessment because they:A. experienced reduce sensory perceptionB. have increased sensory perceptionC. are expected to experience chronic painD. have a decreased pain threshold27. Administration of analgesics to the older personsrequires careful patient assessment becauseolder people:A. are more sensitive to drugs
  • 18B. have increased hepatic, renal andgastrointestinal functionC. have increased sensory perceptionD. mobilize drugs more rapidly28. The elderly patient is at higher risk for urinaryincontinence because of:A. increased glomerular filtrationB. decreased bladder capacityC. diuretic useD. dilated urethra29. Which of the following is the MOST COMMONsign of infection among the elderly?A. decreased breath sounds with cracklesB. painC. feverD. change in mental status30. Priorities when caring for the elderly traumapatient:A. circulation, airway, breathingB. airway, breathing, disability (neurologic)C. disability (neurologic), airway, breathingD. airway, breathing, circulation31. Preschoolers are able to see things from whichof the following perspectives?A. Their peersB. Their own and their mother’sC. Their own and their caregivers’D. Only their own32. In conflict management, the win-win approachoccurs when:A. There are two conflicts and the partiesagree to each oneB. Each party gives in on 50% of thedisagreements making up the conflictC. Both parties involved are committed tosolving the conflictD. The conflict is settled out of court so thelegal system and the parties win33. According to the social-interactional perspectiveof child abuse and neglect, four factors place thefamily members at risk for abuse. These riskfactors are the family members at risk for abuse.These risk factors are the family itself, thecaregiver, the child, andA. The presence of a family crisisB. The national emphasis on sexC. GeneticsD. Chronic poverty34. Which of the following signs and symptomswould you most likely find when assessing andinfant with Arnold-Chiari malformation?A. Weakness of the leg muscles, loss ofsensation in the legs, and restlessnessB. Difficulty swallowing, diminished orabsent gag reflex, and respiratorydistressC. Difficulty sleeping, hypervigilant, and anarching of the backD. Paradoxical irritability, diarrhea, andvomiting.35. A parent calls you and frantically reports that herchild has gotten into her famous ferrous sulfatepills and ingested a number of these pills. Herchild is now vomiting, has bloody diarrhea, and iscomplaining of abdominal pain. You will tell themother to:A. Call emergency medical services (EMS)and get the child to the emergency roomB. Relax because these symptoms will passand the child will be fineC. Administer syrup of ipecacD. Call the poison control center36. A client says she heard from a friend that youstop having periods once you are on the “pill”.The most appropriate response would be:A. “The pill prevents the uterus frommaking such endometrial lining, that iswhy periods may often be scant orskipped occasionally.”B. “If your friend has missed her period,she should stop taking the pills and get apregnancy test as soon as possible.”C. “The pill should cause a normalmenstrual period every month. Itsounds like your friend has not beentaking the pills properly.”D. “Missed period can be very dangerousand may lead to the formation ofprecancerous cells.”37. The nurse assessing newborn babies and infantsduring their hospital stay after birth will noticewhich of the following symptoms as a primarymanifestation of Hirschsprung’s disease?A. A fine rash over the trunkB. Failure to pass meconium during thefirst 24 to 48 hours after birth
  • 19C. The skin turns yellow and then brownover the first 48 hours of lifeD. High-grade fever38. A client is 7 months pregnant and has just beendiagnosed as having a partial placenta previa.She is stable and has minimal spotting and isbeing sent home. Which of these instructions tothe client may indicate a need for furtherteaching?A. Maintain bed rest with bathroomprivilegesB. Avoid intercourse for three days.C. Call if contractions occur.D. Stay on left side as much as possiblewhen lying down.39. A woman has been rushed to the hospital withruptured membrane. Which of the followingshould the nurse check first?A. Check for the presence of infectionB. Assess for Prolapse of the umbilicalcordC. Check the maternal heart rateD. Assess the color of the amniotic fluid40. The nurse notes that the infant is wearing aplastic-coated diaper. If a topical medicationwere to be prescribed and it were to go on thestomachs or buttocks, the nurse would teach thecaregivers to:A. avoid covering the area of the topicalmedication with the diaperB. avoid the use of clothing on top of thediaperC. put the diaper on as usualD. apply an icepack for 5 minutes to theoutside of the diaper41. Which of the following factors is most importantin determining the success of relationships usedin delivering nursing care?A. Type of illness of the clientB. Transference and counter transferenceC. Effective communicationD. Personality of the participants42. Grace sustained a laceration on her leg fromautomobile accident. Why are lacerations oflower extremities potentially more seriousamong pregnant women than other?A. lacerations can provoke allergicresponses due to gonadotropic hormonereleaseB. a woman is less able to keep thelaceration clean because of her fatigueC. healing is limited during pregnancy sothese will not heal until after birthD. increased bleeding can occur fromuterine pressure on leg veins43. In working with the caregivers of a client with anacute or chronic illness, the nurse would:A. Teach care daily and let the caregiversdo a return demonstration just beforedischargeB. Difficulty swallowing, diminished orabsent gag reflex, and respiratorydistress.C. Difficulty sleeping, hypervigilant, and anarching of the backD. Paradoxical irritability, diarrhea, andvomiting44. Which of the following roles BEST exemplifiesthe expanded role of the nurse?A. Circulating nurse in surgeryB. Medication nurseC. Obstetrical nurseD. Pediatric nurse practitioner45. According to DeRosa and Kochura’s (2006)article entitled “Implement Culturally CompetentHealth Care in your work place,” cultures havedifferent patterns of verbal and nonverbalcommunication. Which difference does?A. NOT necessarily belong?B. Personal behaviorC. Subject matterD. Eye contactE. Conversational style46. You are the nurse assigned to work with a childwith acute glomerulonephritis. By following theprescribed treatment regimen, the childexperiences a remission. You are now checkingto make sure the child does not have a relapse.Which finding would most lead you to theconclusion that a relapse is happening?A. Elevated temperature, cough, sorethroat, changing complete blood count(CBC) with diiferentialB. A urine dipstick measurement of 2+proteinuria or more for 3 days, or thechild found to have 3-4+ proteinutriaplus edema.
  • 20C. The urine dipstick showing glucose in theurine for 3 days, extreme thirst, increasein urine output, and a moon face.D. A temperature of 37.8 degrees (100degrees F), flank pain, burningfrequency, urgency on voiding, andcloudy urine.47. The nurse is working with an adolescent whocomplains of being lonely and having a lack offulfillment in her life. This adolescent shies awayfrom intimate relationships at times yet at othertimes she appears promiscuous. The nurse willlikely work with this adolescent in which of thefollowing areas?A. IsolationB. Lack of fulfillmentC. LonelinessD. Identity48. The use of interpersonal decision making,psychomotor skills, and application ofknowledge expected in the role of a licensedhealth care professional in the context of publichealth welfare and safety is an example of:A. DelegationB. ResponsibilityC. SupervisionD. Competence49. The painful phenomenon known as “back labor”occurs in a client whose fetus in what position?A. Brow positionB. Breech positionC. Right Occipito-Anterior PositionD. Left Occipito-Posterior Position50. FOCUS methodology stands for:A. Focus, Organize, Clarify, Understandand SolutionB. Focus, Opportunity, Continuous, Utilize,SubstantiateC. Focus, Organize, Clarify, Understand,SubstantiateD. Focus, Opportunity, Continuous(process), Understand, SolutionSITUATION: The infant and child mortality rate in the lowto middle income countries is ten times higher thanindustrialized countries. In response to this, the WHOand UNICEF launched the protocol IntegratedManagement of Childhood Illnesses to reduce themorbidity and mortality against childhood illnesses.51. If a child with diarrhea registers two signs in theyellow row in the IMCI chart, we can classify thepatient as:A. Moderate dehydrationB. Severe dehydrationC. Some dehydrationD. No dehydration52. Celeste has had diarrhea for 8 days. There is noblood in the stool, he is irritable, his eyes aresunken, the nurse offers fluid to Celeste and hedrinks eagerly. When the nurse pinched theabdomen it goes back slowly. How will youclassify Celeste’s illness?A. Moderate dehydrationB. Severe dehydrationC. Some dehydrationD. No dehydration53. A child who is 7 weeks has had diarrhea for 14days but has no sign of dehydration is classifiedas:A. Persistent diarrheaB. DysenteryC. Severe dysenteryD. Severe persistent diarrhea54. The child with no dehydration needs hometreatment. Which of the following is notincluded in the rules for home treatment in thiscase?A. Forced fluidsB. When to returnC. Give vitamin A supplementD. Feeding more55. Fever as used in IMCI includes:A. Axillary temperature of 37.5 or higherB. Rectal temperature of 38 or higherC. Feeling hot to touchD. All of the aboveE. A and C onlySituation: Prevention of Dengue is an important nursingresponsibility and controlling it’s spread is a priority onceoutbreak has been observed.56. An important role of the community healthnurse in the prevention and control of DengueH-fever includes:A. Advising the elimination of vectors bykeeping water containers covered
  • 21B. Conducting strong health educationdrives/campaign directed towardsproper garbage disposalC. Explaining to the individuals, families,groups and community the nature ofthe disease and its causationD. Practicing residual spraying withinsecticides57. Community health nurses should be alert inobserving a Dengue suspect. The following isNOT an indicator for hospitalization of H-feversuspects?A. Marked anorexia, abdominal pain andvomitingB. Increasing hematocrit countC. Cough of 30 daysD. Persistent headache58. The community health nurses’ primary concernin the immediate control of hemorrhage amongpatients with dengue is:A. Advising low fiber and non-fat dietB. Providing warmth through light weightcoversC. Observing closely the patient for vitalsigns leading to shockD. Keeping the patient at rest59. Which of these signs may NOT be REGARDED asa truly positive signs indicative of Dengue H-fever?A. Prolonged bleeding timeB. Appearance of at least 20 petechiaewithin 1cm squareC. Steadily increasing hematocrit countD. Fall in the platelet count60. Which of the following is the most importanttreatment of patients with Dengue H-fever?A. Give aspirin for feverB. Replacement of body fluidsC. Avoid unnecessary movement of patientD. Ice cap over the abdomen in case ofmelenaSituation: Health education and Health promotion is animportant part of nursing responsibility in thecommunity. Immunization is a form of health promotionthat aims at preventing the common childhood illnesses.61. In correcting misconceptions and myths aboutcertain diseases and their management, thehealth worker should first:A. Identify the myths and misconceptionsprevailing in the communityB. Identify the source of these myths andmisconceptionsC. Explain how and why these myths cameaboutD. Select the appropriate IEC strategies tocorrect them62. How many percent of measles are prevented byimmunization at 9 months of age?A. 80%B. 99%C. 90%D. 95%63. After TT3 vaccination a mother is said to beprotected to tetanus by around:A. 80%B. 99%C. 85%D. 90%64. If ever convulsions occur after administeringDPT, what should the nurse best suggest to themother?A. Do not continue DPT vaccinationanymoreB. Advise mother to comeback after 1 weekC. Give DT instead of DPTD. Give pertussis of the DPT and remove DT65. These vaccines are given 3 doses at one monthintervals:A. DPT, BCG, TTB. OPV, HEP. B, DPTC. DPT, TT, OPVD. Measles, OPV, DPTSituation – With the increasing documented cases ofCANCER the best alternative to treatment still remains tobe PREVENTION. The following conditions apply.66. Which among the following is the primary focusof prevention of cancer?A. Elimination of conditions causing cancerB. Diagnosis and treatmentC. Treatment at early stageD. Early detection67. In the prevention and control of cancer, which ofthe following activities is the most important
  • 22function of the community health nurse?A. Conduct community assemblies.B. Referral to cancer specialist those clientswith symptoms of cancer.C. Use the nine warning signs of cancer asparameters in our process of detection,control and treatment modalities.D. Teach woman about proper/correctnutrition.68. Who among the following are recipients of thesecondary level of care for cancer cases?A. Those under early case detectionB. Those under post case treatmentC. Those scheduled for surgeryD. Those undergoing treatment69. Who among the following are recipients of thetertiary level of care for cancer cases?A. Those under early treatmentB. Those under early detectionC. Those under supportive careD. Those scheduled for surgery70. In Community Health Nursing, despite theavailability and use of many equipment anddevices to facilitate the job of the communityhealth nurse, the best tool any nurse should bewel be prepared to apply is a scientific approach.This approach ensures quality of care even at thecommunity setting. This is nursing parlance isnothing less than the:A. nursing diagnosisB. nursing researchC. nursing protocolD. nursing processSituation – Two children were brought to you. One withchest indrawing and the other had diarrhea. Thefollowing questions apply:71. Using Integrated Management and ChildhoodIllness (IMCI) approach, how would you classifythe 1st child?A. BronchopneumoniaB. Severe pneumoniaC. No pneumonia : cough or coldD. Pneumonia72. The 1st child who is 13 months has fastbreathing using IMCI parameters he has:A. 40 breaths per minute or moreB. 50 breaths per minuteC. 30 breaths per minute or moreD. 60 breaths per minute73. Nina, the 2nd child has diarrhea for 5 days.There is no blood in the stool. She is irritable,and her eyes are sunken. The nurse offeredfluids and and the child drinks eagerly. Howwould you classify Nina’s illness?A. Some dehydrationB. Severe dehydrationC. DysenteryD. No dehydration74. Nina’s treatment should include the followingEXCEPT:A. reassess the child and classify him fordehydrationB. for infants under 6 months old who arenot breastfed, give 100-200 ml cleanwater as well during this periodC. Give in the health center therecommended amount of ORS for 4hours.D. Do not give any other foods to the childfor home treatment75. While on treatment, Nina 18 months oldweighed 18 kgs. and her temperature registeredat 37 degrees C. Her mother says she developedcough 3 days ago. Nina has no general dangersigns. She has 45 breaths/minute, no chest in-drawing, no stridor. How would you classifyNina’s manifestation?A. No pneumoniaB. PneumoniaC. Severe pneumoniaD. Bronchopneumonia76. Carol is 15 months old and weighs 5.5 kgs and itis her initial visit. Her mother says that Carol isnot eating well and unable to breastfeed, he hasno vomiting, has no convulsion and notabnormally sleepy or difficult to awaken. Hertemperature is 38.9 deg C. Using the integratedmanagement of childhood illness or IMCIstrategy, if you were the nurse in charge ofCarol, how will you classify her illness?A. a child at a general danger signB. severe pneumoniaC. very severe febrile diseaseD. severe malnutrition77. Why are small for gestational age newborns at
  • 23risk for difficulty maintaining body temperature?A. their skin is more susceptible toconduction of coldB. they are preterm so are born relativelysmall in sizeC. they do not have as many fat stored asother infantsD. they are more active than usual so theythrow off comes78. Oxytocin is administered to Rita to augmentlabor. What are the first symptoms of waterintoxication to observe for during thisprocedure?A. headache and vomitingB. a high choking voiceC. a swollen tender tongueD. abdominal bleeding and pain79. Which of the following treatment should NOT beconsidered if the child has severe denguehemorrhagic fever?A. use plan C if there is bleeding from thenose or gumsB. give ORS if there is skin Petechiae,persistent vomiting, and positivetourniquet testC. give aspirinD. prevent low blood sugar80. In assessing the patient’s condition using theIntegrated Management of Childhood Illnessapproach strategy, the first thing that a nurseshould do is to:A. ask what are the child’s problemB. check for the four main symptomsC. check the patient’s level ofconsciousnessD. check for the general danger signs81. A child with diarrhea is observed for thefollowing EXCEPT:A. how long the child has diarrheaB. presence of blood in the stoolC. skin PetechiaeD. signs of dehydration82. The child with no dehydration needs hometreatment. Which of the following is NOTincluded in the care for home management atthis case?A. give drugs every 4 hoursB. give the child more fluidsC. continue feeding the childD. inform when to return to the healthcenter83. Ms. Jordan, RN, believes that a patient should betreated as individual. This ethical principle thatthe patient referred to:A. beneficenceB. respect for personC. nonmaleficenceD. autonomy84. When patients cannot make decisions forthemselves, the nurse advocate relies on theethical principle of:A. justice and beneficenceB. beneficence and nonmaleficenceC. fidelity and nonmaleficenceD. fidelity and justice85. Being a community health nurse, you have theresponsibility of participating in protecting thehealth of people. Consider this situation:Vendors selling bread with their bare hands.They receive money with these hands. You donot see them washing their hands. What shouldyou say/do?A. “Miss, may I get the bread myselfbecause you have not washed yourhands”B. All of theseC. “Miss, it is better to use a pick upforceps/ bread tong”D. “Miss, your hands are dirty. Wash yourhands first before getting the bread”Situation: The following questions refer to commonclinical encounters experienced by an entry level nurse.86. A female client asks the nurse about the use of acervical cap. Which statement is correctregarding the use of the cervical cap?A. It may affect Pap smear results.B. It does not need to be fitted by thephysician.C. It does not require the use ofspermicide.D. It must be removed within 24 hours.87. The major components of the communicationprocess are:A. Verbal, written and nonverbal
  • 24B. Speaker, listener and replyC. Facial expression, tone of voice andgesturesD. Message, sender, channel, receiver andfeedback88. The extent of burns in children are normallyassessed and expressed in terms of:A. The amount of body surface that isunburnedB. Percentages of total body surface area(TBSA)C. How deep the deepest burns areD. The severity of the burns on a 1 to 5burn scale.89. The school nurse notices a child who is wearingold, dirty, poor-fitting clothes; is always hungry;has no lunch money; and is always tired. Whenthe nurse asks the boy his tiredness, he talks ofplaying outside until midnight. The nurse willsuspect that this child is:A. Being raised by a parent of lowintelligence quotient (IQ)B. An orphanC. A victim of child neglectD. The victim of poverty90. Which of the following indicates the type(s) ofacute renal failure?A. Four types: hemorrhagic with andwithout clotting, and nonhemorrhagicwith and without clottingsB. One type: acuteC. Three types: prerenal, intrarenal andpostrenalD. Two types: acute and subacuteSituation: Mike 16 y/o has been diagnosed to have AIDS;he worked as entertainer in a cruise ship;91. Which method of transmission is common tocontract AIDS?A. Syringe and needlesB. Sexual contactC. Body fluidsD. Transfusion92. Causative organism in AIDS is one of thefollowing;A. FungusB. retrovirusC. BacteriaD. Parasites93. You are assigned in a private room of Mike.Which procedure should be of outmostimportance;A. Alcohol washB. Washing IsolationC. Universal precautionD. Gloving technique94. What primary health teaching would you give tomike;A. Daily exerciseB. reverse isolationC. Prevent infectionD. Proper nutrition95. Exercise precaution must be taken to protecthealth worker dealing with the AIDS patients .which among these must be done as priority:A. Boil used syringe and needlesB. Use gloves when handling specimenC. Label personal belongingD. Avoid accidental woundSituation: Michelle is a 6 year old preschooler. She wasreported by her sister to have measles but she is athome because of fever, upper respiratory problem andwhite sports in her mouth.96. Rubeola is an Arabic term meaning Red, the rashappears on the skin in invasive stage prior toeruption behind the ears. As a nurse, yourphysical examination must determinecomplication especially:A. Otitis mediaB. Inflammatory conjunctivaC. Bronchial pneumoniaD. Membranous laryngitis97. To render comfort measure is one of thepriorities, Which includes care of the skin, eyes,ears, mouth and nose. To clean the mouth, yourantiseptic solution is in some form of which onebelow?A. WaterB. AlkalineC. SulfurD. Salt98. As a public health nurse, you teach mother andfamily members the prevention of complicationof measles. Which of the following should be
  • 25closely watched?A. Temperature fails to dropB. Inflammation of the nasophraynxC. Inflammation of the conjunctivaD. Ulcerative stomatitis99. Source of infection of measles is secretion ofnose and throat of infection person. Filterablevirus of measles is transmitted by:A. Water supplyB. Food ingestionC. DropletD. Sexual contact100. Method of prevention is to avoidexposure to an infection person. Nursingresponsibility for rehabilitation of patientincludes the provision of:A. Terminal disinfectionB. ImmunizationC. Injection of gamma globulinD. Comfort measures
  • 26NURSING PRACTICE IIISituation: Leo lives in the squatter area. He goes tonearby school. He helps his mother gather molassesafter school. One day, he was absent because of fever,malaise, anorexia and abdominal discomfort.1. Upon assessment, Leo was diagnosed to havehepatitis A. Which mode of transmission has theinfection agent taken?a. Fecal-oralb. Dropletc. Airborned. Sexual contact2. Which of the following is concurrent disinfectionin the case of Leo?a. Investigation of contactb. Sanitary disposal of faeces, urine andbloodc. Quarantine of the sick individuald. removing all detachable objects in theroom, cleaning lighting and air ductsurfaces in the ceiling, and cleaningeverything downward to the floor3. Which of the following must be emphasizedduring mother’s class to Leo’s mother?a. Administration of Immunoglobulin tofamiliesb. Thorough hand washing before andafter eating and toiletingc. Use of attenuated vaccinesd. Boiling of food especially meat4. Disaster control should be undertaken whenthere are 3 or more hepatitis A cases. Which ofthese measures is a priority?a. Eliminate faecal contamination fromfoodsb. Mass vaccination of uninfectedindividualsc. Health promotion and education tofamilies and communities about thedisease it’s cause and transmissiond. Mass administration of Immunoglobulin5. What is the average incubation period ofHepatitis A?a. 30 daysb. 60 daysc. 50 daysd. 14 daysSituation: As a nurse researcher you must have a verygood understanding of the common terms of conceptused in research.6. The information that an investigator collectsfrom the subjects or participants in a researchstudy is usually called;a. Hypothesisb. Variablec. Datad. Concept7. Which of the following usually refers to theindependent variables in doing researcha. Resultb. outputc. Caused. Effect8. The recipients of experimental treatment is anexperimental design or the individuals to beobserved in a non experimental design arecalled;a. Settingb. Treatmentc. Subjectsd. Sample9. The device or techniques an investigatoremploys to collect data is called;a. Sampleb. hypothesisc. Instrumentd. Concept10. The use of another person’s ideas or wordingswithout giving appropriate credit results frominaccurate or incomplete attribution of materialsto its sources. Which of the following is referredto when another person’s idea is inappropriatecredited as one’s own;a. Plagiarismb. assumptionc. Quotationd. ParaphraseSituation – Mrs. Pichay is admitted to your ward. TheMD ordered “Prepare for thoracentesis this pm toremove excess air from the pleural cavity.”
  • 2711. Which of the following nursing responsibilities isessential in Mrs. Pichay who will undergothoracentesis?a. Support and reassure client during theprocedureb. Ensure that informed consent has beensignedc. Determine if client has allergic reactionto local anesthesiad. Ascertain if chest x-rays and other testshave been prescribed and completed12. Mrs. Pichay who is for thoracentesis is assignedby the nurse to which of the following positions?a. Trendelenburg positionb. Supine positionc. Dorsal Recumbent positiond. Orthopneic position13. During thoracentesis, which of the followingnursing intervention will be most crucial?a. Place patient in a quiet and cool roomb. Maintain strict aseptic techniquec. Advice patient to sit perfectly stillduring needle insertion until it has beenwithdrawn from the chestd. Apply pressure over the puncture site assoon as the needle is withdrawn14. To prevent leakage of fluid in the thoracic cavity,how will you position the client afterthoracentesis?a. Place flat in bedb. Turn on the unaffected sidec. Turn on the affected sided. On bed rest15. Chest x-ray was ordered after thoracentesis.When your client asks what is the reason foranother chest x-ray, you will explain:a. To rule out pneumothoraxb. To rule out any possible perforationc. To decongestd. To rule out any foreign bodySituation: A computer analyst, Mr. Ricardo J. Santos, 25was brought to the hospital for diagnostic workup afterhe had experienced seizure in his office.16. Just as the nurse was entering the room, thepatient who was sitting on his chair begins tohave a seizure. Which of the following must thenurse do first?a. Ease the patient to the floorb. Lift the patient and put him on the bedc. Insert a padded tongue depressorbetween his jawsd. Restraint patient’s body movement17. Mr Santos is scheduled for CT SCAN for the nextday, noon time. Which of the following is thecorrect preparation as instructed by the nurse?a. Shampoo hair thoroughly to remove oiland dirtb. No special preparation is needed.Instruct the patient to keep his headstill and steadc. Give a cleansing enema and give fluidsuntil 8 AMd. Shave scalp and securely attachelectrodes to it18. Mr Santos is placed on seizure precaution.Which of the following would becontraindicated?a. Obtain his oral temperatureb. Encourage to perform his own personalhygienec. Allow him to wear his own clothingd. Encourage him to be out of bed19. Usually, how does the patient behave after hisseizure has subsided?a. Most comfortable walking and movingaboutb. Becomes restless and agitatedc. Sleeps for a period of timed. Say he is thirsty and hungry20. Before, during and after seizure. The nurseknows that the patient is ALWAYS placed in whatposition?a. Low fowler’sb. Side lyingc. Modified trendelenburgd. SupineSituation: Mrs. Damian an immediate post opcholecystectomy and choledocholithotomy patient,complained of severe pain at the wound site.21. Choledocholithotomy is:a. The removal of the gallbladderb. The removal of the stones in thegallbladderc. The removal of the stones in the
  • 28common bile ductd. The removal of the stones in the kidney22. The simplest pain relieving technique is:a. Distractionb. Deep breathing exercisec. Taking aspirind. Positioning23. Which of the following statement on pain isTRUE?a. Culture and pain are not associatedb. Pain accompanies acute illnessc. Patient’s reaction to pain Variesd. Pain produces the same reaction such asgroaning and moaning24. In pain assessment, which of the followingcondition is a more reliable indicator?a. Pain rating scale of 1 to 10b. Facial expression and gesturesc. Physiological responsesd. Patients description of the painsensation25. When a client complains of pain, your initialresponse is:a. Record the description of painb. Verbally acknowledge the painc. Refer the complaint to the doctord. Change to a more comfortable positionSituation: You are assigned at the surgical ward andclients have been complaining of post pain at varyingdegrees. Pain as you know, is very subjective.26. A one-day postoperative abdominal surgeryclient has been complaining of severe throbbingabdominal pain described as 9 in a 1-10 painrating. Your assessment reveals bowel sounds onall quadrants and the dressing is dry and intact.What nursing intervention would you take?a. Medicate client as prescribedb. Encourage client to do imageryc. Encourage deep breathing and turningd. Call surgeon stat27. Pentoxidone 5 mg IV every 8 hours wasprescribed for post abdominal pain. Which willbe your priority nursing action?a. Check abdominal dressing for possibleswellingb. Explain the proper use of PCA toalleviate anxietyc. Avoid overdosing to preventdependence/toleranced. Monitor VS, more importantly RR28. The client complained of abdominal distentionand pain. Your nursing intervention that canalleviate pain is:a. Instruct client to go to sleep and relaxb. Advice the client to close the lips andavoid deep breathing and talkingc. Offer hot and clear soupd. Turn to sides frequently and avoid toomuch talking29. Surgical pain might be minimized by whichnursing action in the O.R.a. Skill of surgical team and lessermanipulationb. Appropriate preparation for thescheduled procedurec. Use of modern technology in closing thewoundd. Proper positioning and draping of clients30. Inadequate anesthesia is said to be one of thecommon cause of pain both in intra and post oppatients. If General anesthesia is desired, it willinvolve loss of consciousness. Which of thefollowing are the 2 general types of GA?a. Epidural and Spinalb. Subarachnoid block and Intravenousc. Inhalation and Regionald. Intravenous and InhalationSituation: Nurse’s attitudes toward the pain influencethe way they perceive and interact with clients in pain.31. Nurses should be aware that older adults are atrisk of underrated pain. Nursing assessment andmanagement of pain should address thefollowing beliefs EXCEPT:a. Older patients seldom tend to reportpain than the younger onesb. Pain is a sign of weaknessc. Older patients do not believe inanalgesics, they are tolerantd. Complaining of pain will lead to beinglabeled a ‘bad’ patient32. Nurses should understand that when a clientresponds favorably to a placebo, it is known asthe ‘placebo effect’. Placebos do not indicate
  • 29whether or not a client has:a. Conscienceb. Diseasec. Real paind. Drug tolerance33. You are the nurse in the pain clinic where youhave client who has difficulty specifying thelocation of pain. How can you assist such client?a. The pain is vagueb. By charting-it hurts all overc. Identify the absence and presence ofpaind. As the client to point to the painful areby just one finger34. What symptom, more distressing than pain,should the nurse monitor when giving opioidsespecially among elderly clients who are in pain?a. Forgetfulnessb. Drowsinessc. Constipationd. Allergic reactions like pruritis35. Physical dependence occurs in anyone whotakes opiods over a period of time. What do youtell a mother of a ‘dependent’ when asked foradvice?a. Start another drug and slowly lessen theopioid dosageb. Indulge in recreational outdoor activitiesc. Isolate opioid dependent to a restfulresortd. Instruct slow tapering of the drugdosage and alleviate physicalwithdrawal symptomsSituation: The nurse is performing health educationactivities for Janevi Segovia, a 30 year old Dentist withInsulin dependent diabetes Miletus.36. Janevi is preparing a mixed dose of insulin. Thenurse is satisfied with her performance whenshe:a. Draw insulin from the vial of clearinsulin firstb. Draw insulin from the vial of theintermediate acting insulin firstc. Fill both syringes with the prescribedinsulin dosage then shake the bottlevigorouslyd. Withdraw the intermediate actinginsulin first before withdrawing the shortacting insulin first37. Janevi complains of nausea, vomiting,diaphoresis and headache. Which of thefollowing nursing intervention are you going tocarry out first?a. Withhold the client’s next insulininjectionb. Test the client’s blood glucose levelc. Administer Tylenol as orderedd. Offer fruit juice, gelatine and chickenbouillon38. Janevi administered regular insulin at 7 A.M andthe nurse should instruct Jane to avoidexercising at around:a. 9 to 11 A.Mb. Between 8 A.M to 9 A.Mc. After 8 hoursd. In the afternoon, after taking lunch39. Janevi was brought at the emergency room afterfour month because she fainted in her clinic. Thenurse should monitor which of the following testto evaluate the overall therapeutic complianceof a diabetic patient?a. Glycosylated hemoglobinb. Ketone levelsc. Fasting blood glucosed. Urine glucose level40. Upon the assessment of Hba1c of Mrs. Segovia,The nurse has been informed of a 9% Hba1cresult. In this case, she will teach the patient to:a. Avoid infectionb. Prevent and recognize hyperglycaemiac. Take adequate food and nutritiond. Prevent and recognize hypoglycaemia41. The nurse is teaching plan of care for Jane withregards to proper foot care. Which of thefollowing should be included in the plan?a. Soak feet in hot waterb. Avoid using mild soap on the feetc. Apply a moisturizing lotion to dry feetbut not between the toesd. Always have a podiatrist to cut your toenails; never cut them yourself42. Another patient was brought to the emergencyroom in an unresponsive state and a diagnosis ofhyperglycaemic hyperosmolar nonketoticsyndrome is made. The nurse immediately
  • 30prepares to initiate which of the followinganticipated physician’s order?a. Endotracheal intubationb. 100 unites of NPH insulinc. Intravenous infusion of normal salined. Intravenous infusion of sodiumbicarbonate43. Jane eventually developed DKA and is beingtreated in the emergency room. Which findingwould the nurse expect to note as confirmingthis diagnosis?a. Comatose stateb. Decreased urine outputc. Increased respiration and an increase inpHd. Elevated blood glucose level and lowplasma bicarbonate level44. The nurse teaches Jane to know the differencebetween hypoglycaemia and ketoacidosis. Janedemonstrates understanding of the teaching bystating that glucose will be taken if which of thefollowing symptoms develops?a. Polyuriab. Shakinessc. Blurred Visiond. Fruity breath odour45. Jane has been scheduled to have a FBS taken inthe morning. The nurse tells Jane not to eat ordrink after midnight. Prior to taking the bloodspecimen, the nurse noticed that Jane is holdinga bottle of distilled water. The nurse asked Janeif she drink any, and she said “yes.” Which of thefollowing is the best nursing action?a. Administer syrup of ipecac to removethe distilled water from the stomachb. Suction the stomach content using NGTprior to specimen collectionc. Advice to physician to reschedule todiagnostic examination next dayd. Continue as usual and have the FBSanalysis performed and specimen betakenSituation: Elderly clients usually produce unusual signswhen it comes to different diseases. The ageing processis a complicated process and the nurse shouldunderstand that it is an inevitable fact and she must beprepared to care for the growing elderly population.46. Hypoxia may occur in the older patients becauseof which of the following physiologic changesassociated with aging.a. Ineffective airway clearanceb. Decreased alveolar surfaced areac. Decreased anterior-posterior chestdiameterd. Hyperventilation47. The older patient is at higher risk forincontinence because of:a. Dilated urethrab. Increased glomerular filtration ratec. Diuretic used. Decreased bladder capacity48. Merle, age 86, is complaining of dizziness whenshe stands up. This may indicate:a. Dementiab. Functional declinec. A visual problemd. Drug toxicity49. Cardiac ischemia in an older patient usuallyproduces:a. ST-T wave changesb. Chest pain radiating to the left armc. Very high creatinine kinase leveld. Acute confusion50. The most dependable sign of infection in theolder patient is:a. Change in mental statusb. Feverc. Paind. Decreased breath sounds with cracklesSituation – In the OR, there are safety protocols thatshould be followed. The OR nurse should be well versedwith all these to safeguard the safety and quality ofpatient delivery outcome.51. Which of the following should be given highestpriority when receiving patient in the OR?a. Assess level of consciousnessb. Verify patient identification andinformed consentc. Assess vital signsd. Check for jewelry, gown, manicure, anddentures52. Surgeries like I and D (incision and drainage) anddebridement are relatively short procedures butconsidered ‘dirty cases’. When are these
  • 31procedures best scheduled?a. Last caseb. In between casesc. According to availability ofanaesthesiologistd. According to the surgeon’s preference53. OR nurses should be aware that maintaining theclient’s safety is the overall goal of nursing careduring the intraoperative phase. As thecirculating nurse, you make certain thatthroughout the procedure…a. the surgeon greets his client beforeinduction of anesthesiab. the surgeon and anesthesiologist are intandemc. strap made of strong non-abrasivematerials are fastened securely aroundthe joints of the knees and ankles andaround the 2 hands around an armboard.d. Client is monitored throughout thesurgery by the assistant anesthesiologist54. Another nursing check that should not be missedbefore the induction of general anesthesia is:a. check for presence underwearb. check for presence denturesc. check patient’s IDd. check baseline vital signs55. Some lifetime habits and hobbies affectpostoperative respiratory function. If your clientsmokes 3 packs of cigarettes a day for the past10 years, you will anticipate increased risk for:a. perioperative anxiety and stressb. delayed coagulation timec. delayed wound healingd. postoperative respiratory infectionSituation: Sterilization is the process of removing ALLliving microorganism. To be free of ALL livingmicroorganism is sterility.56. There are 3 general types of sterilization use inthe hospital, which one is not included?a. Steam sterilizationb. Physical sterilizationc. Chemical sterilizationd. Sterilization by boiling57. Autoclave or steam under pressure is the mostcommon method of sterilization in the hospital.The nurse knows that the temperature and timeis set to the optimum level to destroy not onlythe microorganism, but also the spores. Whichof the following is the ideal setting of theautoclave machine?a. 10,000 degree Celsius for 1 hourb. 5,000 degree Celsius for 30 minutesc. 37 degree Celsius for 15 minutesd. 121 degree Celsius for 15 minutes58. It is important that before a nurse prepares thematerial to be sterilized, a chemical indicatorstrip should be placed above the package,preferably, Muslin sheet. What is the color ofthe striped produced after autoclaving?a. Blackb. Bluec. Grayd. Purple59. Chemical indicators communicate that:a. The items are sterileb. That the items had undergonesterilization process but not necessarilysterilec. The items are disinfectedd. That the items had undergonedisinfection process but not necessarilydisinfected60. If a nurse will sterilize a heat and moisture labileinstruments, It is according to AORNrecommendation to use which of the followingmethod of sterilization?a. Ethylene oxide gasb. Autoclavingc. Flash sterilizerd. Alcohol immersionSituation 5 – Nurses hold a variety of roles whenproviding care to a perioperative patient.61. Which of the following role would be theresponsibility of the scrub nurse?a. Assess the readiness of the client priorto surgeryb. Ensure that the airway is adequatec. Account for the number of sponges,needles, supplies, used during thesurgical procedure.d. Evaluate the type of anesthesiaappropriate for the surgical client
  • 3262. As a perioperative nurse, how can you best meetthe safety need of the client after administeringpreoperative narcotic?a. Put side rails up and ask the client notto get out of bedb. Send the client to OR with the familyc. Allow client to get up to go to thecomfort roomd. Obtain consent form63. It is the responsibility of the pre-op nurse to doskin prep for patients undergoing surgery. If hairat the operative site is not shaved, what shouldbe done to make suturing easy and lessenchance of incision infection?a. Drapedb. Pulledc. Clippedd. Shampooed64. It is also the nurse’s function to determine wheninfection is developing in the surgical incision.The perioperative nurse should observe for whatsigns of impending infection?a. Localized heat and rednessb. Serosanguinous exudates and skinblanchingc. Separation of the incisiond. Blood clots and scar tissue are visible65. Which of the following nursing interventions isdone when examining the incision wound andchanging the dressing?a. Observe the dressing and type and odorof drainage if anyb. Get patient’s consentc. Wash handsd. Request the client to expose the incisionwoundSituation – The preoperative nurse collaborates with theclient significant others, and healthcare providers.66. To control environmental hazards in the OR, thenurse collaborates with the followingdepartments EXCEPT:a. Biomedical divisionb. Infection control committeec. Chaplaincy servicesd. Pathology department67. An air crash occurred near the hospital leadingto a surge of trauma patient. One of the lastpatients will need surgical amputation but thereare no sterile surgical equipments. In this case,which of the following will the nurse expect?a. Equipments needed for surgery need notbe sterilized if this is an emergencynecessitating life saving measuresb. Forwarding the trauma client to thenearest hospital that has available sterileequipments is appropriatec. The nurse will need to sterilize the itembefore using it to the client using theregular sterilization setting at 121degree Celsius in 15 minutesd. In such cases, flash sterlizer will be useat 132 degree Celsius in 3 minutes68. Tess, the PACU nurse, discovered that Malou,who weighs 110 lbs prior to surgery, is in severepain 3 hrs after cholecystectomy. Upon checkingthe chart, Malou found out that she has an orderof Demerol 100 mg I.M. prn for pain. Tess shouldverify the order with:a. Nurse Supervisorb. Surgeonc. Anesthesiologistd. Intern on duty69. Rosie, 57, who is diabetic is for debridement ifincision wound. When the circulating nursechecked the present IV fluid, she found out thatthere is no insulin incorporated as ordered.What should the circulating nurse do?a. Double check the doctor’s order andcall the attending MDb. Communicate with the ward nurse toverify if insulin was incorporated or notc. Communicate with the client to verify ifinsulin was incorporatedd. Incorporate insulin as ordered.70. The documentation of all nursing activitiesperformed is legally and professionally vital.Which of the following should NOT be includedin the patient’s chart?a. Presence of prosthetoid devices such asdentures, artificial limbs hearing aid, etc.b. Baseline physical, emotional, andpsychosocial datac. Arguments between nurses andresidents regarding treatmentsd. Observed untoward signs and symptomsand interventions including contaminantintervening factors
  • 33Situation – Team efforts is best demonstrated in the OR.71. If you are the nurse in charge for schedulingsurgical cases, what important information doyou need to ask the surgeon?a. Who is your internistb. Who is your assistant andanaesthesiologist, and what is yourpreferred time and type of surgery?c. Who are your anaesthesiologist,internist, and assistantd. Who is your anaesthesiologist72. In the OR, the nursing tandem for every surgeryis:a. Instrument technician and circulatingnurseb. Nurse anaesthetist, nurse assistant, andinstrument technicianc. Scrub nurse and nurse anaesthetistd. Scrub and circulating nurses73. While team effort is needed in the OR forefficient and quality patient care delivery, weshould limit the number of people in the roomfor infection control. Who comprise this team?a. Surgeon, anaesthesiologist, scrub nurse,radiologist, orderlyb. Surgeon, assistants, scrub nurse,circulating nurse, anaesthesiologistc. Surgeon, assistant surgeon,anaesthesiologist, scrub nurse,pathologistd. Surgeon, assistant surgeon,anaesthesiologist, intern, scrub nurse74. Who usually act as an important part of the ORpersonnel by getting the wheelchair or stretcher,and pushing/pulling them towards the operatingroom?a. Orderly/clerkb. Nurse Supervisorc. Circulating Nursed. Anaesthesiologist75. The breakdown in teamwork is often times afailure in:a. Electricityb. Inadequate supplyc. Leg workd. CommunicationSituation: Basic knowledge on Intravenous solutions isnecessary for care of clients with problems with fluidsand electrolytes.76. A client involved in a motor vehicle crashpresents to the emergency department withsevere internal bleeding. The client is severelyhypotensive and unresponsive. The nurseanticipates which of the following intravenoussolutions will most likely be prescribed toincrease intravascular volume, replaceimmediate blood loss and increase bloodpressure?a. 0.45% sodium chlorideb. 0.33% sodium chloridec. Normal saline solutiond. Lactated ringer’s solution77. The physician orders the nurse to prepare anisotonic solution. Which of the following IVsolution would the nurse expect the intern toprescribe?a. 5% dextrose in waterb. 0.45% sodium chloridec. 10% dextrose in waterd. 5% dextrose in 0.9% sodium chloride78. The nurse is making initial rounds on the nursingunit to assess the condition of assigned clients.The nurse notes that the client’s IV Site is cool,pale and swollen and the solution is not infusing.The nurse concludes that which of the followingcomplications has been experienced by theclient?a. Infectionb. Phlebitisc. Infiltrationd. Thrombophelibitis79. A nurse reviews the client’s electrolytelaboratory report and notes that the potassiumlevel is 3.2 mEq/L. Which of the following wouldthe nurse note on the electrocardiogram as aresult of the laboratory value?a. U wavesb. Absend P wavesc. Elevated T wavesd. Elevated ST segment80. One patient had a ‘runaway’ IV of 50% dextrose.To prevent temporary excess of insulin ortransient hyperinsulin reaction what solutionyou prepare in anticipation of the doctor’s
  • 34order?a. Any IV solution available to KVOb. Isotonic solutionc. Hypertonic solutiond. Hypotonic solution81. An informed consent is required for:a. closed reduction of a fractureb. irrigation of the external ear canalc. insertion of intravenous catheterd. urethral catheterization82. Which of the following is not true with regardsto the informed consent?a. It should describe different treatmentalternativesb. It should contain a thorough anddetailed explanation of the procedureto be donec. It should describe the client’s diagnosisd. It should give an explanation of theclient’s prognosis83. You know that the hallmark of nursingaccountability is the:a. accurate documentation and reportingb. admitting your mistakesc. filing an incidence reportd. reporting a medication error84. A nurse is assigned to care for a group of clients.On review of the client’s medical records, thenurse determines that which client is at risk forexcess fluid volume?a. The client taking diureticsb. The client with renal failurec. The client with an ileostomyd. The client who requires gastrointestinalsuctioning85. A nurse is assigned to care for a group of clients.On review of the client’s medical records, thenurse determines that which client is at risk fordeficient fluid volume?a. A client with colostomyb. A client with congestive heart failurec. A client with decreased kidney functiond. A client receiving frequent woundirrigationSituation: As a perioperative nurse, you are aware of thecorrect processing methods for preparing instrumentsand other devices for patient use to prevent infection.86. As an OR nurse, what are your foremostconsiderations for selecting chemical agents fordisinfection?a. Material compatibility and efficiencyb. Odor and availabilityc. Cost and duration of disinfection processd. Duration of disinfection and efficiency87. Before you use a disinfected instrument it isessential that you:a. Rinse with tap water followed by alcoholb. Wrap the instrument with sterile waterc. Dry the instrument thoroughlyd. Rinse with sterile water88. You have a critical heat labile instrument tosterilize and are considering to use high leveldisinfectant. What should you do?a. Cover the soaking vessel to contain thevaporb. Double the amount of high leveldisinfectantc. Test the potency of the high leveldisinfectantd. Prolong the exposure time according tomanufacturer’s direction89. To achieve sterilization using disinfectants,which of the following is used?a. Low level disinfectants immersion in 24hoursb. Intermediate level disinfectantsimmersion in 12 hoursc. High level disinfectants immersion in 1hourd. High level disinfectant immersion in 10hours90. Bronchoscope, Thermometer, Endoscope, ETtube, Cytoscope are all BEST sterilized usingwhich of the following?a. Autoclaving at 121 degree Celsius in 15minutesb. Flash sterilizer at 132 degree Celsius in 3minutesc. Ethylene Oxide gas aeration for 20 hoursd. 2% Glutaraldehyde immersion for 10hoursSituation: The OR is divided into three zones to controltraffic flow and contamination
  • 3591. What OR attires are worn in the restricted area?a. Scrub suit, OR shoes, head capb. Head cap, scrub suit, mask, OR shoesc. Mask, OR shoes, scrub suitd. Cap, mask, gloves, shoes92. Nursing intervention for a patient on low dose IVinsulin therapy includes the following, EXCEPT:a. Elevation of serum ketones to monitorketosisb. Vital signs including BPc. Estimate serum potassiumd. Elevation of blood glucose levels93. The doctor ordered to incorporate 1000”u”insulin to the remaining on-going IV. Thestrength is 500 /ml. How much should youincorporate into the IV solution?a. 10 mlb. 0.5 mlc. 2 mld. 5 ml94. Multiple vial-dose-insulin when in use should bea. Kept at room temperatureb. Kept in narcotic cabinetc. Kept in the refrigeratord. Store in the freezer95. Insulins using insulin syringe are given using howmany degrees of needle insertion?a. 45b. 180c. 90d. 15Situation: Maintenance of sterility is an importantfunction a nurse should perform in any OR setting.96. Which of the following is true with regards tosterility?a. Sterility is time related, items are notconsidered sterile after a period of 30days of being not use.b. for 9 months, sterile items areconsidered sterile as long as they arecovered with sterile muslin cover andstored in a dust proof covers.c. Sterility is event related, not timerelatedd. For 3 weeks, items double covered withmuslin are considered sterile as long asthey have undergone the sterilizationprocess97. 2 organizations endorsed that sterility areaffected by factors other than the time itself,these are:a. The PNA and the PRCb. AORN and JCAHOc. ORNAP and MCNAPd. MMDA and DILG98. All of these factors affect the sterility of the ORequipments, these are the following except:a. The material used for packagingb. The handling of the materials as well asits transportc. Storaged. The chemical or process used insterililzing the material99. When you say sterile, it means:a. The material is cleanb. The material as well as the equipmentsare sterilized and had undergone arigorous sterilization processc. There is a black stripe on the paperindicatord. The material has no microorganism norspores present that might cause aninfection100. In using liquid sterilizer versus autoclavemachine, which of the following is true?a. Autoclave is better in sterilizing ORsupplies versus liquid sterilizerb. They are both capable of sterilizing theequipments, however, it is necessary tosoak supplies in the liquid sterilizer fora longer period of timec. Sharps are sterilized using autoclave andnot cidexd. If liquid sterilizer is used, rinsing itbefore using is not necessary
  • 36NURSING PRACTICE IVSituation: After an abdominal surgery, the circulatingand scrub nurses have critical responsibility aboutsponge and instrument count.1. Counting is performed thrice: During thepreincision phase, the operative phase andclosing phase. Who counts the sponges, needlesand instruments?a. The scrub nurse onlyb. The circulating nurse onlyc. The surgeon and the assistant surgeond. The scrub nurse and the circulatingnurse2. The layer of the abdomen is divided into 5.Arrange the following from the first layer goingto the deepest layer:1. Fascia2. Muscle3. Peritoneum4. Subcutaneous/Fat5. Skina. 5,4,3,2,1b. 5,4,1,3,2c. 5,4,2,1,3d. 5,4,1,2,33. When is the first sponge/instrument countreported?a. Before closing the subcutaneous layerb. Before peritoneum is closedc. Before closing the skind. Before the fascia is sutured4. Like any nursing interventions, counts should bedocumented. To whom does the scrub nursereport any discrepancy of counts so thatimmediate and appropriate action is instituted?a. Anaesthesiologistsb. Surgeonc. OR nurse supervisord. Circulating nurse5. Which of the following are 2 interventions of thesurgical team when an instrument wasconfirmed missing?a. MRI and Incidence reportb. CT Scan, MRI, Incidence reportc. X-RAY and Incidence reportd. CT Scan and Incidence reportSituation: An entry level nurse should be able to applytheoretical knowledge in the performance of the basicnursing skills.6. A client has an indwelling urinary catheter andshe is suspected of having urinary infection. Howshould you collect a urine specimen for cultureand sensitivity?a. clamp tubing for 60 minutes and insert asterile needle into the tubing above theclamp to aspirate urineb. drain urine from the drainage bag intothe sterile containerc. disconnect the tubing from the urinarycatheter and let urine flow into a sterilecontainerd. wipe the self-sealing aspiration portwith antiseptic solution and insert asterile needle into the self-sealing port7. To obtain specimen for sputum culture andsensitivity, which of the following instruction isbest?a. Upon waking up, cough deeply andexpectorate into containerb. Cough after pursed lip breathingc. Save sputum for two days in coveredcontainerd. After respiratory treatment, expectorateinto a container8. The best time for collecting the sputumspecimen for culture and sensitivity is:a. Before retiring at nightb. Anytime of the dayc. Upon waking up in the morningd. Before meals9. When suctioning the endotracheal tube, thenurse should:a. Explain procedure to patient; insertcatheter gently applying suction.Withdrawn using twisting motionb. Insert catheter until resistance is met,and then withdraw slightly, applyingsuction intermittently as catheter iswithdrawnc. Hyperoxygenate client insert catheterusing back and forth motiond. Insert suction catheter four inches intothe tube, suction 30 seconds using
  • 37twirling motion as catheter is withdrawn10. The purpose of NGT IMMEDIATELY after anoperation is:a. For feeding or gavageb. For gastric decompressionc. For lavage, or the cleansing of thestomach contentd. For the rapid return of peristalsisSituation - Mr. Santos, 50, is to undergo cystoscopy dueto multiple problems like scantly urination, hematuriaand dysuria.11. You are the nurse in charge in Mr. Santos. Whenasked what are the organs to be examinedduring cystoscopy, you will enumerate asfollows:a. Urethra, kidney, bladder, urethrab. Urethra, bladder wall, trigone, ureteralopeningc. Bladder wall, uterine wall, and urethralopeningd. Urethral opening, ureteral openingbladder12. In the OR, you will position Mr. Santos who iscystoscopy in:a. Supineb. Lithotomyc. Semi-fowlerd. Trendelenburg13. After cystoscopy, Mr. Santos asked you toexplain why there is no incision of any kind.What do you tell him?a. “Cystoscopy is direct visualization andexamination by urologist”.b. “Cystoscopy is done by x-rayvisualization of the urinary tract”.c. “Cystoscopy is done by using lasers onthe urinary tract”.d. “Cystoscopy is an endoscopic procedureof the urinary tract”.14. Within 24-48 hours post cystoscopy, it is normalto observe one the following:a. Pink-tinged urineb. Distended bladderc. Signs of infectiond. Prolonged hematuria15. Leg cramps are NOT uncommon post cystoscopy.Nursing intervention includes:a. Bed restb. Warm moist soakc. Early ambulationd. Hot sitz bathSituation – Mang Felix, a 79 year old man who is broughtto the Surgical Unit from PACU after a transurethralresection. You are assigned to receive him. You notedthat he has a 3-way indwelling urinary catheter forcontinuous fast drip bladder irrigation which isconnected to a straight drainage.16. Immediately after surgery, what would youexpect his urine to be?a. Light yellowb. Bright redc. Amberd. Pinkish to red17. The purpose of the continuous bladder irrigationis to:a. Allow continuous monitoring of the fluidoutput statusb. Provide continuous flushing of clots anddebris from the bladderc. Allow for proper exchange ofelectrolytes and fluidd. Ensure accurate monitoring of intakeand output18. Mang Felix informs you that he feels somediscomfort on the hypogastric area and he has tovoid. What will be your most appropriate action?a. Remove his catheter then allow him tovoid on his ownb. Irrigate his catheterc. Tell him to “Go ahead and void. Youhave an indwelling catheter.”d. Assess color and rate of outflow, ifthere is changes refer to urologist forpossible irrigation.19. You decided to check on Mang Felix’s IV fluidinfusion. You noted a change in flow rate, pallorand coldness around the insertion site. What isyour assessment finding?a. Phlebitisb. Infiltration to subcutaneous tissuec. Pyrogenic reactiond. Air embolism20. Knowing that proper documentation of
  • 38assessment findings and interventions areimportant responsibilities of the nurse duringfirst post-operative day, which of the following isthe LEAST relevant to document in the case ofMang Felix?a. Chest pain and vital signsb. Intravenous infusion ratec. Amount, color, and consistency ofbladder irrigation drainaged. Activities of daily living startedSituation: Melamine contamination in milk has broughtworldwide crisis both in the milk production sector aswell as the health and economy. Being aware of thecurrent events is one quality that a nurse should possessto prove that nursing is a dynamic profession that willadapt depending on the patient’s needs.21. Melamine is a synthetic resin used forwhiteboards, hard plastics and jewellery boxcovers due to its fire retardant properties. Milkand food manufacturers add melamine in orderto:a. It has a bacteriostatic property leadingto increase food and milk life as a way ofpreserving the foodsb. Gives a glazy and more edible look onfoodsc. Make milks more tasty and creamyd. Create an illusion of a high proteincontent on their products22. Most of the milks contaminated by Melaminecame from which country?a. Indiab. Chinac. Philippinesd. Korea23. Which government agency is responsible fortesting the melamine content of foods and foodproducts?a. DOHb. MMDAc. NBId. BFAD24. Infants are the most vulnerable to melaminepoisoning. Which of the following is NOT a signof melamine poisoning?a. Irritability, Back ache, Urolithiasisb. High blood pressure, feverc. Anuria, Oliguria or Hematuriad. Fever, Irritability and a large output ofdiluted urine25. What kind of renal failure will melaminepoisoning cause?a. Chronic, Prerenalb. Chronic, Intrarenalc. Acute, Postrenald. Acute, PrerenalSituation: Leukemia is the most common type ofchildhood cancer. Acute Lymphoid Leukemia is the causeof almost 1/3 of all cancer that occurs in children underage 15.26. The survival rate for Acute Lymphoid Leukemia isapproximately:a. 25%b. 40%c. 75%d. 95%27. Whereas acute nonlymphoid leukemia has asurvival rate of:a. 25%b. 40%c. 75%d. 95%28. The three main consequence of leukemia thatcause the most danger is:a. Neutropenia causing infection, anemiacausing impaired oxygenation andthrombocytopenia leading to bleedingtendenciesb. Central nervous system infiltration,anemia causing impaired oxygenationand thrombocytopenia leading tobleeding tendenciesc. Splenomegaly, hepatomegaly, fracturesd. Invasion by the leukemic cells to thebone causing severe bone pain29. Gold standard in the diagnosis of leukemia is bywhich of the following?a. Blood culture and sensitivityb. Bone marrow biopsyc. Blood biopsyd. CSF aspiration and examination30. Adriamycin,Vincristine,Prednisone and Lasparaginase are given to the client for longterm therapy. One common side effect,
  • 39especially of adriamycin is alopecia. The childasks: “Will I get my hair back once again?” Thenurse best respond is by saying:a. “Don’t be silly, ofcourse you will get yourhair back”b. “We are not sure, let’s hope it’ll grow”c. “This side effect is usually permanent,But I will get the doctor to discuss it foryou”d. “Your hair will regrow in 3 to 6 monthsbut of different color, usually darkerand of different texture”Situation: Breast Cancer is the 2nd most common type ofcancer after lung cancer and 99% of which, occurs inwoman. Survival rate is 98% if this is detected early andtreated promptly. Carmen is a 53 year old patient in thehigh risk group for breast cancer was recently diagnosedwith Breast cancer.31. All of the following are factors that said tocontribute to the development of breast cancerexcept:a. Prolonged exposure to estrogen such asan early menarche or late menopause,nulliparity and childbirth after age 30b. Geneticsc. Increasing Aged. Prolonged intake of Tamoxifen(Nolvadex)32. Protective factors for the development of breastcancer includes which of the following except:a. Exerciseb. Breast feedingc. Prophylactic Tamoxifend. Alcohol intake33. A patient diagnosed with breast cancer has beenoffered the treatment choices of breastconservation surgery with radiation or amodified radical mastectomy. When questionedby the patient about these options, the nurseinforms the patient that the lumpectomy withradiation:a. reduces the fear and anxiety thataccompany the diagnosis and treatmentof cancerb. has about the same 10-year survival rateas the modified radical mastectomyc. provides a shorter treatment period witha fewer long term complicationsd. preserves the normal appearance andsensitivity of the breast.34. Carmen, who is asking the nurse the mostappropriate time of the month to do her self-examination of the breast. The MOSTappropriate reply by the nurse would be:a. the 26th day of the menstrual cycleb. 7 to 8 days after conclusion of themenstrual periodc. during her menstruationd. the same day each month35. Carmen being treated with radiation therapy.What should be included in the plan of care tominimize skin damage from the radiationtherapy?a. Cover the areas with thick clothingmaterialsb. Apply a heating pad to the sitec. Wash skin with water after the therapyd. Avoid applying creams and powders tothe area36. Based on the DOH and World HealthOrganization (WHO) guidelines, the mainstay forearly detection method for breast cancer that isrecommended for developing countries is:a. a monthly breast self-examination (BSE)and an annual health worker breastexamination (HWBE)b. an annual hormone receptor assayc. an annual mammogramd. a physician conduct a breast clinicalexamination every 2 years37. The purpose of performing the breast self-examination (BSE) regularly is to discover:a. fibrocystic massesb. areas of thickness or fullnessc. cancerous lumpsd. changes from previous BSE38. If you are to instruct a postmenopausal womanabout BSE, when would you tell her to do BSE:a. on the same day of each monthb. on the first day of her menstruationc. right after the menstrual periodd. on the last day of her menstruation39. During breast self-examination, the purpose ofstanding in front of the mirror it to observe thebreast for:a. thickening of the tissue
  • 40b. lumps in the breast tissuec. axillary lymphnodesd. change in size and contour40. When preparing to examine the left breast in areclining position, the purpose of placing a smallfolded towel under the client’s left shoulder isto:a. bring the breast closer to the examiner’sright handb. tense the pectoral musclec. balance the breast tissue more evenlyon the chest walld. facilitate lateral positioning of the breastSituation – Radiation therapy is another modality ofcancer management. With emphasis on multidisciplinarymanagement you have important responsibilities asnurse.41. Albert is receiving external radiation therapy andhe complains of fatigue and malaise. Which ofthe following nursing interventions would bemost helpful for Albert?a. Tell him that sometimes these feelingscan be psychogenicb. Refer him to the physicianc. Reassure him that these feelings arenormald. Help him plan his activities42. Immediately following the radiation teletherapy,Albert isa. Considered radioactive for 24 hrsb. Given a complete bathc. Placed on isolation for 6 hoursd. Free from radiation43. Albert is admitted with a radiation inducedthrombocytopenia. As a nurse you shouldobserve the following symptoms:a. Petechiae, ecchymosis, epistaxisb. Weakness, easy fatigability, pallorc. Headache, dizziness, blurred visiond. Severe sore throat, bacteremia,hepatomegaly44. What nursing diagnosis should be of highestpriority?a. Knowledge deficit regardingthrombocytopenia precautionsb. Activity intolerancec. Impaired tissue integrityd. Ineffective tissue perfusion, peripheral,cerebral, cardiovascular,gastrointestinal, renal45. What intervention should you include in yourcare plan?a. Inspect his skin for petechiae, bruising,GI bleeding regularlyb. Place Albert on strict isolationprecautionc. Provide rest in between activitiesd. Administer antipyretics if histemperature exceeds 38CSituation: Burn are cause by transfer of heat source tothe body. It can be thermal, electrical, radiation orchemical.46. A burn characterized by Pale white appearance,charred or with fat exposed and painlessness is:a. Superficial partial thickness burnb. Deep partial thickness burnc. Full thickness burnd. Deep full thickness burn47. Which of the following BEST describes superficialpartial thickness burn or first degree burn?a. Structures beneath the skin are damageb. Dermis is partially damagedc. Epidermis and dermis are both damagedd. Epidermis is damaged48. A burn that is said to be “WEEPING” is classifiedas:a. Superficial partial thickness burnb. Deep partial thickness burnc. Full thickness burnd. Deep full thickness burn49. During the Acute phase of the burn injury, whichof the following is a priority?a. wound healingb. emotional supportc. reconstructive surgeryd. fluid resuscitation50. While in the emergent phase, the nurse knowsthat the priority is to:a. Prevent infectionb. Prevent deformities and contracturesc. Control paind. Return the hemodynamic stability viafluid resuscitation
  • 4151. The MOST effective method of delivering painmedication during the emergent phase is:a. intramuscularlyb. orallyc. subcutaneouslyd. intravenously52. When a client accidentally splashes chemicals tohis eyes, The initial priority care following thechemical burn is to:a. irrigate with normal saline for 1 to 15minutesb. transport to a physician immediatelyc. irrigate with water for 15 minutes orlongerd. cover the eyes with a sterile gauze53. Which of the following can be a fatalcomplication of upper airway burns?a. stress ulcersb. shockc. hemorrhaged. laryngeal spasms and swelling54. When a client will rush towards you and he has aburning clothes on, It is your priority to do whichof the following first?a. log roll on the grass/groundb. slap the flames with his handsc. Try to remove the burning clothesd. Splash the client with 1 bucket of coolwater55. Once the flames are extinguished, it is mostimportant to:a. cover clientwith a warm blanketb. give him sips of waterc. calculate the extent of his burnsd. assess the Sergio’s breathing56. During the first 24 hours after the thermal injury,you should asses Sergio for:a. hypokalemia and hypernatremiab. hypokalemia and hyponatremiac. hyperkalemia and hyponatremiad. hyperkalemia and hypernatremia57. A client who sustained deep partial thicknessand full thickness burns of the face, wholeanterior chest and both upper extremities twodays ago begins to exhibit extreme restlessness.You recognize that this most likely indicates thatthe client is developing:a. Cerebral hypoxiab. metabolic acidosisc. Hypervolemiad. Renal failure58. A 165 lbs trauma client was rushed to theemergency room with full thickness burns on thewhole face, right and left arm, and at theanterior upper chest sparing the abdominal area.He also has superficial partial thickness burn atthe posterior trunk and at the half upper portionof the left leg. He is at the emergent phase ofburn. Using the parkland’s formula, you knowthat during the first 8 hours of burn, the amountof fluid will be given is:a. 5,400 mlb. 9, 450 mlc. 10,800 mld. 6,750 ml59. The doctor incorporated insulin on the client’sfluid during the emergent phase. The nurseknows that insulin is given because:a. Clients with burn also developsMetabolic acidosisb. Clients with burn also developshyperglycemiac. Insulin is needed for additional energyand glucose burning after the stressfulincidence to hasten wound healing,regain of consciousness and rapid returnof hemodynamic stabilityd. For hyperkalemia60. The IV fluid of choice for burn as well asdehydration is:a. 0.45% NaClb. Sterile waterc. NSSd. D5LRSituation: ENTEROSTOMAL THERAPY is now considered aspecialty in nursing. You are participating in the OSTOMYCARE CLASS.61. You plan to teach Fermin how to irrigate thecolostomy when:a. The perineal wound heals And Fermincan sit comfortably on the commodeb. Fermin can lie on the side comfortably,about the 3rd postoperative dayc. The abdominal incision is closed and
  • 42contamination is no longer a dangerd. The stools starts to become formed,around the 7th postoperative day62. When preparing to teach Fermin how to irrigatecolostomy, you should plan to do the procedure:a. When Fermin would have normal bowelmovementb. At least 2 hours before visiting hoursc. Prior to breakfast and morning cared. After Fermin accepts alteration in bodyimage63. When observing a return demonstration of acolostomy irrigation, you know that moreteaching is required if Fermin:a. Lubricates the tip of the catheter prior toinserting into the stomab. Hangs the irrigating bag on thebathroom door cloth hook during fluidinsertionc. Discontinues the insertion of fluid after500 ml of fluid has been instilledd. Clamps of the flow of fluid when fellinguncomfortable64. You are aware that teaching about colostomycare is understood when Fermin states, “I willcontact my physician and report:a. If I have any difficulty inserting theirrigating tub into the stoma.”b. If I noticed a loss of sensation to touch inthe stoma tissue.”c. The expulsion of flatus while theirrigating fluid is running out.”d. When mucus is passed from the stomabetween the irrigations.”65. You would know after teaching Fermin thatdietary instruction for him is effective when hestates, “It is important that I eat:a. Soft food that is easily digested andabsorbed by my large intestines.”b. Bland food so that my intestines do notbecome irritated.”c. Food low in fiber so that there are fewerstools.”d. Everything that I ate before theoperation, while avoiding foods thatcause gas”.Situation: Based on studies of nurses working in specialunits like the intensive care unit and coronary care unit,it is important for nurses to gather as much informationto be able to address their needs for nursing care.66. Critically ill patients frequently complain aboutwhich of the following when hospitalized?a. Hospital foodb. Lack of privacyc. Lack of blanketsd. Inadequate nursing staff67. Who of the following is at greatest risk ofdeveloping sensory problem?a. Female patientb. Transplant patientc. Adoloscentd. Unresponsive patient68. Which of the following factors may inhibitlearning in critically ill patients?a. Genderb. Educational levelc. Medicationd. Previous knowledge of illness69. Which of the following statements does notapply to critically ill patients?a. Majority need extensive rehabilitationb. All have been hospitalized previouslyc. Are physically unstabled. Most have chronic illness70. Families of critically ill patients desire which ofthe following needs to be met first by the nurse?a. Provision of comfortable spaceb. Emotional supportc. Updated information on client’s statusd. Spiritual counsellingSituation: Johnny, sought consultation to the hospitalbecause of fatigability, irritability, jittery and he has beenexperiencing this sign and symptoms for the past 5months.71. His diagnosis was hyperthyroidism, the followingare expected symptoms except:a. Anorexiab. Fine tremors of the handc. Palpitationd. Hyper alertness72. She has to take drugs to treat herhyperthyroidism. Which of the following will youNOT expect that the doctor will prescribe?
  • 43a. Colace (Docusate)b. Tapazole (Methimazole)c. Cytomel (Liothyronine)d. Synthroid (Levothyroxine)73. The nurse knows that Tapazole has which of thefollowing side effect that will warrant immediatewithholding of the medication?a. Deathb. Hyperthermiac. Sore throatd. Thrombocytosis74. You asked questions as soon as she regainedconsciousness from thyroidectomy primarily toassess the evidence of:a. Thyroid stormb. Damage to the laryngeal nervec. Mediastinal shiftd. Hypocalcaemia tetany75. Should you check for haemorrhage, you will:a. Slip your hand under the nape of herneckb. Check for hypotensionc. Apply neck collar to preventhaemorrhaged. Observe the dressing if it is soaked withblood76. Basal Metabolic rate is assessed on Johnny todetermine his metabolic rate. In assessing theBMR using the standard procedure, you need totell Johnny that:a. Obstructing his visionb. Restraining his upper and lowerextremitiesc. Obstructing his hearingd. Obstructing his nostrils with a clamp77. The BMR is based on the measurement that:a. Rate of respiration under differentcondition of activities and restb. Amount of oxygen consumption underresting condition over a measuredperiod of timec. Amount of oxygen consumption understressed condition over a measuredperiod of timed. Ratio of respiration to pulse rate over ameasured period of time78. Her physician ordered lugol’s solution in orderto:a. Decrease the vascularity and size of thethyroid glandb. Decrease the size of the thyroid glandonlyc. Increase the vascularity and size of thethyroid glandd. Increase the size of the thyroid glandonly79. Which of the following is a side effect of Lugol’ssolution?a. Hypokalemiab. Enlargement of the Thryoid glandc. Nystagmusd. Excessive salivation80. In administering Lugol’s solution, theprecautionary measure should include:a. Administer with glass onlyb. Dilute with juice and administer with astrawc. Administer it with milk and drink itd. Follow it with milk of magnesiaSituation: Pharmacological treatment was not effectivefor Johnny’s hyperthyroidism and now, he is scheduledfor Thyroidectomy.81. Instruments in the surgical suite for surgery isclassified as either CRITICAL, SEMI CRITICAL andNON CRITICAL. If the instrument are introduceddirectly into the blood stream or into anynormally sterile cavity or area of the body it isclassified as:a. Criticalb. Non Criticalc. Semi Criticald. Ultra Critical82. Instruments that do not touch the patient orhave contact only to intact skin is classified as:a. Criticalb. Non Criticalc. Semi Criticald. Ultra Critical83. If an instrument is classified as Semi Critical, anacceptable method of making the instrumentready for surgery is through:a. Sterilizationb. Disinfectionc. Decontamination
  • 44d. Cleaning84. While critical items and should be:a. Cleanb. Sterilizedc. Decontaminatedd. Disinfected85. As a nurse, you know that intact skin acts as aneffective barrier to most microorganisms.Therefore, items that come in contact with theintact skin or mucus membranes should be:a. Disinfectedb. Cleanc. Steriled. Alcoholized86. You are caring for Johnny who is scheduled toundergo total thyroidectomy because of adiagnosis of thyroid cancer. Prior to totalthyroidectomy, you should instruct Johnny to:a. Perform range and motion exercise onthe head and neckb. Apply gentle pressure against theincision when swallowingc. Cough and deep breathe every 2 hoursd. Support head with the hands whenchanging position87. As Johnny’s nurse, you plan to set up emergencyequipment at her bedside followingthyroidectomy. You should include:a. An airway and rebreathing tubeb. A tracheostomy set and oxygenc. A crush cart with bed boardd. Two ampules of sodium bicarbonate88. Which of the following nursing interventions isappropriate after a total thyroidectomy?a. Place pillows under your patient’sshoulders.b. Raise the knee-gatch to 30 degreesc. Keep you patient in a high-fowler’sposition.d. Support the patient’s head and neckwith pillows and sandbags.89. If there is an accidental injury to the parathyroidgland during a thyroidectomy which of thefollowing might Leda develops postoperatively?a. Cardiac arrestb. Respiratory failurec. Dyspnead. Tetany90. After surgery Johnny develops peripheralnumbness, tingling and muscle twitching andspasm. What would you anticipate toadminister?a. Magnesium sulfateb. Potassium iodidec. Calcium gluconated. Potassium chlorideSituation: Budgeting is an important part of a nursemanagerial activity. The correct allocation anddistribution of resources is vital in the harmoniousoperation of the financial balance of the agency.91. Which of the following best defines Budget?a. Plan for the allocation of resources forfuture useb. The process of allocating resources forfuture usec. Estimate cost of expensesd. Continuous process in seeing that thegoals and objective of the agency is met92. Which of the following best defines CapitalBudget?a. Budget to estimate the cost of directlabour, number of staff to be hired andnecessary number of workers to meetthe general patient needsb. Includes the monthly and daily expensesand expected revenue and expensesc. These are related to long term planningand includes major replacement orexpansion of the plant, majorequipment and inventories.d. These are expenses that are notdependent on the level of production orsales. They tend to be time-related, suchas salaries or rents being paid per month93. Which of the following best describedOperational Budget?a. Budget to estimate the cost of directlabour, number of staff to be hired andnecessary number of workers to meetthe general patient needsb. Includes the monthly and dailyexpenses and expected revenue andexpensesc. These are related to long term planningand includes major replacement or
  • 45expansion of the plant, majorequipments and inventories.d. These are expenses that are notdependent on the level of production orsales. They tend to be time-related, suchas rent94. Which of the following accurately describes aFixed Cost in budgeting?a. These are usually the raw materials andlabour salaries that depend on theproduction or salesb. These are expenses that change inproportion to the activity of a businessc. These are expenses that are notdependent on the level of production orsales. They tend to be time-related,such as rentd. This is the summation of the VariableCost and the Fixed Cost95. Which of the following accurately describesVariable Cost in budgeting?a. These are related to long term planningand include major replacement orexpansion of the plant, majorequipments and inventories.b. These are expenses that change inproportion to the activity of a businessc. These are expenses that are notdependent on the level of production orsales. They tend to be time-related, suchas rentd. This is the summation of the VariableCost 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 andwaning. You know that this rhythm of respirationis defined as:a. Biot’sb. Cheyne stokesc. Kussmaul’sd. Eupnea97. What do you call the triad of sign and symptomsseen in a client with increasing ICP?a. Virchow’s Triadb. Cushing’s Triadc. The Chinese Triadd. Charcot’s Triad98. Which of the following is true with the Triadseen in head injuries?a. Narrowing of Pulse pressure, Cheynestokes respiration, Tachycardiab. Widening Pulse pressure, Irregularrespiration, Bradycardiac. Hypertension, Kussmaul’s respiration,Tachycardiad. Hypotension, Irregular respiration,Bradycardia99. In a client with a Cheyne stokes respiration,which of the following is the most appropriatenursing diagnosis?a. Ineffective airway clearanceb. Impaired gas exchangec. Ineffective breathing patternd. Activity intolerance100. You know the apnea is seen in client’s withcheyne stokes respiration, APNEA is defined as:a. Inability to breathe in a supine positionso the patient sits up in bed to breatheb. The patient is dead, the breathing stopsc. There is an absence of breathing for aperiod of time, usually 15 seconds ormored. A period of hypercapnea and hypoxiadue to the cessation of respiratory effortinspite of normal respiratory functioning
  • 46NURSING PRACTICE VSituation: Understanding different models of care is anecessary part of the nurse patient relationship.1. The focus of this therapy is to have a positiveenvironmental manipulation, physical and socialto effect a positive change.A. MilieuB. PsychotherapyC. BehaviourD. Group2. The client asks the nurse about Milieu therapy.The nurse responds knowing that the primaryfocus of milieu therapy can be best described bywhich of the following?A. A form of behavior modification therapyB. A cognitive approach of changing thebehaviourC. A living, learning or workingenvironmentD. A behavioural approach to changingbehaviour3. A nurse is caring for a client with phobia who isbeing treated for the condition. The client isintroduced to short periods of exposure to thephobic object while in relaxed state. The nurseunderstands that this form of behaviourmodification can be best described as:A. Systematic desensitizationB. Self-control therapyC. Aversion TherapyD. Operant conditioning4. A client with major depression is consideringcognitive therapy. The client say to the nurse,“How does this treatment works?” The nurseresponds by telling the client that:A. “This type of treatment helps youexamine how your thoughts andfeelings contribute to your difficulties”B. “This type of treatment helps youexamine how your past life hascontributed to your problems.”C. “This type of treatment helps you toconfront your fears by exposing you tothe feared object abruptly.D. “This type of treatment will help yourelax and develop new coping skills.”5. A Client state, “I get down on myself when Imake mistake.” Using Cognitive therapyapproach, the nurse should:A. Teach the client relaxation exercise todiminish stressB. Provide the client with Masteryexperience to boost self esteemC. Explore the client’s past experiences thatcauses the illnessD. Help client modify the belief thatanything less than perfect is horrible6. The most advantageous therapy for a preschoolage child with a history of physical and sexualabuse would be:A. PlayB. PsychoanalysisC. GroupD. Family7. An 18 year old client is admitted with thediagnosis of anorexia nervosa. A cognitivebehavioural approach is used as part of hertreatment plan. The nurse understands that thepurpose of this approach is to:A. Help the client identify and examinedysfunctional thoughts and beliefsB. Emphasize social interaction with clientswho withdrawC. Provide a supportive environment and atherapeutic communityD. Examine intrapsychic conflicts and pastevents in life8. The nurse is preparing to provide reminiscencetherapy for a group of clients. Which of thefollowing clients will the nurse select for thisgroup?A. A client who experiences profounddepression with moderate cognitiveimpairmentB. A catatonic, immobile client withmoderate cognitive impairmentC. An undifferentiated schizophrenic clientwith moderate cognitive impairmentD. A client with mild depression whoexhibits who demonstrates normalcognition9. Which intervention would be typical of a nurseusing cognitive-behavioral approach to a clientexperiencing low self-esteem?
  • 47A. Use of unconditional positive regardB. Analysis of free associationC. Classical conditioningD. Examination of negative thoughtpatterns10. Which of the following therapies has beenstrongly advocated for the treatment of post-traumatic stress disorders?A. ECTB. Group TherapyC. HypnotherapyD. Psychoanalysis11. The nurse knows that in group therapy, themaximum number of members to include is:A. 4B. 8C. 10D. 1612. The nurse is providing information to a clientwith the use of disulfiram (antabuse) for thetreatment of alcohol abuse. The nurseunderstands that this form of therapy works onwhat principle?A. Negative ReinforcementB. Operant ConditioningC. Aversion TherapyD. Gestalt therapy13. A biological or medical approach in treatingpsychiatric patient is:A. Million therapyB. Behavioral therapyC. Somatic therapyD. Psychotherapy14. Which of these nursing actions belong to thesecondary level of preventive intervention?A. Providing mental health consultation tohealth care providersB. Providing emergency psychiatricservicesC. Being politically active in relation tomental health issuesD. Providing mental health education tomembers of the community15. When the nurse identifies a client who hasattempted to commit suicide the nurse should:A. call a priestB. counsel the clientC. refer the client to the psychiatristD. refer the matter to the policeSituation: Rose seeks psychiatric consultation because ofintense fear of flying in an airplane which has greatlyaffected her chances of success in her job.16. The most common defense mechanism used byphobic clients is:A. SupressionB. DenialC. RationalizationD. Displacement17. The goal of the therapy in phobia is:A. Change her lifestyleB. Ignore tension producing situationC. Change her reaction towards anxietyD. Eliminate fear producing situations18. The therapy most effective for client’s withphobia is:A. HypnotherapyB. Cognitive therapyC. Group therapyD. Behavior therapy19. The fear and anxiety related to phobia is said tobe abruptly decreased when the patient isexposed to what is feared through:A. Guided ImageryB. Systematic desensitizationC. FloodingD. Hypotherapy20. Based on the presence of symptom, theappropriate nursing diagnosis is:A. Self-esteem disturbanceB. Activity intoleranceC. Impaired adjustmentD. Ineffective individual copingSituation: Mang Jose, 39 year old farmer, unmarried, hadbeen confined in the National center for mental healthfor three years with a diagnosis of schizophrenia.21. The most common defense mechanism used bya paranoid client is:A. DisplacementB. RationalizationC. SuppressionD. Projection
  • 4822. When Mang Jose says to you: “The voices aretelling me bad things again!” The best responseis:A. “Whose voices are those?”B. “I doubt what the voices are telling you”C. “I do not hear the voice you say youhear”D. “Are you sure you hear these voices?”23. A relevant nursing diagnosis for clients withauditory hallucination is:A. Sensory perceptual alterationB. Altered thought processC. Impaired social interactionD. Impaired verbal communication24. During mealtime, Jose refused to eat telling thatthe food was poisoned. The nurse should:A. Ignore his remarkB. Offer him food in his own containerC. Show him how irrational his thinking isD. Respect his refusal to eat25. When communicating with Jose, The nurseconsiders the following except:A. Be warm and enthusiasticB. Refrain from touching JoseC. Do not argue regarding his hallucinationand delusionD. Use simple, clear languageSituation: Gringo seeks psychiatric counselling for hisritualistic behavior of counting his money as many as 10times before leaving home.26. An initial appropriate nursing diagnosis is:A. Impaired social interactionB. Ineffective individual copingC. Impaired adjustmentD. Anxiety Moderate27. Obsessive compulsive disorder is BEST describedby:A. Uncontrollable impulse to perform anact or ritual repeatedlyB. Persistent thoughtsC. Recurring unwanted and disturbingthought alternating with a behaviorD. Pathological persistence of unwilledthought, feeling or impulse28. The defense mechanism used by persons withobsessive compulsive disorder is undoing and itis best described in one of the followingstatements:A. Unacceptable feelings or behavior arekept out of awareness by developing theopposite behavior or emotionB. Consciously unacceptable instinctualdrives are diverted into personally andsocially acceptable channelsC. Something unacceptable already doneis symbolically acted out in reverseD. Transfer of emotions associated with aparticular person, object or situation toanother less threatening person, objector situation29. To be more effective, the nurse who cares forpersons with obsessive compulsive disordermust possess one of the following qualities:A. CompassionB. PatienceC. ConsistencyD. Friendliness30. Persons with OCD usually manifest:A. FearB. ApathyC. SuspiciousnessD. AnxietySituation: The patient who is depressed will undergoelectroconvulsive therapy.31. Studies on biological depression supportelectroconvulsive therapy as a mode oftreatment. The rationale is:A. ECT produces massive brain damagewhich destroys the specific areacontaining memories related to theevents surrounding the development ofpsychotic conditionB. The treatment serves as a symbolicpunishment for the client who feelsguilty and worthlessC. ECT relieves depression psychologicallyby increasing the norepinephrine levelD. ECT is seen as a life-threateningexperience and depressed patientsmobilize all their bodily defences to dealwith this attack.32. The preparation of a patient for ECT ideally isMOST similar to preparation for a patient for:A. electroencephalogram
  • 49B. general anesthesiaC. X-rayD. electrocardiogram33. Which of the following is a possible side effectwhich you will discuss with the patient?A. hemorrhage within the brainB. encephalitisC. robot-like body stiffnessD. confusion, disorientation and shortterm memory loss34. Informed consent is necessary for the treatmentfor involuntary clients. When this cannot beobtained, permission may be taken from the:A. social workerB. next of kin or guardianC. doctorD. chief nurse35. After ECT, the nurse should do this action beforegiving the client fluids, food or medication:A. assess the gag reflexB. next of kin or guardianC. assess the sensoriumD. check O2 Sat with a pulse oximeterSituation: Mrs Ethel Agustin 50 y/o, teacher is afflictedwith myasthenia gravis.36. Looking at Mrs Agustin, your assessment wouldinclude the following except;A. NystagmusB. Difficulty of hearingC. Weakness of the levator palpebraeD. Weakness of the ocular muscle37. In an effort to combat complications whichmight occur relatives should he taught;A. Checking cardiac rateB. Taking blood pressure readingC. Techniques of oxygen inhalationD. Administration of oxygen inhalation38. The drug of choice for her condition is;A. ProstigmineB. MorphineC. CodeineD. Prednisone39. As her nurse, you have to be cautious aboutadministration of medication, if she is undermedicated this can cause;A. Emotional crisisB. Cholinergic crisisC. Menopausal crisisD. Myasthenia crisis40. If you are not extra careful and by chance yougive over medication, this would lead to;A. Cholinergic crisisB. Menopausal crisisC. Emotional crisisD. Myasthenia crisisSituation: Rosanna 20 y/o unmarried patient believesthat the toilet for the female patient in contaminatedwith AIDS virus and refuses to use it unless she flushes itthree times and wipes the seat same number of timeswith antiseptic solution.41. The fear of using “contaminated” toilet seat canbe attributed to Rosanna’s inability to;A. Adjust to a strange environmentB. Express her anxietyC. Develop the sense of trust in otherpersonD. Control unacceptable impulses orfeelings42. Assessment data upon admission help the nurseto identify this appropriate nursing diagnosisA. Ineffective denialB. Impaired adjustmentC. Ineffective individual copingD. Impaired social interaction43. An effective nursing intervention to help Rosanais;A. Convincing her to use the toilet after thenurse has used it firstB. Explaining to her that AIDS cannot betransmitted by using the toiletC. Allowing her to flush and clear thetoilet seat until she can manage heranxietyD. Explaining to her how AIDS istransmitted44. The goal for treatment for Rosana must bedirected toward helping her to;A. Walk freely about her past experienceB. Develop trusting relationship with othersC. Gain insight that her behaviour is dueto feeling of anxietyD. Accept the environment unconditionally
  • 5045. Psychotherapy which is prescribed for Rosana isdescribed as;A. Establishing an environment adapted toan individual patient needsB. Sustained interaction between thetherapist and client to help her developmore functional behaviourC. Using dramatic techniques to portrayinterpersonal conflictsD. Biologic treatment for mental disorderSituation: Dennis 40 y/o married man, an electricalengineer was admitted with the diagnosis of paranoiddisorders. He has become suspicious and distrustful 2months before admission. Upon admission, he kept onsaying, “my wife has been planning to kill me.”46. A paranoid individual who cannot accept theguilt demonstrate one of the following defensemechanism;A. DenialB. ProjectionC. RationalizationD. Displacement47. One morning, Dennis was seen tilting his head asif he was listening to someone. An appropriatenursing intervention would be;A. Tell him to socialize with other patient todivert his attentionB. Involve him in group activitiesC. Address him by name to ask if he ishearing voices againD. Request for an order of antipsychoticmedicine48. When he says, “these voices are telling me mywife is going to kill me.” A therapeuticcommunication of the nurse is which one of thefollowing;A. “i do not hear the voices you say youhear”B. “are you really sure you heard thosevoices?”C. “I do not think you heard thosevoices?”D. “Whose voices are those?”49. The nurse confirms that Dennis is manifestingauditory hallucination. The appropriate nursingdiagnosis she identifiesis;A. Sensory perceptual alterationB. Self-esteem disturbanceC. Ineffective individual copingD. Defensive coping50. Most appropriate nursing intervention for aclient with suspicious behavior is one of thefollowing;A. Talk to the client constantly to reinforcerealityB. Involve him in competitive activitiesC. Use Non Judgmental and ConsistentapproachD. Project cheerfulness in interacting withthe patientSituation: Clients with Bipolar disorder receives a veryhigh nursing attention due to the increasing rate ofsuicide related to the illness.51. The nurse is assigned to care for a recentlyadmitted client who has attempted suicide.What should the nurse do?A. Search the clients belongings and roomcarefully for items that could be used toattempt suicide.B. Express trust that the client wont causeself-harm while in the facility.C. Respect the clients privacy by notsearching any belongings.D. Remind all staff members to check onthe client frequently.52. In planning activities for the depressed client,especially during the early stages ofhospitalization, which of the following plan isbest?A. Provide an activity that is quiet andsolitary to avoid increased fatigue suchas working on a puzzle and reading abook.B. Plan nothing until the client asks toparticipate in the milieuC. Offer the client a menu of daily activitiesand ask the client to participate in all ofthemD. Provide a structured daily program ofactivities and encourage the client toparticipate53. A client with a diagnosis of major depression,recurrent with psychotic features is admitted tothe mental health unit. To create a safeenvironment for the client, the nurse most
  • 51importantly devises a plan of care that dealsspecifically with the clients:A. Disturbed thought processB. Imbalanced nutritionC. Self-Care DeficitD. Deficient Knowledge54. The client is taking a Tricyclic anti-depressant,which of the following is an example of TCA?A. PaxilB. NardilC. ZoloftD. Pamelor55. A client visits the physicians office to seektreatment for depression, feelings ofhopelessness, poor appetite, insomnia, fatigue,low self-esteem, poor concentration, anddifficulty making decisions. The client states thatthese symptoms began at least 2 years ago.Based on this report, the nurse suspects:A. cyclothymic disorder.B. Bipolar disorderC. major depression.D. dysthymic disorder.56. The nurse is planning activities for a client whohas bipolar disorder, which aggressive socialbehaviour. Which of the following activitieswould be most appropriate for this client?A. Ping PongB. Linen deliveryC. ChessD. Basketball57. The nurse assesses a client with admitteddiagnosis of bipolar affective disorder, mania.The symptom presented by the client thatrequires the nurse’s immediate intervention isthe client’s:A. Outlandish behaviour and inappropriatedressB. Grandiose delusion of being a royaldescendant of king arthutC. Nonstop physical activity and poornutritional intakeD. Constant incessant talking that includessexual topics and teasing the staff58. A nurse is conducting a group therapy sessionand during the session, A client with maniaconsistently talks and dominates the group. Thebehaviour is disrupting the group interaction.The nurse would initially:A. Ask the client to leave the group sessionB. Tell the client that she will not beallowed to attend any more groupsessionsC. Tell the client that she needs to allowother client in a group time to talkD. Ask another nurse to escort the clientout of the group session59. A professional artist is admitted to thepsychiatric unit for treatment of bipolardisorder. During the last 2 weeks, the client hascreated 154 paintings, slept only 2 to 3 hoursevery 2 days, and lost 18 lb (8.2 kg). Based onMaslows hierarchy of needs, what should thenurse provide this client with first?A. The opportunity to explore familydynamicsB. Help with re-establishing a normalsleep patternC. Experiences that build self-esteemD. Art materials and equipment60. The physician orders lithium carbonate(Lithonate) for a client whos in the manic phaseof bipolar disorder. During lithium therapy, thenurse should watch for which adverse reactions?A. Anxiety, restlessness, and sleepdisturbanceB. Nausea, diarrhea, tremor, and lethargyC. Constipation, lethargy, and ataxiaD. Weakness, tremor, and urine retentionSituation – Annie has a morbid fear of heights. She asksthe nurse what desensitization therapy is:61. The accurate information of the nurse of thegoal of desensitization is:A. To help the clients relax andprogressively work up a list of anxietyprovoking situations through imagery.B. To provide corrective emotionalexperiences through a one-to-oneintensive relationship.C. To help clients in a group therapy settingto take on specific roles and reenact infront of an audience, situations in whichinterpersonal conflict is involved.D. To help clients cope with their problemsby learning behaviors that are morefunctional and be better equipped toface reality and make decisions.
  • 5262. It is essential in desensitization for the patientto:A. Have rapport with the therapistB. Use deep breathing or anotherrelaxation techniqueC. Assess one’s self for the need of ananxiolytic drugD. Work through unresolved unconsciousconflicts63. In this level of anxiety, cognitive capacitydiminishes. Focus becomes limited and clientexperiences tunnel vision. Physical signs ofanxiety become more pronounced.A. Severe anxietyB. Mild anxietyC. PanicD. Moderate anxiety64. Antianxiety medications should be used withextreme caution because long term use can leadto:A. Parkinsonian like syndromeB. Hepatic failureC. Hypertensive crisisD. Risk of addiction65. The nursing management of anxiety related withpost-traumatic stress disorder includes all of thefollowing EXCEPT:A. Encourage participation in recreation orsports activitiesB. Reassure client’s safety while touchingclientC. Speak in a calm soothing voiceD. Remain with the client while fear level ishighSITUATION: You are fortunate to be chosen as part ofthe research team in the hospital. A review of thefollowing IMPORTANT nursing concepts was made.66. As a professional, a nurse can do research forvaried reason except:A. Professional advancement throughresearch participationB. To validate results of new nursingmodalitiesC. For financial gainsD. To improve nursing care67. Each nurse participants was asked to identify aproblem. After the identification of the researchproblem, which of the following should be done?A. MethodologyB. AcknowledgementC. Review of related literatureD. Formulate hypothesis68. Which of the following communicate the resultsof the research to the readers. They facilitate thedescription of the data.A. HypothesisB. Research problemC. StatisticsD. Tables and Graphs69. In Quantitative date, which of the following isdescribed as the distance in the scoring unites ofthe variable from the highest to the lower?A. FrequencyB. MedianC. MeanD. Range70. This expresses the variability of the data inreference to the mean. It provides as with anumerical estimate of how far, on the averagethe separate observation are from the mean:A. ModeB. MedianC. Standard deviationD. FrequencySituation: Survey and Statistics are important part ofresearch that is necessary to explain the characteristicsof the population.71. According to the WHO statistics on the Homelesspopulation around the world, which of thefollowing groups of people in the worlddisproportionately represents the homelesspopulation?A. HispanicsB. AsiansC. African AmericansD. Caucasians72. All but one of the following is not a measure ofCentral Tendency:A. ModeB. Standard DeviationC. VarianceD. Range
  • 5373. In the value: 87, 85, 88, 92, 90; what is themean?A. 88.2B. 88.4C. 87D. 9074. In the value: 80, 80, 80, 82, 82, 90, 90, 100; whatis the mode?A. 80B. 82C. 90D. 85.575. In the value: 80, 80, 10, 10, 25, 65, 100, 200;what is the median?A. 71.25B. 22.5C. 10 and 25D. 72.576. Draw Lots, Lottery, Table of random numbers ora sampling that ensures that each element of thepopulation has an equal and independentchance of being chosen is called:A. ClusterB. StratifiedC. SimpleD. Systematic77. An investigator wants to determine some of theproblems that are experienced by diabeticclients when using an insulin pump. Theinvestigator went into a clinic where hepersonally knows several diabetic clients havingproblem with insulin pump. The type of samplingdone by the investigator is called:A. ProbabilityB. SnowballC. PurposiveD. Incidental78. If the researcher implemented a new structuredcounselling program with a randomized group ofsubject and a routine counselling program withanother randomized group of subject, theresearch is utilizing which design?A. Quasi experimentalB. ComparativeC. ExperimentalD. Methodological79. Which of the following is not true about a PureExperimental research?A. There is a control groupB. There is an experimental groupC. Selection of subjects in the control groupis randomizedD. There is a careful selection of subjectsin the experimental group80. The researcher implemented a medicationregimen using a new type of combination drugsto manic patients while another group of manicpatient receives the routine drugs. Theresearcher however handpicked theexperimental group for they are the clients withmultiple episodes of bipolar disorder. Theresearcher utilized which research design?A. Quasi-experimentalB. PhenomenologicalC. Pure experimentalD. LongitudinalSituation 19: As a nurse, you are expected to participatein initiating or participating in the conduct of researchstudies to improve nursing practice. You to be updatedon the latest trends and issues affected the professionand the best practices arrived at by the profession.81. You are interested to study the effects ofmediation and relaxation on the painexperienced by cancer patients. What type ofvariable is pain?A. DependentB. IndependentC. CorrelationalD. Demographic82. You would like to compare the support systemof patient with chronic illness to those withacute illness. How will you best state yourproblem?A. A descriptive study to compare thesupport system of patients with chronicillness and those with acute illness interms of demographic data andknowledge about intervention.B. The effects of the types of supportsystem of patients with chronic illnessand those with acute illness.C. A comparative analysis of the supportsystem of patients with chronic illnessand those with acute illness.D. A study to compare the support systemof patients with chronic illness and thosewith acute illness.
  • 54E. What are the differences of the supportsystem being received by patient withchronic illness and patients with acuteillness?83. You would like to compare the support systemof patients with chronic illness to those withacute illness. Considering that the hypothesiswas: “Client’s with chronic illness have lessersupport system than client’s with acute illness.”What type of research is this?A. DescriptiveB. Correlational, Non experimentalC. ExperimentalD. Quasi Experimental84. In any research study where individual personsare involved, it is important that an informedconsent of the study is obtained. The followingare essential information about the consent thatyou should disclose to the prospective subjectsexcept:A. Consent to incomplete disclosureB. Description of benefits, risks anddiscomfortsC. Explanation of procedureD. Assurance of anonymity andconfidentiality85. In the Hypothesis: “The utilization of technologyin teaching improves the retention and attentionof the nursing students.” Which is thedependent variable?A. Utilization of technologyB. Improvement in the retention andattentionC. Nursing studentsD. TeachingSituation: You are actively practicing nurse who has justfinished you graduate studies. You learned the value ofresearch and would like to utilize the knowledge andskills gained in the application of research to the nursingservice. The following questions apply to research.86. Which type of research inquiry investigates theissues of human complexity (e.g understandingthe human expertise)?A. Logical positionB. PositivismC. Naturalistic inquiryD. Quantitative research87. Which of the following studies is based onquantitative research?A. A study examining the bereavementprocess in spouse of clients withterminal cancerB. A study exploring the factors influencingweight control behaviourC. A Study measuring the effects of sleepdeprivation on wound healingD. A study examining client’s feelingsbefore, during and after bone marrowaspiration.88. Which of the following studies is based on thequalitative research?A. A study examining clients’ reaction tostress after open heart surgeryB. A study measuring nutrition and weightloss/gain in clients with cancerC. A study examining oxygen levels afterendotracheal suctioningD. A study measuring differences in bloodpressure before, during and afterprocedure89. An 85 year old client in a nursing home tells anurse, “I signed the papers of that researchstudy because the doctor was so insistent and Iwant him to continue taking care for me” Whichclient right is being violated?A. Right of self determinationB. Right to full disclosureC. Right to privacy and confidentialityD. Right not to be harmed90. A supposition or system of ideas that isproposed to explain a given phenomenon bestdefines:A. A paradigmB. A theoryC. A ConceptD. A conceptual frameworkSituation: Mastery of research design determination isessential in passing the NLE.91. Ana wants to know if the length of time she willstudy for the board examination is proportionalto her board rating. During the June 2008 boardexamination, she studied for 6 months andgained 68%, On the next board exam, shestudied for 6 months again for a total of 1 yearand gained 74%, On the third board exam, Shestudied for 6 months for a total of 1 and a half
  • 55year and gained 82%. The research design sheused is:A. ComparativeB. ExperimentalC. CorrelationalD. Qualitative92. Anton was always eating high fat diet. You wantto determine if what will be the effect of highcholesterol food to Anton in the next 10 years.You will use:A. ComparativeB. HistoricalC. CorrelationalD. Longitudinal93. Community A was selected randomly as well ascommunity B, nurse Edna conducted teaching tocommunity A and assess if community A willhave a better status than community B. This isan example of:A. ComparativeB. ExperimentalC. CorrelationalD. Qualitative94. Ana researched on the development of a newway to measure intelligence by creating a 100item questionnaire that will assess the cognitiveskills of an individual. The design best suited forthis study is:A. HistoricalB. SurveyC. MethodologicalD. Case study95. Gen is conducting a research study on how mark,an AIDS client lives his life. A design suited forthis is:A. HistoricalB. PhenomenologicalC. Case StudyD. Ethnographic96. Marco is to perform a study about how nursesperform surgical asepsis during World War II. Adesign best for this study is:A. HistoricalB. PhenomenologicalC. Case StudyD. Ethnographic97. Tonyo conducts sampling at barangay 412. Hecollected 100 random individuals and determinewho is their favourite comedian actor. 50% saidDolphy, 20% said Vic Sotto, while someanswered Joey de Leon, Allan K, Michael V.Tonyo conducted what type of research study?A. PhenomenologicalB. Non experimentalC. Case StudyD. Survey98. Jane visited a tribe located somewhere in China,it is called the Shin Jea tribe. She studied the wayof life, tradition and the societal structure ofthese people. Jane will best use which researchdesign?A. HistoricalB. PhenomenologicalC. Case StudyD. Ethnographic99. Anjoe researched on TB. Its transmission,Causative agent and factors, treatment sign andsymptoms as well as medication and all other indepth information about tuberculosis. This studyis best suited for which research design?A. HistoricalB. PhenomenologicalC. Case StudyD. Ethnographic100. Diana is to conduct a study about therelationship of the number of family members inthe household and the electricity bill. Which ofthe following is the best research design suitedfor this study?1. Descriptive2. Exploratory3. Explanatory4. Correlational5. Comparative6. ExperimentalA. 1,4B. 2,5C. 3,6D. 1,5E. 2,4
  • 56TEST I - Foundation of Professional NursingPractice1. The nurse In-charge in labor and delivery unitadministered a dose of terbutaline to a clientwithout checking the client’s pulse. The standardthat would be used to determine if the nursewas negligent is:a. The physician’s orders.b. The action of a clinical nurse specialistwho is recognized expert in the field.c. The statement in the drug literatureabout administration of terbutaline.d. The actions of a reasonably prudentnurse with similar education andexperience.2. Nurse Trish is caring for a female client with ahistory of GI bleeding, sickle cell disease, and aplatelet count of 22,000/μl. The female client isdehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The clientcomplains of severe bone pain and is scheduledto receive a dose of morphine sulfate. Inadministering the medication, Nurse Trishshould avoid which route?a. I.Vb. I.Mc. Orald. S.C3. Dr. Garcia writes the following order for theclient who has been recently admitted “Digoxin.125 mg P.O. once daily.” To prevent a dosageerror, how should the nurse document this orderonto the medication administration record?a. “Digoxin .1250 mg P.O. once daily”b. “Digoxin 0.1250 mg P.O. once daily”c. “Digoxin 0.125 mg P.O. once daily”d. “Digoxin .125 mg P.O. once daily”4. A newly admitted female client was diagnosedwith deep vein thrombosis. Which nursingdiagnosis should receive the highest priority?a. Ineffective peripheral tissue perfusionrelated to venous congestion.b. Risk for injury related to edema.c. Excess fluid volume related to peripheralvascular disease.d. Impaired gas exchange related toincreased blood flow.5. Nurse Betty is assigned to the following clients.The client that the nurse would see first afterendorsement?a. A 34 year-old post-operativeappendectomy client of five hours whois complaining of pain.b. A 44 year-old myocardial infarction (MI)client who is complaining of nausea.c. A 26 year-old client admitted fordehydration whose intravenous (IV) hasinfiltrated.d. A 63 year-old post operative’sabdominal hysterectomy client of threedays whose incisional dressing issaturated with serosanguinous fluid.6. Nurse Gail places a client in a four-point restraintfollowing orders from the physician. The clientcare plan should include:a. Assess temperature frequently.b. Provide diversional activities.c. Check circulation every 15-30 minutes.d. Socialize with other patients once a shift.7. A male client who has severe burns is receivingH2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to:a. Prevent stress ulcerb. Block prostaglandin synthesisc. Facilitate protein synthesis.d. Enhance gas exchange8. The doctor orders hourly urine outputmeasurement for a postoperative male client.The nurse Trish records the following amounts ofoutput for 2 consecutive hours: 8 a.m.: 50 ml; 9a.m.: 60 ml. Based on these amounts, whichaction should the nurse take?a. Increase the I.V. fluid infusion rateb. Irrigate the indwelling urinary catheterc. Notify the physiciand. Continue to monitor and record hourlyurine output9. Tony, a basketball player twist his right anklewhile playing on the court and seeks care forankle pain and swelling. After the nurse appliesice to the ankle for 30 minutes, which statementby Tony suggests that ice application has beeneffective?a. “My ankle looks less swollen now”.b. “My ankle feels warm”.c. “My ankle appears redder now”.
  • 57d. “I need something stronger for painrelief”10. The physician prescribes a loop diuretic for aclient. When administering this drug, the nurseanticipates that the client may develop whichelectrolyte imbalance?a. Hypernatremiab. Hyperkalemiac. Hypokalemiad. Hypervolemia11. She finds out that some managers havebenevolent-authoritative style of management.Which of the following behaviors will she exhibitmost likely?a. Have condescending trust andconfidence in their subordinates.b. Gives economic and ego awards.c. Communicates downward to staffs.d. Allows decision making amongsubordinates.12. Nurse Amy is aware that the following is trueabout functional nursinga. Provides continuous, coordinated andcomprehensive nursing services.b. One-to-one nurse patient ratio.c. Emphasize the use of groupcollaboration.d. Concentrates on tasks and activities.13. Which type of medication order might read"Vitamin K 10 mg I.M. daily × 3 days?"a. Single orderb. Standard written orderc. Standing orderd. Stat order14. A female client with a fecal impaction frequentlyexhibits which clinical manifestation?a. Increased appetiteb. Loss of urge to defecatec. Hard, brown, formed stoolsd. Liquid or semi-liquid stools15. Nurse Linda prepares to perform an otoscopicexamination on a female client. For propervisualization, the nurse should position theclients ear by:a. Pulling the lobule down and backb. Pulling the helix up and forwardc. Pulling the helix up and backd. Pulling the lobule down and forward16. Which instruction should nurse Tom give to amale client who is having external radiationtherapy:a. Protect the irritated skin from sunlight.b. Eat 3 to 4 hours before treatment.c. Wash the skin over regularly.d. Apply lotion or oil to the radiated areawhen it is red or sore.17. In assisting a female client for immediatesurgery, the nurse In-charge is aware that sheshould:a. Encourage the client to void followingpreoperative medication.b. Explore the client’s fears and anxietiesabout the surgery.c. Assist the client in removing denturesand nail polish.d. Encourage the client to drink water priorto surgery.18. A male client is admitted and diagnosed withacute pancreatitis after a holiday celebration ofexcessive food and alcohol. Which assessmentfinding reflects this diagnosis?a. Blood pressure above normal range.b. Presence of crackles in both lung fields.c. Hyperactive bowel soundsd. Sudden onset of continuous epigastricand back pain.19. Which dietary guidelines are important for nurseOliver to implement in caring for the client withburns?a. Provide high-fiber, high-fat dietb. Provide high-protein, high-carbohydratediet.c. Monitor intake to prevent weight gain.d. Provide ice chips or water intake.20. Nurse Hazel will administer a unit of wholeblood, which priority information should thenurse have about the client?a. Blood pressure and pulse rate.b. Height and weight.c. Calcium and potassium levelsd. Hgb and Hct levels.21. Nurse Michelle witnesses a female client sustaina fall and suspects that the leg may be broken.The nurse takes which priority action?a. Takes a set of vital signs.
  • 58b. Call the radiology department for X-ray.c. Reassure the client that everything willbe alright.d. Immobilize the leg before moving theclient.22. A male client is being transferred to the nursingunit for admission after receiving a radiumimplant for bladder cancer. The nurse in-chargewould take which priority action in the care ofthis client?a. Place client on reverse isolation.b. Admit the client into a private room.c. Encourage the client to take frequentrest periods.d. Encourage family and friends to visit.23. A newly admitted female client was diagnosedwith agranulocytosis. The nurse formulateswhich priority nursing diagnosis?a. Constipationb. Diarrheac. Risk for infectiond. Deficient knowledge24. A male client is receiving total parenteralnutrition suddenly demonstrates signs andsymptoms of an air embolism. What is thepriority action by the nurse?a. Notify the physician.b. Place the client on the left side in theTrendelenburg position.c. Place the client in high-Fowlers position.d. Stop the total parenteral nutrition.25. Nurse May attends an educational conferenceon leadership styles. The nurse is sitting with anurse employed at a large trauma center whostates that the leadership style at the traumacenter is task-oriented and directive. The nursedetermines that the leadership style used at thetrauma center is:a. Autocratic.b. Laissez-faire.c. Democratic.d. Situational26. The physician orders DS 500 cc with KCl 10mEq/liter at 30 cc/hr. The nurse in-charge isgoing to hang a 500 cc bag. KCl is supplied 20mEq/10 cc. How many cc’s of KCl will be addedto the IV solution?a. .5 ccb. 5 ccc. 1.5 ccd. 2.5 cc27. A child of 10 years old is to receive 400 cc of IVfluid in an 8 hour shift. The IV drip factor is 60.The IV rate that will deliver this amount is:a. 50 cc/ hourb. 55 cc/ hourc. 24 cc/ hourd. 66 cc/ hour28. The nurse is aware that the most importantnursing action when a client returns fromsurgery is:a. Assess the IV for type of fluid and rate offlow.b. Assess the client for presence of pain.c. Assess the Foley catheter for patencyand urine outputd. Assess the dressing for drainage.29. Which of the following vital sign assessmentsthat may indicate cardiogenic shock aftermyocardial infarction?a. BP – 80/60, Pulse – 110 irregularb. BP – 90/50, Pulse – 50 regularc. BP – 130/80, Pulse – 100 regulard. BP – 180/100, Pulse – 90 irregular30. Which is the most appropriate nursing action inobtaining a blood pressure measurement?a. Take the proper equipment, place theclient in a comfortable position, andrecord the appropriate information inthe client’s chart.b. Measure the client’s arm, if you are notsure of the size of cuff to use.c. Have the client recline or sit comfortablyin a chair with the forearm at the level ofthe heart.d. Document the measurement, whichextremity was used, and the positionthat the client was in during themeasurement.31. Asking the questions to determine if the personunderstands the health teaching provided by thenurse would be included during which step ofthe nursing process?a. Assessmentb. Evaluationc. Implementation
  • 59d. Planning and goals32. Which of the following item is considered thesingle most important factor in assisting thehealth professional in arriving at a diagnosis ordetermining the person’s needs?a. Diagnostic test resultsb. Biographical datec. History of present illnessd. Physical examination33. In preventing the development of an externalrotation deformity of the hip in a client whomust remain in bed for any period of time, themost appropriate nursing action would be touse:a. Trochanter roll extending from the crestof the ileum to the mid-thigh.b. Pillows under the lower legs.c. Footboardd. Hip-abductor pillow34. Which stage of pressure ulcer development doesthe ulcer extend into the subcutaneous tissue?a. Stage Ib. Stage IIc. Stage IIId. Stage IV35. When the method of wound healing is one inwhich wound edges are not surgicallyapproximated and integumentary continuity isrestored by granulations, the wound healing istermeda. Second intention healingb. Primary intention healingc. Third intention healingd. First intention healing36. An 80-year-old male client is admitted to thehospital with a diagnosis of pneumonia. NurseOliver learns that the client lives alone andhasn’t been eating or drinking. When assessinghim for dehydration, nurse Oliver would expectto find:a. Hypothermiab. Hypertensionc. Distended neck veinsd. Tachycardia37. The physician prescribes meperidine (Demerol),75 mg I.M. every 4 hours as needed, to control aclient’s postoperative pain. The package insert is“Meperidine, 100 mg/ml.” How many millilitersof meperidine should the client receive?a. 0.75b. 0.6c. 0.5d. 0.2538. A male client with diabetes mellitus is receivinginsulin. Which statement correctly describes aninsulin unit?a. It’s a common measurement in themetric system.b. It’s the basis for solids in the avoirdupoissystem.c. It’s the smallest measurement in theapothecary system.d. It’s a measure of effect, not a standardmeasure of weight or quantity.39. Nurse Oliver measures a client’s temperature at102° F. What is the equivalent Centigradetemperature?a. 40.1 °Cb. 38.9 °Cc. 48 °Cd. 38 °C40. The nurse is assessing a 48-year-old client whohas come to the physician’s office for his annualphysical exam. One of the first physical signs ofaging is:a. Accepting limitations while developingassets.b. Increasing loss of muscle tone.c. Failing eyesight, especially close vision.d. Having more frequent aches and pains.41. The physician inserts a chest tube into a femaleclient to treat a pneumothorax. The tube isconnected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:a. Checking and taping all connections.b. Checking patency of the chest tube.c. Keeping the head of the bed slightlyelevated.d. Keeping the chest drainage systembelow the level of the chest.42. Nurse Trish must verify the client’s identitybefore administering medication. She is awarethat the safest way to verify identity is to:a. Check the client’s identification band.b. Ask the client to state his name.
  • 60c. State the client’s name out loud andwait a client to repeat it.d. Check the room number and the client’sname on the bed.43. The physician orders dextrose 5 % in water,1,000 ml to be infused over 8 hours. The I.V.tubing delivers 15 drops/ml. Nurse John shouldrun the I.V. infusion at a rate of:a. 30 drops/minuteb. 32 drops/minutec. 20 drops/minuted. 18 drops/minute44. If a central venous catheter becomesdisconnected accidentally, what should thenurse in-charge do immediately?a. Clamp the catheterb. Call another nursec. Call the physiciand. Apply a dry sterile dressing to the site.45. A female client was recently admitted. She hasfever, weight loss, and watery diarrhea is beingadmitted to the facility. While assessing theclient, Nurse Hazel inspects the client’s abdomenand notice that it is slightly concave. Additionalassessment should proceed in which order:a. Palpation, auscultation, and percussion.b. Percussion, palpation, and auscultation.c. Palpation, percussion, and auscultation.d. Auscultation, percussion, and palpation.46. Nurse Betty is assessing tactile fremitus in aclient with pneumonia. For this examination,nurse Betty should use the:a. Fingertipsb. Finger padsc. Dorsal surface of the handd. Ulnar surface of the hand47. Which type of evaluation occurs continuouslythroughout the teaching and learning process?a. Summativeb. Informativec. Formatived. Retrospective48. A 45 year old client, has no family history ofbreast cancer or other risk factors for thisdisease. Nurse John should instruct her to havemammogram how often?a. Twice per yearb. Once per yearc. Every 2 yearsd. Once, to establish baseline49. A male client has the following arterial blood gasvalues: pH 7.30; Pao2 89 mmHg; Paco2 50mmHg; and HCO3 26mEq/L. Based on thesevalues, Nurse Patricia should expect whichcondition?a. Respiratory acidosisb. Respiratory alkalosisc. Metabolic acidosisd. Metabolic alkalosis50. Nurse Len refers a female client with terminalcancer to a local hospice. What is the goal of thisreferral?a. To help the client find appropriatetreatment options.b. To provide support for the client andfamily in coping with terminal illness.c. To ensure that the client gets counselingregarding health care costs.d. To teach the client and family aboutcancer and its treatment.51. When caring for a male client with a 3-cm stage Ipressure ulcer on the coccyx, which of thefollowing actions can the nurse instituteindependently?a. Massaging the area with an astringentevery 2 hours.b. Applying an antibiotic cream to the areathree times per day.c. Using normal saline solution to clean theulcer and applying a protective dressingas necessary.d. Using a povidone-iodine wash on theulceration three times per day.52. Nurse Oliver must apply an elastic bandage to aclient’s ankle and calf. He should apply thebandage beginning at the client’s:a. Kneeb. Anklec. Lower thighd. Foot53. A 10 year old child with type 1 diabetes developsdiabetic ketoacidosis and receives a continuousinsulin infusion. Which condition represents thegreatest risk to this child?a. Hypernatremiab. Hypokalemiac. Hyperphosphatemia
  • 61d. Hypercalcemia54. Nurse Len is administering sublingual nitrglycerin(Nitrostat) to the newly admitted client.Immediately afterward, the client mayexperience:a. Throbbing headache or dizzinessb. Nervousness or paresthesia.c. Drowsiness or blurred vision.d. Tinnitus or diplopia.55. Nurse Michelle hears the alarm sound on thetelemetry monitor. The nurse quickly looks atthe monitor and notes that a client is in aventricular tachycardia. The nurse rushes to theclient’s room. Upon reaching the client’sbedside, the nurse would take which actionfirst?a. Prepare for cardioversionb. Prepare to defibrillate the clientc. Call a coded. Check the client’s level of consciousness56. Nurse Hazel is preparing to ambulate a femaleclient. The best and the safest position for thenurse in assisting the client is to stand:a. On the unaffected side of the client.b. On the affected side of the client.c. In front of the client.d. Behind the client.57. Nurse Janah is monitoring the ongoing caregiven to the potential organ donor who has beendiagnosed with brain death. The nursedetermines that the standard of care had beenmaintained if which of the following data isobserved?a. Urine output: 45 ml/hrb. Capillary refill: 5 secondsc. Serum pH: 7.32d. Blood pressure: 90/48 mmHg58. Nurse Amy has an order to obtain a urinalysisfrom a male client with an indwelling urinarycatheter. The nurse avoids which of thefollowing, which contaminate the specimen?a. Wiping the port with an alcohol swabbefore inserting the syringe.b. Aspirating a sample from the port on thedrainage bag.c. Clamping the tubing of the drainage bag.d. Obtaining the specimen from the urinarydrainage bag.59. Nurse Meredith is in the process of giving aclient a bed bath. In the middle of theprocedure, the unit secretary calls the nurse onthe intercom to tell the nurse that there is anemergency phone call. The appropriate nursingaction is to:a. Immediately walk out of the client’sroom and answer the phone call.b. Cover the client, place the call lightwithin reach, and answer the phone call.c. Finish the bed bath before answeringthe phone call.d. Leave the client’s door open so the clientcan be monitored and the nurse cananswer the phone call.60. Nurse Janah is collecting a sputum specimen forculture and sensitivity testing from a client whohas a productive cough. Nurse Janah plans toimplement which intervention to obtain thespecimen?a. Ask the client to expectorate a smallamount of sputum into the emesis basin.b. Ask the client to obtain the specimenafter breakfast.c. Use a sterile plastic container forobtaining the specimen.d. Provide tissues for expectoration andobtaining the specimen.61. Nurse Ron is observing a male client using awalker. The nurse determines that the client isusing the walker correctly if the client:a. Puts all the four points of the walker flaton the floor, puts weight on the handpieces, and then walks into it.b. Puts weight on the hand pieces, movesthe walker forward, and then walks intoit.c. Puts weight on the hand pieces, slidesthe walker forward, and then walks intoit.d. Walks into the walker, puts weight onthe hand pieces, and then puts all fourpoints of the walker flat on the floor.62. Nurse Amy has documented an entry regardingclient care in the client’s medical record. Whenchecking the entry, the nurse realizes that
  • 62incorrect information was documented. Howdoes the nurse correct this error?a. Erases the error and writes in the correctinformation.b. Uses correction fluid to cover up theincorrect information and writes in thecorrect information.c. Draws one line to cross out the incorrectinformation and then initials the change.d. Covers up the incorrect informationcompletely using a black pen and writesin the correct information63. Nurse Ron is assisting with transferring a clientfrom the operating room table to a stretcher. Toprovide safety to the client, the nurse should:a. Moves the client rapidly from the tableto the stretcher.b. Uncovers the client completely beforetransferring to the stretcher.c. Secures the client safety belts aftertransferring to the stretcher.d. Instructs the client to move self from thetable to the stretcher.64. Nurse Myrna is providing instructions to anursing assistant assigned to give a bed bath to aclient who is on contact precautions. NurseMyrna instructs the nursing assistant to usewhich of the following protective items whengiving bed bath?a. Gown and gogglesb. Gown and glovesc. Gloves and shoe protectorsd. Gloves and goggles65. Nurse Oliver is caring for a client with impairedmobility that occurred as a result of a stroke. Theclient has right sided arm and leg weakness. Thenurse would suggest that the client use which ofthe following assistive devices that wouldprovide the best stability for ambulating?a. Crutchesb. Single straight-legged canec. Quad caned. Walker66. A male client with a right pleural effusion notedon a chest X-ray is being prepared forthoracentesis. The client experiences severedizziness when sitting upright. To provide a safeenvironment, the nurse assists the client towhich position for the procedure?a. Prone with head turned toward the sidesupported by a pillow.b. Sims’ position with the head of the bedflat.c. Right side-lying with the head of the bedelevated 45 degrees.d. Left side-lying with the head of the bedelevated 45 degrees.67. Nurse John develops methods for datagathering. Which of the following criteria of agood instrument refers to the ability of theinstrument to yield the same results upon itsrepeated administration?a. Validityb. Specificityc. Sensitivityd. Reliability68. Harry knows that he has to protect the rights ofhuman research subjects. Which of the followingactions of Harry ensures anonymity?a. Keep the identities of the subject secretb. Obtain informed consentc. Provide equal treatment to all thesubjects of the study.d. Release findings only to the participantsof the study69. Patient’s refusal to divulge information is alimitation because it is beyond the control ofTifanny”. What type of research is appropriatefor this study?a. Descriptive- correlationalb. Experimentc. Quasi-experimentd. Historical70. Nurse Ronald is aware that the best tool for datagathering is?a. Interview scheduleb. Questionnairec. Use of laboratory datad. Observation71. Monica is aware that there are times when onlymanipulation of study variables is possible andthe elements of control or randomization arenot attendant. Which type of research isreferred to this?a. Field studyb. Quasi-experimentc. Solomon-Four group design
  • 63d. Post-test only design72. Cherry notes down ideas that were derived fromthe description of an investigation written by theperson who conducted it. Which type ofreference source refers to this?a. Footnoteb. Bibliographyc. Primary sourced. Endnotes73. When Nurse Trish is providing care to hispatient, she must remember that her duty isbound not to do doing any action that will causethe patient harm. This is the meaning of thebioethical principle:a. Non-maleficenceb. Beneficencec. Justiced. Solidarity74. When a nurse in-charge causes an injury to afemale patient and the injury caused becomesthe proof of the negligent act, the presence ofthe injury is said to exemplify the principle of:a. Force majeureb. Respondeat superiorc. Res ipsa loquitord. Holdover doctrine75. Nurse Myrna is aware that the Board of Nursinghas quasi-judicial power. An example of thispower is:a. The Board can issue rules andregulations that will govern the practiceof nursingb. The Board can investigate violations ofthe nursing law and code of ethicsc. The Board can visit a school applying fora permit in collaboration with CHEDd. The Board prepares the boardexaminations76. When the license of nurse Krina is revoked, itmeans that she:a. Is no longer allowed to practice theprofession for the rest of her lifeb. Will never have her/his license re-issuedsince it has been revokedc. May apply for re-issuance of his/herlicense based on certain conditionsstipulated in RA 9173d. Will remain unable to practiceprofessional nursing77. Ronald plans to conduct a research on the use ofa new method of pain assessment scale. Whichof the following is the second step in theconceptualizing phase of the research process?a. Formulating the research hypothesisb. Review related literaturec. Formulating and delimiting the researchproblemd. Design the theoretical and conceptualframework78. The leader of the study knows that certainpatients who are in a specialized research settingtend to respond psychologically to theconditions of the study. This referred to as :a. Cause and effectb. Hawthorne effectc. Halo effectd. Horns effect79. Mary finally decides to use judgment samplingon her research. Which of the following actionsof is correct?a. Plans to include whoever is there duringhis study.b. Determines the different nationality ofpatients frequently admitted anddecides to get representations samplesfrom each.c. Assigns numbers for each of thepatients, place these in a fishbowl anddraw 10 from it.d. Decides to get 20 samples from theadmitted patients80. The nursing theorist who developedtranscultural nursing theory is:a. Florence Nightingaleb. Madeleine Leiningerc. Albert Moored. Sr. Callista Roy81. Marion is aware that the sampling method thatgives equal chance to all units in the populationto get picked is:a. Randomb. Accidentalc. Quotad. Judgment
  • 6482. John plans to use a Likert Scale to his study todetermine the:a. Degree of agreement and disagreementb. Compliance to expected standardsc. Level of satisfactiond. Degree of acceptance83. Which of the following theory addresses the fourmodes of adaptation?a. Madeleine Leiningerb. Sr. Callista Royc. Florence Nightingaled. Jean Watson84. Ms. Garcia is responsible to the number ofpersonnel reporting to her. This principle refersto:a. Span of controlb. Unity of commandc. Downward communicationd. Leader85. Ensuring that there is an informed consent onthe part of the patient before a surgery is done,illustrates the bioethical principle of:a. Beneficenceb. Autonomyc. Veracityd. Non-maleficence86. Nurse Reese is teaching a female client withperipheral vascular disease about foot care;Nurse Reese should include which instruction?a. Avoid wearing cotton socks.b. Avoid using a nail clipper to cut toenails.c. Avoid wearing canvas shoes.d. Avoid using cornstarch on feet.87. A client is admitted with multiple pressureulcers. When developing the clients diet plan,the nurse should include:a. Fresh orange slicesb. Steamed broccolic. Ice creamd. Ground beef patties88. The nurse prepares to administer a cleansingenema. What is the most common clientposition used for this procedure?a. Lithotomyb. Supinec. Proned. Sims’ left lateral89. Nurse Marian is preparing to administer a bloodtransfusion. Which action should the nurse takefirst?a. Arrange for typing and cross matching ofthe client’s blood.b. Compare the client’s identificationwristband with the tag on the unit ofblood.c. Start an I.V. infusion of normal salinesolution.d. Measure the client’s vital signs.90. A 65 years old male client requests hismedication at 9 p.m. instead of 10 p.m. so thathe can go to sleep earlier. Which type of nursingintervention is required?a. Independentb. Dependentc. Interdependentd. Intradependent91. A female client is to be discharged from an acutecare facility after treatment for right legthrombophlebitis. The Nurse Betty notes thatthe clients leg is pain-free, without redness oredema. The nurses actions reflect which step ofthe nursing process?a. Assessmentb. Diagnosisc. Implementationd. Evaluation92. Nursing care for a female client includesremoving elastic stockings once per day. TheNurse Betty is aware that the rationale for thisintervention?a. To increase blood flow to the heartb. To observe the lower extremitiesc. To allow the leg muscles to stretch andrelaxd. To permit veins in the legs to fill withblood.93. Which nursing intervention takes highest prioritywhen caring for a newly admitted client whosreceiving a blood transfusion?a. Instructing the client to report anyitching, swelling, or dyspnea.b. Informing the client that the transfusionusually take 1 ½ to 2 hours.c. Documenting blood administration inthe client care record.
  • 65d. Assessing the client’s vital signs whenthe transfusion ends.94. A male client complains of abdominal discomfortand nausea while receiving tube feedings. Whichintervention is most appropriate for thisproblem?a. Give the feedings at room temperature.b. Decrease the rate of feedings and theconcentration of the formula.c. Place the client in semi-Fowlers positionwhile feeding.d. Change the feeding container every 12hours.95. Nurse Patricia is reconstituting a powderedmedication in a vial. After adding the solution tothe powder, she nurse should:a. Do nothing.b. Invert the vial and let it stand for 3 to 5minutes.c. Shake the vial vigorously.d. Roll the vial gently between the palms.96. Which intervention should the nurse Trish usewhen administering oxygen by face mask to afemale client?a. Secure the elastic band tightly aroundthe clients head.b. Assist the client to the semi-Fowlerposition if possible.c. Apply the face mask from the clientschin up over the nose.d. Loosen the connectors between theoxygen equipment and humidifier.97. The maximum transfusion time for a unit ofpacked red blood cells (RBCs) is:a. 6 hoursb. 4 hoursc. 3 hoursd. 2 hours98. Nurse Monique is monitoring the effectivenessof a clients drug therapy. When should thenurse Monique obtain a blood sample tomeasure the trough drug level?a. 1 hour before administering the nextdose.b. Immediately before administering thenext dose.c. Immediately after administering thenext dose.d. 30 minutes after administering the nextdose.99. Nurse May is aware that the main advantage ofusing a floor stock system is:a. The nurse can implement medicationorders quickly.b. The nurse receives input from thepharmacist.c. The system minimizes transcriptionerrors.d. The system reinforces accuratecalculations.100. Nurse Oliver is assessing a clients abdomen.Which finding should the nurse report asabnormal?a. Dullness over the liver.b. Bowel sounds occurring every 10seconds.c. Shifting dullness over the abdomen.d. Vascular sounds heard over the renalarteries.
  • 66Answers and Rationale – Foundation ofProfessional Nursing Practice1. Answer: (D) The actions of a reasonablyprudent nurse with similar education andexperience.Rationale: The standard of care is determinedby the average degree of skill, care, anddiligence by nurses in similar circumstances.2. Answer: (B) I.MRationale: With a platelet count of 22,000/μl,the clients tends to bleed easily. Therefore,the nurse should avoid using the I.M. routebecause the area is a highly vascular and canbleed readily when penetrated by a needle.The bleeding can be difficult to stop.3. Answer: (C) “Digoxin 0.125 mg P.O. once daily”Rationale: The nurse should always place azero before a decimal point so that no onemisreads the figure, which could result in adosage error. The nurse should never insert azero at the end of a dosage that includes adecimal point because this could be misread,possibly leading to a tenfold increase in thedosage.4. Answer: (A) Ineffective peripheral tissueperfusion related to venous congestion.Rationale: Ineffective peripheral tissueperfusion related to venous congestion takesthe highest priority because venousinflammation and clot formation impede bloodflow in a client with deep vein thrombosis.5. Answer: (B) A 44 year-old myocardialinfarction (MI) client who is complaining ofnausea.Rationale: Nausea is a symptom of impendingmyocardial infarction (MI) and should beassessed immediately so that treatment canbe instituted and further damage to the heartis avoided.6. Answer: (C) Check circulation every 15-30minutes.Rationale: Restraints encircle the limbs, whichplace the client at risk for circulation beingrestricted to the distal areas of theextremities. Checking the client’s circulationevery 15-30 minutes will allow the nurse toadjust the restraints before injury fromdecreased blood flow occurs.7. Answer: (A) Prevent stress ulcerRationale: Curling’s ulcer occurs as ageneralized stress response in burn patients.This results in a decreased production ofmucus and increased secretion of gastric acid.The best treatment for this prophylactic use ofantacids and H2 receptor blockers.8. Answer: (D) Continue to monitor and recordhourly urine outputRationale: Normal urine output for an adult isapproximately 1 ml/minute (60 ml/hour).Therefore, this clients output is normal.Beyond continued evaluation, no nursingaction is warranted.9. Answer: (B) “My ankle feels warm”.Rationale: Ice application decreases pain andswelling. Continued or increased pain, redness,and increased warmth are signs ofinflammation that shouldnt occur after iceapplication10. Answer: (B) HyperkalemiaRationale: A loop diuretic removes water and,along with it, sodium and potassium. This mayresult in hypokalemia, hypovolemia, andhyponatremia.11. Answer:(A) Have condescending trust andconfidence in their subordinatesRationale: Benevolent-authoritative managerspretentiously show their trust and confidenceto their followers.12. Answer: (A) Provides continuous, coordinatedand comprehensive nursing services.Rationale: Functional nursing is focused ontasks and activities and not on the care of thepatients.13. Answer: (B) Standard written orderRationale: This is a standard written order.Prescribers write a single order formedications given only once. A stat order iswritten for medications given immediately foran urgent client problem. A standing order,also known as a protocol, establishesguidelines for treating a particular disease orset of symptoms in special care areas such asthe coronary care unit. Facilities also mayinstitute medication protocols that specificallydesignate drugs that a nurse may not give.14. Answer: (D) Liquid or semi-liquid stoolsRationale: Passage of liquid or semi-liquidstools results from seepage of unformedbowel contents around the impacted stool inthe rectum. Clients with fecal impaction dontpass hard, brown, formed stools because thefeces cant move past the impaction. These
  • 67clients typically report the urge to defecate(although they cant pass stool) and adecreased appetite.15. Answer: (C) Pulling the helix up and backRationale: To perform an otoscopicexamination on an adult, the nurse grasps thehelix of the ear and pulls it up and back tostraighten the ear canal. For a child, the nursegrasps the helix and pulls it down to straightenthe ear canal. Pulling the lobule in anydirection wouldnt straighten the ear canal forvisualization.16. Answer: (A) Protect the irritated skin fromsunlight.Rationale: Irradiated skin is very sensitive andmust be protected with clothing or sunblock.The priority approach is the avoidance ofstrong sunlight.17. Answer: (C) Assist the client in removingdentures and nail polish.Rationale: Dentures, hairpins, and combs mustbe removed. Nail polish must be removed sothat cyanosis can be easily monitored byobserving the nail beds.18. Answer: (D) Sudden onset of continuousepigastric and back pain.Rationale: The autodigestion of tissue by thepancreatic enzymes results in pain frominflammation, edema, and possiblehemorrhage. Continuous, unrelieved epigastricor back pain reflects the inflammatory processin the pancreas.19. Answer: (B) Provide high-protein, high-carbohydrate diet.Rationale: A positive nitrogen balance isimportant for meeting metabolic needs, tissuerepair, and resistance to infection. Caloricgoals may be as high as 5000 calories per day.20. Answer: (A) Blood pressure and pulse rate.Rationale: The baseline must be established torecognize the signs of an anaphylactic orhemolytic reaction to the transfusion.21. Answer: (D) Immobilize the leg before movingthe client.Rationale: If the nurse suspects a fracture,splinting the area before moving the client isimperative. The nurse should call foremergency help if the client is not hospitalizedand call for a physician for the hospitalizedclient.22. Answer: (B) Admit the client into a privateroom.Rationale: The client who has a radiationimplant is placed in a private room and has alimited number of visitors. This reduces theexposure of others to the radiation.23. Answer: (C) Risk for infectionRationale: Agranulocytosis is characterized bya reduced number of leukocytes (leucopenia)and neutrophils (neutropenia) in the blood.The client is at high risk for infection becauseof the decreased body defenses againstmicroorganisms. Deficient knowledge relatedto the nature of the disorder may beappropriate diagnosis but is not the priority.24. Answer: (B) Place the client on the left side inthe Trendelenburg position.Rationale: Lying on the left side may preventair from flowing into the pulmonary veins. TheTrendelenburg position increases intrathoracicpressure, which decreases the amount ofblood pulled into the vena cava duringaspiration.25. Answer: (A) Autocratic.Rationale: The autocratic style of leadership isa task-oriented and directive.26. Answer: (D) 2.5 ccRationale: 2.5 cc is to be added, because only a500 cc bag of solution is being medicatedinstead of a 1 liter.27. Answer: (A) 50 cc/ hourRationale: A rate of 50 cc/hr. The child is toreceive 400 cc over a period of 8 hours = 50cc/hr.28. Answer: (B) Assess the client for presence ofpain.Rationale: Assessing the client for pain is avery important measure. Postoperative pain isan indication of complication. The nurseshould also assess the client for pain toprovide for the client’s comfort.29. Answer: (A) BP – 80/60, Pulse – 110 irregularRationale: The classic signs of cardiogenicshock are low blood pressure, rapid and weakirregular pulse, cold, clammy skin, decreasedurinary output, and cerebral hypoxia.30. Answer: (A) Take the proper equipment, placethe client in a comfortable position, andrecord the appropriate information in theclient’s chart.Rationale: It is a general or comprehensivestatement about the correct procedure, and itincludes the basic ideas which are found in theother options31. Answer: (B) Evaluation
  • 68Rationale: Evaluation includes observing theperson, asking questions, and comparing thepatient’s behavioral responses with theexpected outcomes.32. Answer: (C) History of present illnessRationale: The history of present illness is thesingle most important factor in assisting thehealth professional in arriving at a diagnosis ordetermining the person’s needs.33. Answer: (A) Trochanter roll extending from thecrest of the ileum to the mid-thigh.Rationale: A trochanter roll, properly placed,provides resistance to the external rotation ofthe hip.34. Answer: (C) Stage IIIRationale: Clinically, a deep crater or withoutundermining of adjacent tissue is noted.35. Answer: (A) Second intention healingRationale: When wounds dehisce, they willallowed to heal by secondary Intention36. Answer: (D) TachycardiaRationale: With an extracellular fluid or plasmavolume deficit, compensatory mechanismsstimulate the heart, causing an increase inheart rate.37. Answer: (A) 0.75Rationale: To determine the number ofmilliliters the client should receive, the nurseuses the fraction method in the followingequation.75 mg/X ml = 100 mg/1 mlTo solve for X, cross-multiply:75 mg x 1 ml = X ml x 100 mg75 = 100X75/100 = X0.75 ml (or ¾ ml) = X38. Answer: (D) it’s a measure of effect, not astandard measure of weight or quantity.Rationale: An insulin unit is a measure ofeffect, not a standard measure of weight orquantity. Different drugs measured in unitsmay have no relationship to one another inquality or quantity.39. Answer: (B) 38.9 °CRationale: To convert Fahrenheit degreed toCentigrade, use this formula°C = (°F – 32) ÷ 1.8°C = (102 – 32) ÷ 1.8°C = 70 ÷ 1.8°C = 38.940. Answer: (C) Failing eyesight, especially closevision.Rationale: Failing eyesight, especially closevision, is one of the first signs of aging inmiddle life (ages 46 to 64). More frequentaches and pains begin in the early late years(ages 65 to 79). Increase in loss of muscle toneoccurs in later years (age 80 and older).41. Answer: (A) Checking and taping allconnectionsRationale: Air leaks commonly occur if thesystem isn’t secure. Checking all connectionsand taping them will prevent air leaks. Thechest drainage system is kept lower topromote drainage – not to prevent leaks.42. Answer: (A) Check the client’s identificationband.Rationale: Checking the client’s identificationband is the safest way to verify a client’sidentity because the band is assigned onadmission and isn’t be removed at any time. (Ifit is removed, it must be replaced). Asking theclient’s name or having the client repeated hisname would be appropriate only for a clientwho’s alert, oriented, and able to understandwhat is being said, but isn’t the safe standardof practice. Names on bed aren’t alwaysreliable43. Answer: (B) 32 drops/minuteRationale: Giving 1,000 ml over 8 hours is thesame as giving 125 ml over 1 hour (60minutes). Find the number of milliliters perminute as follows:125/60 minutes = X/1 minute60X = 125 = 2.1 ml/minuteTo find the number of drops per minute:2.1 ml/X gtt = 1 ml/ 15 gttX = 32 gtt/minute, or 32 drops/minute44. Answer: (A) Clamp the catheterRationale: If a central venous catheterbecomes disconnected, the nurse shouldimmediately apply a catheter clamp, ifavailable. If a clamp isn’t available, the nursecan place a sterile syringe or catheter plug inthe catheter hub. After cleaning the hub withalcohol or povidone-iodine solution, the nursemust replace the I.V. extension and restart theinfusion.45. Answer: (D) Auscultation, percussion, andpalpation.Rationale: The correct order of assessment forexamining the abdomen is inspection,auscultation, percussion, and palpation. Thereason for this approach is that the lessintrusive techniques should be performed
  • 69before the more intrusive techniques.Percussion and palpation can alter naturalfindings during auscultation.46. Answer: (D) Ulnar surface of the handRationale: The nurse uses the ulnar surface, orball, of the hand to assess tactile fremitus,thrills, and vocal vibrations through the chestwall. The fingertips and finger pads bestdistinguish texture and shape. The dorsalsurface best feels warmth.47. Answer: (C) FormativeRationale: Formative (or concurrent)evaluation occurs continuously throughout theteaching and learning process. One benefit isthat the nurse can adjust teaching strategiesas necessary to enhance learning. Summative,or retrospective, evaluation occurs at theconclusion of the teaching and learningsession. Informative is not a type ofevaluation.48. Answer: (B) Once per yearRationale: Yearly mammograms should beginat age 40 and continue for as long as thewoman is in good health. If health risks, suchas family history, genetic tendency, or pastbreast cancer, exist, more frequentexaminations may be necessary.49. Answer: (A) Respiratory acidosisRationale: The client has a below-normal(acidic) blood pH value and an above-normalpartial pressure of arterial carbon dioxide(Paco2) value, indicating respiratory acidosis.In respiratory alkalosis, the pH value is abovenormal and in the Paco2 value is belownormal. In metabolic acidosis, the pH andbicarbonate (Hco3) values are below normal.In metabolic alkalosis, the pH and Hco3 valuesare above normal.50. Answer: (B) To provide support for the clientand family in coping with terminal illness.Rationale: Hospices provide supportive carefor terminally ill clients and their families.Hospice care doesn’t focus on counselingregarding health care costs. Most clientreferred to hospices have been treated fortheir disease without success and will receiveonly palliative care in the hospice.51. Answer: (C) Using normal saline solution toclean the ulcer and applying a protectivedressing as necessary.Rationale: Washing the area with normalsaline solution and applying a protectivedressing are within the nurse’s realm ofinterventions and will protect the area. Using apovidone-iodine wash and an antibiotic creamrequire a physician’s order. Massaging with anastringent can further damage the skin.52. Answer: (D) FootRationale: An elastic bandage should beapplied form the distal area to the proximalarea. This method promotes venous return. Inthis case, the nurse should begin applying thebandage at the client’s foot. Beginning at theankle, lower thigh, or knee does not promotevenous return.53. Answer: (B) HypokalemiaRationale: Insulin administration causesglucose and potassium to move into the cells,causing hypokalemia.54. Answer: (A) Throbbing headache or dizzinessRationale: Headache and dizziness often occurwhen nitroglycerin is taken at the beginning oftherapy. However, the client usually developstolerance55. Answer: (D) Check the client’s level ofconsciousnessRationale: Determining unresponsiveness isthe first step assessment action to take. Whena client is in ventricular tachycardia, there is asignificant decrease in cardiac output.However, checking the unresponsivenessensures whether the client is affected by thedecreased cardiac output.56. Answer: (B) On the affected side of the client.Rationale: When walking with clients, thenurse should stand on the affected side andgrasp the security belt in the midspine area ofthe small of the back. The nurse shouldposition the free hand at the shoulder area sothat the client can be pulled toward the nursein the event that there is a forward fall. Theclient is instructed to look up and outwardrather than at his or her feet.57. Answer: (A) Urine output: 45 ml/hrRationale: Adequate perfusion must bemaintained to all vital organs in order for theclient to remain visible as an organ donor. Aurine output of 45 ml per hour indicatesadequate renal perfusion. Low blood pressureand delayed capillary refill time are circulatorysystem indicators of inadequate perfusion. Aserum pH of 7.32 is acidotic, which adverselyaffects all body tissues.58. Answer: (D ) Obtaining the specimen from theurinary drainage bag.
  • 70Rationale: A urine specimen is not taken fromthe urinary drainage bag. Urine undergoeschemical changes while sitting in the bag anddoes not necessarily reflect the current clientstatus. In addition, it may becomecontaminated with bacteria from opening thesystem.59. Answer: (B) Cover the client, place the calllight within reach, and answer the phone call.Rationale: Because telephone call is anemergency, the nurse may need to answer it.The other appropriate action is to ask anothernurse to accept the call. However, is not one ofthe options. To maintain privacy and safety,the nurse covers the client and places the calllight within the client’s reach. Additionally, theclient’s door should be closed or the roomcurtains pulled around the bathing area.60. Answer: (C) Use a sterile plastic container forobtaining the specimen.Rationale: Sputum specimens for culture andsensitivity testing need to be obtained usingsterile techniques because the test is done todetermine the presence of organisms. If theprocedure for obtaining the specimen is notsterile, then the specimen is not sterile, thenthe specimen would be contaminated and theresults of the test would be invalid.61. Answer: (A) Puts all the four points of thewalker flat on the floor, puts weight on thehand pieces, and then walks into it.Rationale: When the client uses a walker, thenurse stands adjacent to the affected side. Theclient is instructed to put all four points of thewalker 2 feet forward flat on the floor beforeputting weight on hand pieces. This will ensureclient safety and prevent stress cracks in thewalker. The client is then instructed to movethe walker forward and walk into it.62. Answer: (C) Draws one line to cross out theincorrect information and then initials thechange.Rationale: To correct an error documented in amedical record, the nurse draws one linethrough the incorrect information and theninitials the error. An error is never erased andcorrection fluid is never used in the medicalrecord.63. Answer: (C) Secures the client safety beltsafter transferring to the stretcher.Rationale: During the transfer of the clientafter the surgical procedure is complete, thenurse should avoid exposure of the clientbecause of the risk for potential heat loss.Hurried movements and rapid changes in theposition should be avoided because thesepredispose the client to hypotension. At thetime of the transfer from the surgery table tothe stretcher, the client is still affected by theeffects of the anesthesia; therefore, the clientshould not move self. Safety belts can preventthe client from falling off the stretcher.64. Answer: (B) Gown and glovesRationale: Contact precautions require the useof gloves and a gown if direct client contact isanticipated. Goggles are not necessary unlessthe nurse anticipates the splashes of blood,body fluids, secretions, or excretions mayoccur. Shoe protectors are not necessary.65. Answer: (C) Quad caneRationale: Crutches and a walker can bedifficult to maneuver for a client withweakness on one side. A cane is better suitedfor client with weakness of the arm and leg onone side. However, the quad cane wouldprovide the most stability because of thestructure of the cane and because a quad canehas four legs.66. Answer: (D) Left side-lying with the head ofthe bed elevated 45 degrees.Rationale: To facilitate removal of fluid fromthe chest wall, the client is positioned sitting atthe edge of the bed leaning over the bedsidetable with the feet supported on a stool. If theclient is unable to sit up, the client ispositioned lying in bed on the unaffected sidewith the head of the bed elevated 30 to 45degrees.67. Answer: (D) ReliabilityRationale: Reliability is consistency of theresearch instrument. It refers to therepeatability of the instrument in extractingthe same responses upon its repeatedadministration.68. Answer: (A) Keep the identities of the subjectsecretRationale: Keeping the identities of theresearch subject secret will ensure anonymitybecause this will hinder providing link betweenthe information given to whoever is its source.69. Answer: (A) Descriptive- correlationalRationale: Descriptive- correlational study isthe most appropriate for this study because itstudies the variables that could be theantecedents of the increased incidence ofnosocomial infection.
  • 7170. Answer: (C) Use of laboratory dataRationale: Incidence of nosocomial infection isbest collected through the use ofbiophysiologic measures, particularly in vitromeasurements, hence laboratory data isessential.71. Answer: (B) Quasi-experimentRationale: Quasi-experiment is done whenrandomization and control of the variables arenot possible.72. Answer: (C) Primary sourceRationale: This refers to a primary sourcewhich is a direct account of the investigationdone by the investigator. In contrast to this is asecondary source, which is written bysomeone other than the original researcher.73. Answer: (A) Non-maleficenceRationale: Non-maleficence means do notcause harm or do any action that will causeany harm to the patient/client. To do good isreferred as beneficence.74. Answer: (C) Res ipsa loquitorRationale: Res ipsa loquitor literally means thething speaks for itself. This means inoperational terms that the injury caused is theproof that there was a negligent act.75. Answer: (B) The Board can investigateviolations of the nursing law and code of ethicsRationale: Quasi-judicial power means that theBoard of Nursing has the authority toinvestigate violations of the nursing law andcan issue summons, subpoena or subpoenaduces tecum as needed.76. Answer: (C) May apply for re-issuance ofhis/her license based on certain conditionsstipulated in RA 9173Rationale: RA 9173 sec. 24 states that forequity and justice, a revoked license maybe re-issued provided that the following conditionsare met: a) the cause for revocation of licensehas already been corrected or removed; and,b) at least four years has elapsed since thelicense has been revoked.77. Answer: (B) Review related literatureRationale: After formulating and delimiting theresearch problem, the researcher conducts areview of related literature to determine theextent of what has been done on the study byprevious researchers.78. Answer: (B) Hawthorne effectRationale: Hawthorne effect is based on thestudy of Elton Mayo and company about theeffect of an intervention done to improve theworking conditions of the workers on theirproductivity. It resulted to an increasedproductivity but not due to the interventionbut due to the psychological effects of beingobserved. They performed differently becausethey were under observation.79. Answer: (B) Determines the differentnationality of patients frequently admitted anddecides to get representations samples fromeach.Rationale: Judgment sampling involvesincluding samples according to the knowledgeof the investigator about the participants inthe study.80. Answer: (B) Madeleine LeiningerRationale: Madeleine Leininger developed thetheory on transcultural theory based on herobservations on the behavior of selectedpeople within a culture.81. Answer: (A) RandomRationale: Random sampling gives equalchance for all the elements in the populationto be picked as part of the sample.82. Answer: (A) Degree of agreement anddisagreementRationale: Likert scale is a 5-point summatedscale used to determine the degree ofagreement or disagreement of therespondents to a statement in a study83. Answer: (B) Sr. Callista RoyRationale: Sr. Callista Roy developed theAdaptation Model which involves thephysiologic mode, self-concept mode, rolefunction mode and dependence mode.84. Answer: (A) Span of controlRationale: Span of control refers to thenumber of workers who report directly to amanager.85. Answer: (B) AutonomyRationale: Informed consent means that thepatient fully understands about the surgery,including the risks involved and the alternativesolutions. In giving consent it is done with fullknowledge and is given freely. The action ofallowing the patient to decide whether asurgery is to be done or not exemplifies thebioethical principle of autonomy.86. Answer: (C) Avoid wearing canvas shoes.Rationale: The client should be instructed toavoid wearing canvas shoes. Canvas shoescause the feet to perspire, which may, in turn,cause skin irritation and breakdown. Bothcotton and cornstarch absorb perspiration.
  • 72The client should be instructed to cut toenailsstraight across with nail clippers.87. Answer: (D) Ground beef pattiesRationale: Meat is an excellent source ofcomplete protein, which this client needs torepair the tissue breakdown caused bypressure ulcers. Oranges and broccoli supplyvitamin C but not protein. Ice cream suppliesonly some incomplete protein, making it lesshelpful in tissue repair.88. Answer: (D) Sims’ left lateralRationale: The Sims left lateral position is themost common position used to administer acleansing enema because it allows gravity toaid the flow of fluid along the curve of thesigmoid colon. If the client cant assume thisposition nor has poor sphincter control, thedorsal recumbent or right lateral position maybe used. The supine and prone positions areinappropriate and uncomfortable for theclient.89. Answer: (A) Arrange for typing and crossmatching of the client’s blood.Rationale: The nurse first arranges for typingand cross matching of the clients blood toensure compatibility with donor blood. Theother options, although appropriate whenpreparing to administer a blood transfusion,come later.90. Answer: (A) IndependentRationale: Nursing interventions are classifiedas independent, interdependent, ordependent. Altering the drug schedule tocoincide with the clients daily routinerepresents an independent intervention,whereas consulting with the physician andpharmacist to change a clients medicationbecause of adverse reactions represents aninterdependent intervention. Administering analready-prescribed drug on time is adependent intervention. An intradependentnursing intervention doesnt exist.91. Answer: (D) EvaluationRationale: The nursing actions describedconstitute evaluation of the expectedoutcomes. The findings show that theexpected outcomes have been achieved.Assessment consists of the clients history,physical examination, and laboratory studies.Analysis consists of considering assessmentinformation to derive the appropriate nursingdiagnosis. Implementation is the phase of thenursing process where the nurse puts the planof care into action.92. Answer: (B) To observe the lower extremitiesRationale: Elastic stockings are used topromote venous return. The nurse needs toremove them once per day to observe thecondition of the skin underneath the stockings.Applying the stockings increases blood flow tothe heart. When the stockings are in place, theleg muscles can still stretch and relax, and theveins can fill with blood.93. Answer :(A) Instructing the client to report anyitching, swelling, or dyspnea.Rationale: Because administration of blood orblood products may cause serious adverseeffects such as allergic reactions, the nursemust monitor the client for these effects. Signsand symptoms of life-threatening allergicreactions include itching, swelling, anddyspnea. Although the nurse should informthe client of the duration of the transfusionand should document its administration, theseactions are less critical to the clientsimmediate health. The nurse should assessvital signs at least hourly during thetransfusion.94. Answer: (B) Decrease the rate of feedings andthe concentration of the formula.Rationale: Complaints of abdominaldiscomfort and nausea are common in clientsreceiving tube feedings. Decreasing the rate ofthe feeding and the concentration of theformula should decrease the clientsdiscomfort. Feedings are normally given atroom temperature to minimize abdominalcramping. To prevent aspiration duringfeeding, the head of the clients bed should beelevated at least 30 degrees. Also, to preventbacterial growth, feeding containers should beroutinely changed every 8 to 12 hours.95. Answer: (D) Roll the vial gently between thepalms.Rationale: Rolling the vial gently between thepalms produces heat, which helps dissolve themedication. Doing nothing or inverting the vialwouldnt help dissolve the medication. Shakingthe vial vigorously could cause the medicationto break down, altering its action.96. Answer: (B) Assist the client to the semi-Fowler position if possible.Rationale: By assisting the client to the semi-Fowler position, the nurse promotes easierchest expansion, breathing, and oxygen intake.
  • 73The nurse should secure the elastic band sothat the face mask fits comfortably and snuglyrather than tightly, which could lead toirritation. The nurse should apply the facemask from the clients nose down to the chin— not vice versa. The nurse should check theconnectors between the oxygen equipmentand humidifier to ensure that theyre airtight;loosened connectors can cause loss of oxygen.97. Answer: (B) 4 hoursRationale: A unit of packed RBCs may be givenover a period of between 1 and 4 hours. Itshouldnt infuse for longer than 4 hoursbecause the risk of contamination and sepsisincreases after that time. Discard or return tothe blood bank any blood not given within thistime, according to facility policy.98. Answer: (B) Immediately before administeringthe next dose.Rationale: Measuring the blood drugconcentration helps determine whether thedosing has achieved the therapeutic goal. Formeasurement of the trough, or lowest, bloodlevel of a drug, the nurse draws a bloodsample immediately before administering thenext dose. Depending on the drugs durationof action and half-life, peak blood drug levelstypically are drawn after administering thenext dose.99. Answer: (A) The nurse can implementmedication orders quickly.Rationale: A floor stock system enables thenurse to implement medication orders quickly.It doesnt allow for pharmacist input, nor doesit minimize transcription errors or reinforceaccurate calculations.100. Answer: (C) Shifting dullness over theabdomen.Rationale: Shifting dullness over the abdomenindicates ascites, an abnormal finding. Theother options are normal abdominal findings.
  • 74TEST II - Community Health Nursing and Care of theMother and Child1. May arrives at the health care clinic and tells thenurse that her last menstrual period was 9weeks ago. She also tells the nurse that a homepregnancy test was positive but she began tohave mild cramps and is now having moderatevaginal bleeding. During the physicalexamination of the client, the nurse notes thatMay has a dilated cervix. The nurse determinesthat May is experiencing which type of abortion?a. Inevitableb. Incompletec. Threatenedd. Septic2. Nurse Reese is reviewing the record of apregnant client for her first prenatal visit. Whichof the following data, if noted on the client’srecord, would alert the nurse that the client is atrisk for a spontaneous abortion?a. Age 36 yearsb. History of syphilisc. History of genital herpesd. History of diabetes mellitus3. Nurse Hazel is preparing to care for a client whois newly admitted to the hospital with a possiblediagnosis of ectopic pregnancy. Nurse Hazeldevelops a plan of care for the client anddetermines that which of the following nursingactions is the priority?a. Monitoring weightb. Assessing for edemac. Monitoring apical pulsed. Monitoring temperature4. Nurse Oliver is teaching a diabetic pregnantclient about nutrition and insulin needs duringpregnancy. The nurse determines that the clientunderstands dietary and insulin needs if theclient states that the second half of pregnancyrequires:a. Decreased caloric intakeb. Increased caloric intakec. Decreased Insulind. Increase Insulin5. Nurse Michelle is assessing a 24 year old clientwith a diagnosis of hydatidiform mole. She isaware that one of the following is unassociatedwith this condition?a. Excessive fetal activity.b. Larger than normal uterus forgestational age.c. Vaginal bleedingd. Elevated levels of human chorionicgonadotropin.6. A pregnant client is receiving magnesium sulfatefor severe pregnancy induced hypertension(PIH). The clinical findings that would warrantuse of the antidote , calcium gluconate is:a. Urinary output 90 cc in 2 hours.b. Absent patellar reflexes.c. Rapid respiratory rate above 40/min.d. Rapid rise in blood pressure.7. During vaginal examination of Janah who is inlabor, the presenting part is at station plus two.Nurse, correctly interprets it as:a. Presenting part is 2 cm above the planeof the ischial spines.b. Biparietal diameter is at the level of theischial spines.c. Presenting part in 2 cm below the planeof the ischial spines.d. Biparietal diameter is 2 cm above theischial spines.8. A pregnant client is receiving oxytocin (Pitocin)for induction of labor. A condition that warrantthe nurse in-charge to discontinue I.V. infusionof Pitocin is:a. Contractions every 1 ½ minutes lasting70-80 seconds.b. Maternal temperature 101.2c. Early decelerations in the fetal heartrate.d. Fetal heart rate baseline 140-160 bpm.9. Calcium gluconate is being administered to aclient with pregnancy induced hypertension(PIH). A nursing action that must be initiated asthe plan of care throughout injection of the drugis:a. Ventilator assistanceb. CVP readingsc. EKG tracingsd. Continuous CPR10. A trial for vaginal delivery after an earliercaesarean, would likely to be given to a gravida,who had:
  • 75a. First low transverse cesarean was foractive herpes type 2 infections; vaginalculture at 39 weeks pregnancy waspositive.b. First and second caesareans were forcephalopelvic disproportion.c. First caesarean through a classic incisionas a result of severe fetal distress.d. First low transverse caesarean was forbreech position. Fetus in this pregnancyis in a vertex presentation.11. Nurse Ryan is aware that the best initialapproach when trying to take a crying toddler’stemperature is:a. Talk to the mother first and then to thetoddler.b. Bring extra help so it can be donequickly.c. Encourage the mother to hold the child.d. Ignore the crying and screaming.12. Baby Tina a 3 month old infant just had a cleft lipand palate repair. What should the nurse do toprevent trauma to operative site?a. Avoid touching the suture line, evenwhen cleaning.b. Place the baby in prone position.c. Give the baby a pacifier.d. Place the infant’s arms in soft elbowrestraints.13. Which action should nurse Marian include in thecare plan for a 2 month old with heart failure?a. Feed the infant when he cries.b. Allow the infant to rest before feeding.c. Bathe the infant and administermedications before feeding.d. Weigh and bathe the infant beforefeeding.14. Nurse Hazel is teaching a mother who plans todiscontinue breast feeding after 5 months. Thenurse should advise her to include which foodsin her infant’s diet?a. Skim milk and baby food.b. Whole milk and baby food.c. Iron-rich formula only.d. Iron-rich formula and baby food.15. Mommy Linda is playing with her infant, who issitting securely alone on the floor of the clinic.The mother hides a toy behind her back and theinfant looks for it. The nurse is aware thatestimated age of the infant would be:a. 6 monthsb. 4 monthsc. 8 monthsd. 10 months16. Which of the following is the most prominentfeature of public health nursing?a. It involves providing home care to sickpeople who are not confined in thehospital.b. Services are provided free of charge topeople within the catchments area.c. The public health nurse functions as partof a team providing a public healthnursing services.d. Public health nursing focuses onpreventive, not curative, services.17. When the nurse determines whether resourceswere maximized in implementing Ligtas Tigdas,she is evaluatinga. Effectivenessb. Efficiencyc. Adequacyd. Appropriateness18. Vangie is a new B.S.N. graduate. She wants tobecome a Public Health Nurse. Where shouldshe apply?a. Department of Healthb. Provincial Health Officec. Regional Health Officed. Rural Health Unit19. Tony is aware the Chairman of the MunicipalHealth Board is:a. Mayorb. Municipal Health Officerc. Public Health Nursed. Any qualified physician20. Myra is the public health nurse in a municipalitywith a total population of about 20,000. Thereare 3 rural health midwives among the RHUpersonnel. How many more midwife items willthe RHU need?a. 1b. 2c. 3d. The RHU does not need any moremidwife item.
  • 7621. According to Freeman and Heinrich, communityhealth nursing is a developmental service. Whichof the following best illustrates this statement?a. The community health nursecontinuously develops himselfpersonally and professionally.b. Health education and communityorganizing are necessary in providingcommunity health services.c. Community health nursing is intendedprimarily for health promotion andprevention and treatment of disease.d. The goal of community health nursing isto provide nursing services to people intheir own places of residence.22. Nurse Tina is aware that the disease declaredthrough Presidential Proclamation No. 4 as atarget for eradication in the Philippines is?a. Poliomyelitisb. Measlesc. Rabiesd. Neonatal tetanus23. May knows that the step in communityorganizing that involves training of potentialleaders in the community is:a. Integrationb. Community organizationc. Community studyd. Core group formation24. Beth a public health nurse takes an active role incommunity participation. What is the primarygoal of community organizing?a. To educate the people regardingcommunity health problemsb. To mobilize the people to resolvecommunity health problemsc. To maximize the community’s resourcesin dealing with health problems.d. To maximize the community’s resourcesin dealing with health problems.25. Tertiary prevention is needed in which stage ofthe natural history of disease?a. Pre-pathogenesisb. Pathogenesisc. Prodromald. Terminal26. The nurse is caring for a primigravid client in thelabor and delivery area. Which condition wouldplace the client at risk for disseminatedintravascular coagulation (DIC)?a. Intrauterine fetal death.b. Placenta accreta.c. Dysfunctional labor.d. Premature rupture of the membranes.27. A fullterm client is in labor. Nurse Betty is awarethat the fetal heart rate would be:a. 80 to 100 beats/minuteb. 100 to 120 beats/minutec. 120 to 160 beats/minuted. 160 to 180 beats/minute28. The skin in the diaper area of a 7 month oldinfant is excoriated and red. Nurse Hazel shouldinstruct the mother to:a. Change the diaper more often.b. Apply talc powder with diaper changes.c. Wash the area vigorously with eachdiaper change.d. Decrease the infant’s fluid intake todecrease saturating diapers.29. Nurse Carla knows that the common cardiacanomalies in children with Down Syndrome (tri-somy 21) is:a. Atrial septal defectb. Pulmonic stenosisc. Ventricular septal defectd. Endocardial cushion defect30. Malou was diagnosed with severe preeclampsiais now receiving I.V. magnesium sulfate. Theadverse effects associated with magnesiumsulfate is:a. Anemiab. Decreased urine outputc. Hyperreflexiad. Increased respiratory rate31. A 23 year old client is having her menstrualperiod every 2 weeks that last for 1 week. Thistype of menstrual pattern is bets defined by:a. Menorrhagiab. Metrorrhagiac. Dyspareuniad. Amenorrhea
  • 7732. Jannah is admitted to the labor and deliveryunit. The critical laboratory result for this clientwould be:a. Oxygen saturationb. Iron binding capacityc. Blood typingd. Serum Calcium33. Nurse Gina is aware that the most commoncondition found during the second-trimester ofpregnancy is:a. Metabolic alkalosisb. Respiratory acidosisc. Mastitisd. Physiologic anemia34. Nurse Lynette is working in the triage area of anemergency department. She sees that severalpediatric clients arrive simultaneously. The clientwho needs to be treated first is:a. A crying 5 year old child with alaceration on his scalp.b. A 4 year old child with a barking coughsand flushed appearance.c. A 3 year old child with Down syndromewho is pale and asleep in his mother’sarms.d. A 2 year old infant with stridorousbreath sounds, sitting up in his mother’sarms and drooling.35. Maureen in her third trimester arrives at theemergency room with painless vaginal bleeding.Which of the following conditions is suspected?a. Placenta previab. Abruptio placentaec. Premature labord. Sexually transmitted disease36. A young child named Richard is suspected ofhaving pinworms. The community nurse collectsa stool specimen to confirm the diagnosis. Thenurse should schedule the collection of thisspecimen for:a. Just before bedtimeb. After the child has been bathec. Any time during the dayd. Early in the morning37. In doing a child’s admission assessment, NurseBetty should be alert to note which signs orsymptoms of chronic lead poisoning?a. Irritability and seizuresb. Dehydration and diarrheac. Bradycardia and hypotensiond. Petechiae and hematuria38. To evaluate a woman’s understanding about theuse of diaphragm for family planning, NurseTrish asks her to explain how she will use theappliance. Which response indicates a need forfurther health teaching?a. “I should check the diaphragm carefullyfor holes every time I use it”b. “I may need a different size ofdiaphragm if I gain or lose weight morethan 20 pounds”c. “The diaphragm must be left in place foratleast 6 hours after intercourse”d. “I really need to use the diaphragm andjelly most during the middle of mymenstrual cycle”.39. Hypoxia is a common complication oflaryngotracheobronchitis. Nurse Oliver shouldfrequently assess a child withlaryngotracheobronchitis for:a. Droolingb. Muffled voicec. Restlessnessd. Low-grade fever40. How should Nurse Michelle guide a child who isblind to walk to the playroom?a. Without touching the child, talkcontinuously as the child walks down thehall.b. Walk one step ahead, with the child’shand on the nurse’s elbow.c. Walk slightly behind, gently guiding thechild forward.d. Walk next to the child, holding thechild’s hand.41. When assessing a newborn diagnosed withductus arteriosus, Nurse Olivia should expectthat the child most likely would have an:a. Loud, machinery-like murmur.b. Bluish color to the lips.c. Decreased BP reading in the upperextremitiesd. Increased BP reading in the upperextremities.42. The reason nurse May keeps the neonate in aneutral thermal environment is that when a
  • 78newborn becomes too cool, the neonaterequires:a. Less oxygen, and the newborn’smetabolic rate increases.b. More oxygen, and the newborn’smetabolic rate decreases.c. More oxygen, and the newborn’smetabolic rate increases.d. Less oxygen, and the newborn’smetabolic rate decreases.43. Before adding potassium to an infant’s I.V. line,Nurse Ron must be sure to assess whether thisinfant has:a. Stable blood pressureb. Patant fontanellesc. Moro’s reflexd. Voided44. Nurse Carla should know that the most commoncausative factor of dermatitis in infants andyounger children is:a. Baby oilb. Baby lotionc. Laundry detergentd. Powder with cornstarch45. During tube feeding, how far above an infant’sstomach should the nurse hold the syringe withformula?a. 6 inchesb. 12 inchesc. 18 inchesd. 24 inches46. In a mothers’ class, Nurse Lhynnete discussedchildhood diseases such as chicken pox. Whichof the following statements about chicken pox iscorrect?a. The older one gets, the more susceptiblehe becomes to the complications ofchicken pox.b. A single attack of chicken pox willprevent future episodes, includingconditions such as shingles.c. To prevent an outbreak in thecommunity, quarantine may be imposedby health authorities.d. Chicken pox vaccine is best given whenthere is an impending outbreak in thecommunity.47. Barangay Pinoy had an outbreak of Germanmeasles. To prevent congenital rubella, what isthe BEST advice that you can give to women inthe first trimester of pregnancy in the barangayPinoy?a. Advise them on the signs of Germanmeasles.b. Avoid crowded places, such as marketsand movie houses.c. Consult at the health center whererubella vaccine may be given.d. Consult a physician who may give themrubella immunoglobulin.48. Myrna a public health nurse knows that todetermine possible sources of sexuallytransmitted infections, the BEST method thatmay be undertaken is:a. Contact tracingb. Community surveyc. Mass screening testsd. Interview of suspects49. A 33-year old female client came forconsultation at the health center with the chiefcomplaint of fever for a week. Accompanyingsymptoms were muscle pains and body malaise.A week after the start of fever, the client notedyellowish discoloration of his sclera. Historyshowed that he waded in flood waters about 2weeks before the onset of symptoms. Based onher history, which disease condition will yoususpect?a. Hepatitis Ab. Hepatitis Bc. Tetanusd. Leptospirosis50. Mickey a 3-year old client was brought to thehealth center with the chief complaint of severediarrhea and the passage of “rice water” stools.The client is most probably suffering from whichcondition?a. Giardiasisb. Cholerac. Amebiasisd. Dysentery51. The most prevalent form of meningitis amongchildren aged 2 months to 3 years is caused bywhich microorganism?a. Hemophilus influenzaeb. Morbillivirus
  • 79c. Steptococcus pneumoniaed. Neisseria meningitidis52. The student nurse is aware that thepathognomonic sign of measles is Koplik’s spotand you may see Koplik’s spot by inspecting the:a. Nasal mucosab. Buccal mucosac. Skin on the abdomend. Skin on neck53. Angel was diagnosed as having Dengue fever.You will say that there is slow capillary refillwhen the color of the nailbed that you presseddoes not return within how many seconds?a. 3 secondsb. 6 secondsc. 9 secondsd. 10 seconds54. In Integrated Management of Childhood Illness,the nurse is aware that the severe conditionsgenerally require urgent referral to a hospital.Which of the following severe conditions DOESNOT always require urgent referral to a hospital?a. Mastoiditisb. Severe dehydrationc. Severe pneumoniad. Severe febrile disease55. Myrna a public health nurse will conductoutreach immunization in a barangay Masaywith a population of about 1500. The estimatednumber of infants in the barangay would be:a. 45 infantsb. 50 infantsc. 55 infantsd. 65 infants56. The community nurse is aware that thebiological used in Expanded Program onImmunization (EPI) should NOT be stored in thefreezer?a. DPTb. Oral polio vaccinec. Measles vaccined. MMR57. It is the most effective way of controllingschistosomiasis in an endemic area?a. Use of molluscicidesb. Building of foot bridgesc. Proper use of sanitary toiletsd. Use of protective footwear, such asrubber boots58. Several clients is newly admitted and diagnosedwith leprosy. Which of the following clientsshould be classified as a case of multibacillaryleprosy?a. 3 skin lesions, negative slit skin smearb. 3 skin lesions, positive slit skin smearc. 5 skin lesions, negative slit skin smeard. 5 skin lesions, positive slit skin smear59. Nurses are aware that diagnosis of leprosy ishighly dependent on recognition of symptoms.Which of the following is an early sign ofleprosy?a. Macular lesionsb. Inability to close eyelidsc. Thickened painful nervesd. Sinking of the nosebridge60. Marie brought her 10 month old infant forconsultation because of fever, started 4 daysprior to consultation. In determining malariarisk, what will you do?a. Perform a tourniquet test.b. Ask where the family resides.c. Get a specimen for blood smear.d. Ask if the fever is present every day.61. Susie brought her 4 years old daughter to theRHU because of cough and colds. Following theIMCI assessment guide, which of the following isa danger sign that indicates the need for urgentreferral to a hospital?a. Inability to drinkb. High grade feverc. Signs of severe dehydrationd. Cough for more than 30 days62. Jimmy a 2-year old child revealed “baggy pants”.As a nurse, using the IMCI guidelines, how willyou manage Jimmy?a. Refer the child urgently to a hospital forconfinement.b. Coordinate with the social worker toenroll the child in a feeding program.c. Make a teaching plan for the mother,focusing on menu planning for her child.d. Assess and treat the child for healthproblems like infections and intestinalparasitism.
  • 8063. Gina is using Oresol in the management ofdiarrhea of her 3-year old child. She asked youwhat to do if her child vomits. As a nurse you willtell her to:a. Bring the child to the nearest hospitalfor further assessment.b. Bring the child to the health center forintravenous fluid therapy.c. Bring the child to the health center forassessment by the physician.d. Let the child rest for 10 minutes thencontinue giving Oresol more slowly.64. Nikki a 5-month old infant was brought by hismother to the health center because of diarrheafor 4 to 5 times a day. Her skin goes back slowlyafter a skin pinch and her eyes are sunken. Usingthe IMCI guidelines, you will classify this infant inwhich category?a. No signs of dehydrationb. Some dehydrationc. Severe dehydrationd. The data is insufficient.65. Chris a 4-month old infant was brought by hermother to the health center because of cough.His respiratory rate is 42/minute. Using theIntegrated Management of Child Illness (IMCI)guidelines of assessment, his breathing isconsidered as:a. Fastb. Slowc. Normald. Insignificant66. Maylene had just received her 4th dose oftetanus toxoid. She is aware that her baby willhave protection against tetanus fora. 1 yearb. 3 yearsc. 5 yearsd. Lifetime67. Nurse Ron is aware that unused BCG should bediscarded after how many hours ofreconstitution?a. 2 hoursb. 4 hoursc. 8 hoursd. At the end of the day68. The nurse explains to a breastfeeding motherthat breast milk is sufficient for all of the baby’snutrient needs only up to:a. 5 monthsb. 6 monthsc. 1 yeard. 2 years69. Nurse Ron is aware that the gestational age of aconceptus that is considered viable (able to liveoutside the womb) is:a. 8 weeksb. 12 weeksc. 24 weeksd. 32 weeks70. When teaching parents of a neonate the properposition for the neonate’s sleep, the nursePatricia stresses the importance of placing theneonate on his back to reduce the risk of whichof the following?a. Aspirationb. Sudden infant death syndrome (SIDS)c. Suffocationd. Gastroesophageal reflux (GER)71. Which finding might be seen in baby James aneonate suspected of having an infection?a. Flushed cheeksb. Increased temperaturec. Decreased temperatured. Increased activity level72. Baby Jenny who is small-for-gestation is atincreased risk during the transitional period forwhich complication?a. Anemia probably due to chronic fetalhyposiab. Hyperthermia due to decreasedglycogen storesc. Hyperglycemia due to decreasedglycogen storesd. Polycythemia probably due to chronicfetal hypoxia73. Marjorie has just given birth at 42 weeks’gestation. When the nurse assessing theneonate, which physical finding is expected?a. A sleepy, lethargic babyb. Lanugo covering the bodyc. Desquamation of the epidermisd. Vernix caseosa covering the body
  • 8174. After reviewing the Myrna’s maternal history ofmagnesium sulfate during labor, which conditionwould nurse Richard anticipate as a potentialproblem in the neonate?a. Hypoglycemiab. Jitterinessc. Respiratory depressiond. Tachycardia75. Which symptom would indicate the BabyAlexandra was adapting appropriately to extra-uterine life without difficulty?a. Nasal flaringb. Light audible gruntingc. Respiratory rate 40 to 60breaths/minuted. Respiratory rate 60 to 80breaths/minute76. When teaching umbilical cord care for Jennifer anew mother, the nurse Jenny would includewhich information?a. Apply peroxide to the cord with eachdiaper changeb. Cover the cord with petroleum jelly afterbathingc. Keep the cord dry and open to aird. Wash the cord with soap and water eachday during a tub bath.77. Nurse John is performing an assessment on aneonate. Which of the following findings isconsidered common in the healthy neonate?a. Simian creaseb. Conjunctival hemorrhagec. Cystic hygromad. Bulging fontanelle78. Dr. Esteves decides to artificially rupture themembranes of a mother who is on labor.Following this procedure, the nurse Hazel checksthe fetal heart tones for which the followingreasons?a. To determine fetal well-being.b. To assess for prolapsed cordc. To assess fetal positiond. To prepare for an imminent delivery.79. Which of the following would be least likely toindicate anticipated bonding behaviors by newparents?a. The parents’ willingness to touch andhold the new born.b. The parent’s expression of interestabout the size of the new born.c. The parents’ indication that they want tosee the newborn.d. The parents’ interactions with eachother.80. Following a precipitous delivery, examination ofthe clients vagina reveals a fourth-degreelaceration. Which of the following would becontraindicated when caring for this client?a. Applying cold to limit edema during thefirst 12 to 24 hours.b. Instructing the client to use two or moreperipads to cushion the area.c. Instructing the client on the use of sitzbaths if ordered.d. Instructing the client about theimportance of perineal (kegel) exercises.81. A pregnant woman accompanied by herhusband, seeks admission to the labor anddelivery area. She states that shes in labor andsays she attended the facility clinic for prenatalcare. Which question should the nurse Oliver askher first?a. “Do you have any chronic illnesses?”b. “Do you have any allergies?”c. “What is your expected due date?”d. “Who will be with you during labor?”82. A neonate begins to gag and turns a dusky color.What should the nurse do first?a. Calm the neonate.b. Notify the physician.c. Provide oxygen via face mask as orderedd. Aspirate the neonate’s nose and mouthwith a bulb syringe.83. When a client states that her "water broke,"which of the following actions would beinappropriate for the nurse to do?a. Observing the pooling of straw-coloredfluid.b. Checking vaginal discharge with nitrazinepaper.c. Conducting a bedside ultrasound for anamniotic fluid index.d. Observing for flakes of vernix in thevaginal discharge.84. A baby girl is born 8 weeks premature. At birth,she has no spontaneous respirations but is
  • 82successfully resuscitated. Within several hoursshe develops respiratory grunting, cyanosis,tachypnea, nasal flaring, and retractions. Shesdiagnosed with respiratory distress syndrome,intubated, and placed on a ventilator. Whichnursing action should be included in the babysplan of care to prevent retinopathy ofprematurity?a. Cover his eyes while receiving oxygen.b. Keep her body temperature low.c. Monitor partial pressure of oxygen(Pao2) levels.d. Humidify the oxygen.85. Which of the following is normal newborncalorie intake?a. 110 to 130 calories per kg.b. 30 to 40 calories per lb of body weight.c. At least 2 ml per feedingd. 90 to 100 calories per kg86. Nurse John is knowledgeable that usuallyindividual twins will grow appropriately and atthe same rate as singletons until how manyweeks?a. 16 to 18 weeksb. 18 to 22 weeksc. 30 to 32 weeksd. 38 to 40 weeks87. Which of the following classifications applies tomonozygotic twins for whom the cleavage of thefertilized ovum occurs more than 13 days afterfertilization?a. conjoined twinsb. diamniotic dichorionic twinsc. diamniotic monochorionic twind. monoamniotic monochorionic twins88. Tyra experienced painless vaginal bleeding hasjust been diagnosed as having a placenta previa.Which of the following procedures is usuallyperformed to diagnose placenta previa?a. Amniocentesisb. Digital or speculum examinationc. External fetal monitoringd. Ultrasound89. Nurse Arnold knows that the following changesin respiratory functioning during pregnancy isconsidered normal:a. Increased tidal volumeb. Increased expiratory volumec. Decreased inspiratory capacityd. Decreased oxygen consumption90. Emily has gestational diabetes and it is usuallymanaged by which of the following therapy?a. Dietb. Long-acting insulinc. Oral hypoglycemicd. Oral hypoglycemic drug and insulin91. Magnesium sulfate is given to Jemma withpreeclampsia to prevent which of the followingcondition?a. Hemorrhageb. Hypertensionc. Hypomagnesemiad. Seizure92. Cammile with sickle cell anemia has an increasedrisk for having a sickle cell crisis duringpregnancy. Aggressive management of a sicklecell crisis includes which of the followingmeasures?a. Antihypertensive agentsb. Diuretic agentsc. I.V. fluidsd. Acetaminophen (Tylenol) for pain93. Which of the following drugs is the antidote formagnesium toxicity?a. Calcium gluconate (Kalcinate)b. Hydralazine (Apresoline)c. Naloxone (Narcan)d. Rho (D) immune globulin (RhoGAM)94. Marlyn is screened for tuberculosis during herfirst prenatal visit. An intradermal injection ofpurified protein derivative (PPD) of thetuberculin bacilli is given. She is considered tohave a positive test for which of the followingresults?a. An indurated wheal under 10 mm indiameter appears in 6 to 12 hours.b. An indurated wheal over 10 mm indiameter appears in 48 to 72 hours.c. A flat circumcised area under 10 mm indiameter appears in 6 to 12 hours.d. A flat circumcised area over 10 mm indiameter appears in 48 to 72 hours.95. Dianne, 24 year-old is 27 weeks’ pregnantarrives at her physician’s office with complaintsof fever, nausea, vomiting, malaise, unilateral
  • 83flank pain, and costovertebral angle tenderness.Which of the following diagnoses is most likely?a. Asymptomatic bacteriuriab. Bacterial vaginosisc. Pyelonephritisd. Urinary tract infection (UTI)96. Rh isoimmunization in a pregnant clientdevelops during which of the followingconditions?a. Rh-positive maternal blood crosses intofetal blood, stimulating fetal antibodies.b. Rh-positive fetal blood crosses intomaternal blood, stimulating maternalantibodies.c. Rh-negative fetal blood crosses intomaternal blood, stimulating maternalantibodies.d. Rh-negative maternal blood crosses intofetal blood, stimulating fetal antibodies.97. To promote comfort during labor, the nurse Johnadvises a client to assume certain positions andavoid others. Which position may causematernal hypotension and fetal hypoxia?a. Lateral positionb. Squatting positionc. Supine positiond. Standing position98. Celeste who used heroin during her pregnancydelivers 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 thinlips.d. Congenital defects such as limbanomalies.99. The uterus returns to the pelvic cavity in whichof 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, hasjust completed a difficult, forceps-assisteddelivery of twins. Her labor was unusuallylong and required oxytocin (Pitocin)augmentation. The nurse whos caring for hershould stay alert for:a. Uterine inversionb. Uterine atonyc. Uterine involutiond. Uterine discomfort
  • 84Answers and Rationale – Community HealthNursing and Care of the Mother and Child1. Answer: (A) InevitableRationale: An inevitable abortion is terminationof pregnancy that cannot be prevented.Moderate to severe bleeding with mildcramping and cervical dilation would be notedin this type of abortion.2. Answer: (B) History of syphilisRationale: Maternal infections such as syphilis,toxoplasmosis, and rubella are causes ofspontaneous abortion.3. Answer: (C) Monitoring apical pulseRationale: Nursing care for the client with apossible ectopic pregnancy is focused onpreventing or identifying hypovolemic shockand controlling pain. An elevated pulse rate isan indicator of shock.4. Answer: (B) Increased caloric intakeRationale: Glucose crosses the placenta, butinsulin does not. High fetal demands forglucose, combined with the insulin resistancecaused by hormonal changes in the last half ofpregnancy can result in elevation of maternalblood glucose levels. This increases themother’s demand for insulin and is referred toas the diabetogenic effect of pregnancy.5. Answer: (A) Excessive fetal activity.Rationale: The most common signs andsymptoms of hydatidiform mole includeselevated levels of human chorionicgonadotropin, vaginal bleeding, larger thannormal uterus for gestational age, failure todetect fetal heart activity even with sensitiveinstruments, excessive nausea and vomiting,and early development of pregnancy-inducedhypertension. Fetal activity would not be noted.6. Answer: (B) Absent patellar reflexesRationale: Absence of patellar reflexes is anindicator of hypermagnesemia, which requiresadministration of calcium gluconate.7. Answer: (C) Presenting part in 2 cm below theplane of the ischial spines.Rationale: Fetus at station plus two indicatesthat the presenting part is 2 cm below theplane of the ischial spines.8. Answer: (A) Contractions every 1 ½ minuteslasting 70-80 seconds.Rationale: Contractions every 1 ½ minuteslasting 70-80 seconds, is indicative ofhyperstimulation of the uterus, which couldresult in injury to the mother and the fetus ifPitocin is not discontinued.9. Answer: (C) EKG tracingsRationale: A potential side effect of calciumgluconate administration is cardiac arrest.Continuous monitoring of cardiac activity (EKG)throught administration of calcium gluconate isan essential part of care.10. Answer: (D) First low transverse caesarean wasfor breech position. Fetus in this pregnancy is ina vertex presentation.Rationale: This type of client has no obstetricalindication for a caesarean section as she didwith her first caesarean delivery.11. Answer: (A) Talk to the mother first and then tothe toddler.Rationale: When dealing with a crying toddler,the best approach is to talk to the mother andignore the toddler first. This approach helps thetoddler get used to the nurse before sheattempts any procedures. It also gives thetoddler an opportunity to see that the mothertrusts the nurse.12. Answer: (D) Place the infant’s arms in softelbow restraints.Rationale: Soft restraints from the upper arm tothe wrist prevent the infant from touching herlip but allow him to hold a favorite item such asa blanket. Because they could damage theoperative site, such as objects as pacifiers,suction catheters, and small spoons shouldn’tbe placed in a baby’s mouth after cleft repair. Ababy in a prone position may rub her face onthe sheets and traumatize the operative site.The suture line should be cleaned gently toprevent infection, which could interfere withhealing and damage the cosmetic appearanceof the repair.13. Answer: (B) Allow the infant to rest beforefeeding.Rationale: Because feeding requires so muchenergy, an infant with heart failure should restbefore feeding.14. Answer: (C) Iron-rich formula only.Rationale: The infants at age 5 months shouldreceive iron-rich formula and that theyshouldn’t receive solid food, even baby fooduntil age 6 months.15. Answer: (D) 10 monthsRationale: A 10 month old infant can sit aloneand understands object permanence, so hewould look for the hidden toy. At age 4 to 6
  • 85months, infants can’t sit securely alone. At age8 months, infants can sit securely alone butcannot understand the permanence of objects.16. Answer: (D) Public health nursing focuses onpreventive, not curative, services.Rationale: The catchments area in PHN consistsof a residential community, many of whom arewell individuals who have greater need forpreventive rather than curative services.17. Answer: (B) EfficiencyRationale: Efficiency is determining whether thegoals were attained at the least possible cost.18. Answer: (D) Rural Health UnitRationale: R.A. 7160 devolved basic healthservices to local government units (LGU’s ). Thepublic health nurse is an employee of the LGU.19. Answer: (A) MayorRationale: The local executive serves as thechairman of the Municipal Health Board.20. Answer: (A) 1Rationale: Each rural health midwife is given apopulation assignment of about 5,000.21. Answer: (B) Health education and communityorganizing are necessary in providingcommunity health services. Rationale: Thecommunity health nurse develops the healthcapability of people through health educationand community organizing activities.22. Answer: (B) MeaslesRationale: Presidential Proclamation No. 4 is onthe Ligtas Tigdas Program.23. Answer: (D) Core group formationRationale: In core group formation, the nurse isable to transfer the technology of communityorganizing to the potential or informalcommunity leaders through a training program.24. Answer: (D) To maximize the community’sresources in dealing with health problems.Rationale: Community organizing is adevelopmental service, with the goal ofdeveloping the people’s self-reliance in dealingwith community health problems. A, B and Care objectives of contributory objectives to thisgoal.25. Answer: (D) TerminalRationale: Tertiary prevention involvesrehabilitation, prevention of permanentdisability and disability limitations appropriatefor convalescents, the disabled, complicatedcases and the terminally ill (those in theterminal stage of a disease).26. Answer: (A) Intrauterine fetal death.Rationale: Intrauterine fetal death, abruptioplacentae, septic shock, and amniotic fluidembolism may trigger normal clottingmechanisms; if clotting factors are depleted,DIC may occur. Placenta accreta, dysfunctionallabor, and premature rupture of themembranes arent associated with DIC.27. Answer: (C) 120 to 160 beats/minuteRationale: A rate of 120 to 160 beats/minute inthe fetal heart appropriate for filling the heartwith blood and pumping it out to the system.28. Answer: (A) Change the diaper more often.Rationale: Decreasing the amount of time theskin comes contact with wet soiled diapers willhelp heal the irritation.29. Answer: (D) Endocardial cushion defectRationale: Endocardial cushion defects are seenmost in children with Down syndrome,asplenia, or polysplenia.30. Answer: (B) Decreased urine outputRationale: Decreased urine output may occur inclients receiving I.V. magnesium and should bemonitored closely to keep urine output atgreater than 30 ml/hour, because magnesium isexcreted through the kidneys and can easilyaccumulate to toxic levels.31. Answer: (A) MenorrhagiaRationale: Menorrhagia is an excessivemenstrual period.32. Answer: (C) Blood typingRationale: Blood type would be a critical valueto have because the risk of blood loss is alwaysa potential complication during the labor anddelivery process. Approximately 40% of awoman’s cardiac output is delivered to theuterus, therefore, blood loss can occur quiterapidly in the event of uncontrolled bleeding.33. Answer: (D) Physiologic anemiaRationale: Hemoglobin values and hematocritdecrease during pregnancy as the increase inplasma volume exceeds the increase in redblood cell production.34. Answer: (D) A 2 year old infant with stridorousbreath sounds, sitting up in his mother’s armsand drooling.Rationale: The infant with the airwayemergency should be treated first, because ofthe risk of epiglottitis.35. Answer: (A) Placenta previaRationale: Placenta previa with painless vaginalbleeding.36. Answer: (D) Early in the morning
  • 86Rationale: Based on the nurse’s knowledge ofmicrobiology, the specimen should be collectedearly in the morning. The rationale for thistiming is that, because the female worm layseggs at night around the perineal area, the firstbowel movement of the day will yield the bestresults. The specific type of stool specimenused in the diagnosis of pinworms is called thetape test.37. Answer: (A) Irritability and seizuresRationale: Lead poisoning primarily affects theCNS, causing increased intracranial pressure.This condition results in irritability and changesin level of consciousness, as well as seizuredisorders, hyperactivity, and learningdisabilities.38. Answer: (D) “I really need to use the diaphragmand jelly most during the middle of mymenstrual cycle”.Rationale: The woman must understand that,although the “fertile” period is approximatelymid-cycle, hormonal variations do occur andcan result in early or late ovulation. To beeffective, the diaphragm should be insertedbefore every intercourse.39. Answer: (C) RestlessnessRationale: In a child, restlessness is the earliestsign of hypoxia. Late signs of hypoxia in a childare associated with a change in color, such aspallor or cyanosis.40. Answer: (B) Walk one step ahead, with thechild’s hand on the nurse’s elbow.Rationale: This procedure is generallyrecommended to follow in guiding a personwho is blind.41. Answer: (A) Loud, machinery-like murmur.Rationale: A loud, machinery-like murmur is acharacteristic finding associated with patentductus arteriosus.42. Answer: (C) More oxygen, and the newborn’smetabolic rate increases.Rationale: When cold, the infant requires moreoxygen and there is an increase in metabolicrate. Non-shievering thermogenesis is acomplex process that increases the metabolicrate and rate of oxygen consumption,therefore, the newborn increase heatproduction.43. Answer: (D) VoidedRationale: Before administering potassium I.V.to any client, the nurse must first check that theclient’s kidneys are functioning and that theclient is voiding. If the client is not voiding, thenurse should withhold the potassium and notifythe physician.44. Answer: (c) Laundry detergentRationale: Eczema or dermatitis is an allergicskin reaction caused by an offending allergen.The topical allergen that is the most commoncausative factor is laundry detergent.45. Answer: (A) 6 inchesRationale: This distance allows for easy flow ofthe formula by gravity, but the flow will be slowenough not to overload the stomach toorapidly.46. Answer: (A) The older one gets, the moresusceptible he becomes to the complications ofchicken pox.Rationale: Chicken pox is usually more severe inadults than in children. Complications, such aspneumonia, are higher in incidence in adults.47. Answer: (D) Consult a physician who may givethem rubella immunoglobulin.Rationale: Rubella vaccine is made up ofattenuated German measles viruses. This iscontraindicated in pregnancy. Immune globulin,a specific prophylactic against German measles,may be given to pregnant women.48. Answer: (A) Contact tracingRationale: Contact tracing is the most practicaland reliable method of finding possible sourcesof person-to-person transmitted infections,such as sexually transmitted diseases.49. Answer: (D) LeptospirosisRationale: Leptospirosis is transmitted throughcontact with the skin or mucous membranewith water or moist soil contaminated withurine of infected animals, like rats.50. Answer: (B) CholeraRationale: Passage of profuse watery stools isthe major symptom of cholera. Both amebicand bacillary dysentery are characterized by thepresence of blood and/or mucus in the stools.Giardiasis is characterized by fat malabsorptionand, therefore, steatorrhea.51. Answer: (A) Hemophilus influenzaeRationale: Hemophilus meningitis is unusualover the age of 5 years. In developing countries,the peak incidence is in children less than 6months of age. Morbillivirus is the etiology ofmeasles. Streptococcus pneumonia andNeisseria meningitidis may cause meningitis,but age distribution is not specific in youngchildren.52. Answer: (B) Buccal mucosa
  • 87Rationale: Koplik’s spot may be seen on themucosa of the mouth or the throat.53. Answer: (A) 3 secondsRationale: Adequate blood supply to the areaallows the return of the color of the nailbedwithin 3 seconds.54. Answer: (B) Severe dehydrationRationale: The order of priority in themanagement of severe dehydration is asfollows: intravenous fluid therapy, referral to afacility where IV fluids can be initiated within 30minutes, Oresol or nasogastric tube. When theforegoing measures are not possible oreffective, then urgent referral to the hospital isdone.55. Answer: (A) 45 infantsRationale: To estimate the number of infants,multiply total population by 3%.56. Answer: (A) DPTRationale: DPT is sensitive to freezing. Theappropriate storage temperature of DPT is 2 to8° C only. OPV and measles vaccine are highlysensitive to heat and require freezing. MMR isnot an immunization in the Expanded Programon Immunization.57. Answer: (C) Proper use of sanitary toiletsRationale: The ova of the parasite get out of thehuman body together with feces. Cutting thecycle at this stage is the most effective way ofpreventing the spread of the disease tosusceptible hosts.58. Answer: (D) 5 skin lesions, positive slit skinsmearRationale: A multibacillary leprosy case is onewho has a positive slit skin smear and at least 5skin lesions.59. Answer: (C) Thickened painful nervesRationale: The lesion of leprosy is not macular.It is characterized by a change in skin color(either reddish or whitish) and loss of sensation,sweating and hair growth over the lesion.Inability to close the eyelids (lagophthalmos)and sinking of the nosebridge are latesymptoms.60. Answer: (B) Ask where the family resides.Rationale: Because malaria is endemic, the firstquestion to determine malaria risk is where theclient’s family resides. If the area of residence isnot a known endemic area, ask if the child hadtraveled within the past 6 months, where shewas brought and whether she stayed overnightin that area.61. Answer: (A) Inability to drinkRationale: A sick child aged 2 months to 5 yearsmust be referred urgently to a hospital ifhe/she has one or more of the following signs:not able to feed or drink, vomits everything,convulsions, abnormally sleepy or difficult toawaken.62. Answer: (A) Refer the child urgently to ahospital for confinement.Rationale: “Baggy pants” is a sign of severemarasmus. The best management is urgentreferral to a hospital.63. Answer: (D) Let the child rest for 10 minutesthen continue giving Oresol more slowly.Rationale: If the child vomits persistently, thatis, he vomits everything that he takes in, he hasto be referred urgently to a hospital. Otherwise,vomiting is managed by letting the child rest for10 minutes and then continuing with Oresoladministration. Teach the mother to give Oresolmore slowly.64. Answer: (B) Some dehydrationRationale: Using the assessment guidelines ofIMCI, a child (2 months to 5 years old) withdiarrhea is classified as having SOMEDEHYDRATION if he shows 2 or more of thefollowing signs: restless or irritable, sunkeneyes, the skin goes back slow after a skin pinch.65. Answer: (C) NormalRationale: In IMCI, a respiratory rate of50/minute or more is fast breathing for aninfant aged 2 to 12 months.66. Answer: (A) 1 yearRationale: The baby will have passive naturalimmunity by placental transfer of antibodies.The mother will have active artificial immunitylasting for about 10 years. 5 doses will give themother lifetime protection.67. Answer: (B) 4 hoursRationale: While the unused portion of otherbiologicals in EPI may be given until the end ofthe day, only BCG is discarded 4 hours afterreconstitution. This is why BCG immunization isscheduled only in the morning.68. Answer: (B) 6 monthsRationale: After 6 months, the baby’s nutrientneeds, especially the baby’s iron requirement,can no longer be provided by mother’s milkalone.69. Answer: (C) 24 weeksRationale: At approximately 23 to 24 weeks’gestation, the lungs are developed enough tosometimes maintain extrauterine life. The lungsare the most immature system during the
  • 88gestation period. Medical care for prematurelabor begins much earlier (aggressively at 21weeks’ gestation)70. Answer: (B) Sudden infant death syndrome(SIDS)Rationale: Supine positioning is recommendedto reduce the risk of SIDS in infancy. The risk ofaspiration is slightly increased with the supineposition. Suffocation would be less likely withan infant supine than prone and the positionfor GER requires the head of the bed to beelevated.71. Answer: (C) Decreased temperatureRationale: Temperature instability, especiallywhen it results in a low temperature in theneonate, may be a sign of infection. Theneonate’s color often changes with an infectionprocess but generally becomes ashen ormottled. The neonate with an infection willusually show a decrease in activity level orlethargy.72. Answer: (D) Polycythemia probably due tochronic fetal hypoxiaRationale: The small-for-gestation neonate is atrisk for developing polycythemia during thetransitional period in an attempt to decreasehypoxia. The neonates are also at increased riskfor developing hypoglycemia and hypothermiadue to decreased glycogen stores.73. Answer: (C) Desquamation of the epidermisRationale: Postdate fetuses lose the vernixcaseosa, and the epidermis may becomedesquamated. These neonates are usually veryalert. Lanugo is missing in the postdateneonate.74. Answer: (C) Respiratory depressionRationale: Magnesium sulfate crosses theplacenta and adverse neonatal effects arerespiratory depression, hypotonia, andbradycardia. The serum blood sugar isn’taffected by magnesium sulfate. The neonatewould be floppy, not jittery.75. Answer: (C) Respiratory rate 40 to 60breaths/minuteRationale: A respiratory rate 40 to 60breaths/minute is normal for a neonate duringthe transitional period. Nasal flaring,respiratory rate more than 60 breaths/minute,and audible grunting are signs of respiratorydistress.76. Answer: (C) Keep the cord dry and open to airRationale: Keeping the cord dry and open to airhelps reduce infection and hastens drying.Infants aren’t given tub bath but are spongedoff until the cord falls off. Petroleum jellyprevents the cord from drying and encouragesinfection. Peroxide could be painful and isn’trecommended.77. Answer: (B) Conjunctival hemorrhageRationale: Conjunctival hemorrhages arecommonly seen in neonates secondary to thecranial pressure applied during the birthprocess. Bulging fontanelles are a sign ofintracranial pressure. Simian creases arepresent in 40% of the neonates with trisomy 21.Cystic hygroma is a neck mass that can affectthe airway.78. Answer: (B) To assess for prolapsed cordRationale: After a client has an amniotomy, thenurse should assure that the cord isntprolapsed and that the baby tolerated theprocedure well. The most effective way to dothis is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetalposition is determined by vaginal examination.Artificial rupture of membranes doesntindicate an imminent delivery.79. Answer: (D) The parents’ interactions with eachother.Rationale: Parental interaction will provide thenurse with a good assessment of the stability ofthe familys home life but it has no indicationfor parental bonding. Willingness to touch andhold the newborn, expressing interest aboutthe newborns size, and indicating a desire tosee the newborn are behaviors indicatingparental bonding.80. Answer: (B) Instructing the client to use two ormore peripads to cushion the areaRationale: Using two or more peripads woulddo little to reduce the pain or promote perinealhealing. Cold applications, sitz baths, and Kegelexercises are important measures when theclient has a fourth-degree laceration.81. Answer: (C) “What is your expected due date?”Rationale: When obtaining the history of aclient who may be in labor, the nurses highestpriority is to determine her current status,particularly her due date, gravidity, and parity.Gravidity and parity affect the duration of laborand the potential for labor complications. Later,the nurse should ask about chronic illnesses,allergies, and support persons.82. Answer: (D) Aspirate the neonate’s nose andmouth with a bulb syringe.
  • 89Rationale: The nurses first action should be toclear the neonates airway with a bulb syringe.After the airway is clear and the neonates colorimproves, the nurse should comfort and calmthe neonate. If the problem recurs or theneonates color doesnt improve readily, thenurse should notify the physician.Administering oxygen when the airway isntclear would be ineffective.83. Answer: (C) Conducting a bedside ultrasoundfor an amniotic fluid index.Rationale: It isnt within a nurses scope ofpractice to perform and interpret a bedsideultrasound under these conditions and withoutspecialized training. Observing for pooling ofstraw-colored fluid, checking vaginal dischargewith nitrazine paper, and observing for flakes ofvernix are appropriate assessments fordetermining whether a client has rupturedmembranes.84. Answer: (C) Monitor partial pressure of oxygen(Pao2) levels.Rationale: Monitoring PaO2 levels and reducingthe oxygen concentration to keep PaO2 withinnormal limits reduces the risk of retinopathy ofprematurity in a premature infant receivingoxygen. Covering the infants eyes andhumidifying the oxygen dont reduce the risk ofretinopathy of prematurity. Because coolingincreases the risk of acidosis, the infant shouldbe kept warm so that his respiratory distressisnt aggravated.85. Answer: (A) 110 to 130 calories per kg.Rationale: Calories per kg is the accepted wayof determined appropriate nutritional intakefor a newborn. The recommended calorierequirement is 110 to 130 calories per kg ofnewborn body weight. This level will maintain aconsistent blood glucose level and provideenough calories for continued growth anddevelopment.86. Answer: (C) 30 to 32 weeksRationale: Individual twins usually grow at thesame rate as singletons until 30 to 32 weeks’gestation, then twins don’t’ gain weight asrapidly as singletons of the same gestationalage. The placenta can no longer keep pace withthe nutritional requirements of both fetusesafter 32 weeks, so there’s some growthretardation in twins if they remain in utero at38 to 40 weeks.87. Answer: (A) conjoined twinsRationale: The type of placenta that develops inmonozygotic twins depends on the time atwhich cleavage of the ovum occurs. Cleavage inconjoined twins occurs more than 13 days afterfertilization. Cleavage that occurs less than 3day after fertilization results in diamnioticdicchorionic twins. Cleavage that occursbetween days 3 and 8 results in diamnioticmonochorionic twins. Cleavage that occursbetween days 8 to 13 result in monoamnioticmonochorionic twins.88. Answer: (D) UltrasoundRationale: Once the mother and the fetus arestabilized, ultrasound evaluation of theplacenta should be done to determine thecause of the bleeding. Amniocentesis iscontraindicated in placenta previa. A digital orspeculum examination shouldn’t be done asthis may lead to severe bleeding orhemorrhage. External fetal monitoring won’tdetect a placenta previa, although it will detectfetal distress, which may result from blood lossor placenta separation.89. Answer: (A) Increased tidal volumeRationale: A pregnant client breathes deeper,which increases the tidal volume of gas movedin and out of the respiratory tract with eachbreath. The expiratory volume and residualvolume decrease as the pregnancy progresses.The inspiratory capacity increases duringpregnancy. The increased oxygen consumptionin the pregnant client is 15% to 20% greaterthan in the nonpregnant state.90. Answer: (A) DietRationale: Clients with gestational diabetes areusually managed by diet alone to control theirglucose intolerance. Oral hypoglycemic drugsare contraindicated in pregnancy. Long-actinginsulin usually isn’t needed for blood glucosecontrol in the client with gestational diabetes.91. Answer: (D) SeizureRationale: The anticonvulsant mechanism ofmagnesium is believes to depress seizure foci inthe brain and peripheral neuromuscularblockade. Hypomagnesemia isn’t acomplication of preeclampsia. Antihypertensivedrug other than magnesium are preferred forsustained hypertension. Magnesium doesn’thelp prevent hemorrhage in preeclampticclients.92. Answer: (C) I.V. fluidsRationale: A sickle cell crisis during pregnancy isusually managed by exchange transfusion
  • 90oxygen, and L.V. Fluids. The client usually needsa stronger analgesic than acetaminophen tocontrol the pain of a crisis. Antihypertensivedrugs usually aren’t necessary. Diureticwouldn’t be used unless fluid overload resulted.93. Answer: (A) Calcium gluconate (Kalcinate)Rationale: Calcium gluconate is the antidote formagnesium toxicity. Ten milliliters of 10%calcium gluconate is given L.V. push over 3 to 5minutes. Hydralazine is given for sustainedelevated blood pressure in preeclamptic clients.Rho (D) immune globulin is given to womenwith Rh-negative blood to prevent antibodyformation from RH-positive conceptions.Naloxone is used to correct narcotic toxicity.94. Answer: (B) An indurated wheal over 10 mm indiameter appears in 48 to 72 hours.Rationale: A positive PPD result would be anindurated wheal over 10 mm in diameter thatappears in 48 to 72 hours. The area must be araised wheal, not a flat circumcised area to beconsidered positive.95. Answer: (C) PyelonephritisRationale The symptoms indicate acutepyelonephritis, a serious condition in apregnant client. UTI symptoms include dysuria,urgency, frequency, and suprapubictenderness. Asymptomatic bacteriuria doesn’tcause symptoms. Bacterial vaginosis causesmilky white vaginal discharge but no systemicsymptoms.96. Answer: (B) Rh-positive fetal blood crosses intomaternal blood, stimulating maternalantibodies.Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternalcirculation and stimulate maternal antibodyproduction. In subsequent pregnancies with Rh-positive fetuses, maternal antibodies may crossback into the fetal circulation and destroy thefetal blood cells.97. Answer: (C) Supine positionRationale: The supine position causescompression of the clients aorta and inferiorvena cava by the fetus. This, in turn, inhibitsmaternal circulation, leading to maternalhypotension and, ultimately, fetal hypoxia. Theother positions promote comfort and aid laborprogress. For instance, the lateral, or side-lying,position improves maternal and fetalcirculation, enhances comfort, increasesmaternal relaxation, reduces muscle tension,and eliminates pressure points. The squattingposition promotes comfort by taking advantageof gravity. The standing position also takesadvantage of gravity and aligns the fetus withthe pelvic angle.98. Answer: (B) Irritability and poor sucking.Rationale: Neonates of heroin-addictedmothers are physically dependent on the drugand experience withdrawal when the drug is nolonger supplied. Signs of heroin withdrawalinclude irritability, poor sucking, andrestlessness. Lethargy isnt associated withneonatal heroin addiction. A flattened nose,small eyes, and thin lips are seen in infants withfetal alcohol syndrome. Heroin use duringpregnancy hasnt been linked to specificcongenital anomalies.99. Answer: (A) 7th to 9th day postpartumRationale: The normal involutional processreturns the uterus to the pelvic cavity in 7 to 9days. A significant involutional complication isthe failure of the uterus to return to the pelviccavity within the prescribed time period. This isknown as subinvolution.100. Answer: (B) Uterine atonyRationale: Multiple fetuses, extended laborstimulation with oxytocin, and traumaticdelivery commonly are associated with uterineatony, which may lead to postpartumhemorrhage. Uterine inversion may precede orfollow delivery and commonly results fromapparent excessive traction on the umbilicalcord and attempts to deliver the placentamanually. Uterine involution and some uterinediscomfort are normal after delivery.
  • 91TEST III - Care of Clients with Physiologic andPsychosocial Alterations1. Nurse Michelle should know that the drainage isnormal 4 days after a sigmoid colostomy whenthe stool is:a. Green liquidb. Solid formedc. Loose, bloodyd. Semiformed2. Where would nurse Kristine place the call lightfor a male client with a right-sided brain attackand left homonymous hemianopsia?a. On the client’s right sideb. On the client’s left sidec. Directly in front of the clientd. Where the client like3. A male client is admitted to the emergencydepartment following an accident. What are thefirst nursing actions of the nurse?a. Check respiration, circulation,neurological response.b. Align the spine, check pupils, and checkfor hemorrhage.c. Check respirations, stabilize spine, andcheck circulation.d. Assess level of consciousness andcirculation.4. In evaluating the effect of nitroglycerin, NurseArthur should know that it reduces preload andrelieves angina by:a. Increasing contractility and slowingheart rate.b. Increasing AV conduction and heart rate.c. Decreasing contractility and oxygenconsumption.d. Decreasing venous return throughvasodilation.5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the siderails of the bed and unresponsive to shaking orshouting. Which is the nurse next action?a. Call for help and note the time.b. Clear the airwayc. Give two sharp thumps to theprecordium, and check the pulse.d. Administer two quick blows.6. Nurse Monett is caring for a client recoveringfrom gastro-intestinal bleeding. The nurseshould:a. Plan care so the client can receive 8hours of uninterrupted sleep each night.b. Monitor vital signs every 2 hours.c. Make sure that the client takes food andmedications at prescribed intervals.d. Provide milk every 2 to 3 hours.7. A male client was on warfarin (Coumadin) beforeadmission, and has been receiving heparin I.V.for 2 days. The partial thromboplastin time (PTT)is 68 seconds. What should Nurse Carla do?a. Stop the I.V. infusion of heparin andnotify the physician.b. Continue treatment as ordered.c. Expect the warfarin to increase the PTT.d. Increase the dosage, because the level islower than normal.8. A client undergone ileostomy, when should thedrainage appliance be applied to the stoma?a. 24 hours later, when edema hassubsided.b. In the operating room.c. After the ileostomy begin to function.d. When the client is able to begin self-careprocedures.9. A client undergone spinal anesthetic, it will beimportant that the nurse immediately positionthe client in:a. On the side, to prevent obstruction ofairway by tongue.b. Flat on back.c. On the back, with knees flexed 15degrees.d. Flat on the stomach, with the headturned to the side.10. While monitoring a male client several hoursafter a motor vehicle accident, whichassessment data suggest increasing intracranialpressure?a. Blood pressure is decreased from160/90 to 110/70.b. Pulse is increased from 87 to 95, with anoccasional skipped beat.c. The client is oriented when arousedfrom sleep, and goes back to sleepimmediately.
  • 92d. The client refuses dinner because ofanorexia.11. Mrs. Cruz, 80 years old is diagnosed withpneumonia. Which of the following symptomsmay appear first?a. Altered mental status and dehydrationb. Fever and chillsc. Hemoptysis and Dyspnead. Pleuritic chest pain and cough12. A male client has active tuberculosis (TB). Whichof the following symptoms will be exhibit?a. Chest and lower back painb. Chills, fever, night sweats, andhemoptysisc. Fever of more than 104°F (40°C) andnausead. Headache and photophobia13. Mark, a 7-year-old client is brought to theemergency department. He’s tachypneic andafebrile and has a respiratory rate of 36breaths/minute and has a nonproductive cough.He recently had a cold. Form this history; theclient may have which of the followingconditions?a. Acute asthmab. Bronchial pneumoniac. Chronic obstructive pulmonary disease(COPD)d. Emphysema14. Marichu was given morphine sulfate for pain.She is sleeping and her respiratory rate is 4breaths/minute. If action isn’t taken quickly, shemight have which of the following reactions?a. Asthma attackb. Respiratory arrestc. Seizured. Wake up on his own15. A 77-year-old male client is admitted for electiveknee surgery. Physical examination revealsshallow respirations but no sign of respiratorydistress. Which of the following is a normalphysiologic change related to aging?a. Increased elastic recoil of the lungsb. Increased number of functionalcapillaries in the alveolic. Decreased residual volumed. Decreased vital capacity16. Nurse John is caring for a male client receivinglidocaine I.V. Which factor is the most relevantto administration of this medication?a. Decrease in arterial oxygen saturation(SaO2) when measured with a pulseoximeter.b. Increase in systemic blood pressure.c. Presence of premature ventricularcontractions (PVCs) on a cardiacmonitor.d. Increase in intracranial pressure (ICP).17. Nurse Ron is caring for a male client taking ananticoagulant. The nurse should teach the clientto:a. Report incidents of diarrhea.b. Avoid foods high in vitamin Kc. Use a straight razor when shaving.d. Take aspirin to pain relief.18. Nurse Lhynnette is preparing a site for theinsertion of an I.V. catheter. The nurse shouldtreat excess hair at the site by:a. Leaving the hair intactb. Shaving the areac. Clipping the hair in the aread. Removing the hair with a depilatory.19. Nurse Michelle is caring for an elderly femalewith osteoporosis. When teaching the client, thenurse should include information about whichmajor complication:a. Bone fractureb. Loss of estrogenc. Negative calcium balanced. Dowager’s hump20. Nurse Len is teaching a group of women toperform BSE. The nurse should explain that thepurpose of performing the examination is todiscover:a. Cancerous lumpsb. Areas of thickness or fullnessc. Changes from previous examinations.d. Fibrocystic masses21. When caring for a female client who is beingtreated for hyperthyroidism, it is important to:a. Provide extra blankets and clothing tokeep the client warm.b. Monitor the client for signs ofrestlessness, sweating, and excessive
  • 93weight loss during thyroid replacementtherapy.c. Balance the client’s periods of activityand rest.d. Encourage the client to be active toprevent constipation.22. Nurse Kris is teaching a client with history ofatherosclerosis. To decrease the risk ofatherosclerosis, the nurse should encourage theclient to:a. Avoid focusing on his weight.b. Increase his activity level.c. Follow a regular diet.d. Continue leading a high-stress lifestyle.23. Nurse Greta is working on a surgical floor. NurseGreta must logroll a client following a:a. Laminectomyb. Thoracotomyc. Hemorrhoidectomyd. Cystectomy.24. A 55-year old client underwent cataract removalwith intraocular lens implant. Nurse Oliver isgiving the client discharge instructions. Theseinstructions should include which of thefollowing?a. Avoid lifting objects weighing more than5 lb (2.25 kg).b. Lie on your abdomen when in bedc. Keep rooms brightly lit.d. Avoiding straining during bowelmovement or bending at the waist.25. George should be taught about testicularexaminations during:a. when sexual activity startsb. After age 69c. After age 40d. Before age 20.26. A male client undergone a colon resection. Whileturning him, wound dehiscence withevisceration occurs. Nurse Trish first response isto:a. Call the physicianb. Place a saline-soaked sterile dressing onthe wound.c. Take a blood pressure and pulse.d. Pull the dehiscence closed.27. Nurse Audrey is caring for a client who hassuffered a severe cerebrovascular accident.During routine assessment, the nurse noticesCheyne- Strokes respirations. Cheyne-strokesrespirations are:a. A progressively deeper breaths followedby shallower breaths with apneicperiods.b. Rapid, deep breathing with abruptpauses between each breath.c. Rapid, deep breathing and irregularbreathing without pauses.d. Shallow breathing with an increasedrespiratory rate.28. Nurse Bea is assessing a male client with heartfailure. The breath sounds commonlyauscultated in clients with heart failure are:a. Trachealb. Fine cracklesc. Coarse cracklesd. Friction rubs29. The nurse is caring for Kenneth experiencing anacute asthma attack. The client stops wheezingand breath sounds aren’t audible. The reason forthis change is that:a. The attack is over.b. The airways are so swollen that no aircannot get through.c. The swelling has decreased.d. Crackles have replaced wheezes.30. Mike with epilepsy is having a seizure. Duringthe active seizure phase, the nurse should:a. Place the client on his back removedangerous objects, and insert a biteblock.b. Place the client on his side, removedangerous objects, and insert a biteblock.c. Place the client o his back, removedangerous objects, and hold down hisarms.d. Place the client on his side, removedangerous objects, and protect his head.31. After insertion of a cheat tube for apneumothorax, a client becomes hypotensivewith neck vein distention, tracheal shift, absentbreath sounds, and diaphoresis. Nurse Amandasuspects a tension pneumothorax has occurred.What cause of tension pneumothorax should thenurse check for?a. Infection of the lung.
  • 94b. Kinked or obstructed chest tubec. Excessive water in the water-sealchamberd. Excessive chest tube drainage32. Nurse Maureen is talking to a male client; theclient begins choking on his lunch. He’s coughingforcefully. The nurse should:a. Stand him up and perform theabdominal thrust maneuver frombehind.b. Lay him down, straddle him, andperform the abdominal thrustmaneuver.c. Leave him to get assistanced. Stay with him but not intervene at thistime.33. Nurse Ron is taking a health history of an 84 yearold client. Which information will be most usefulto the nurse for planning care?a. General health for the last 10 years.b. Current health promotion activities.c. Family history of diseases.d. Marital status.34. When performing oral care on a comatose client,Nurse Krina should:a. Apply lemon glycerin to the client’s lipsat least every 2 hours.b. Brush the teeth with client lying supine.c. Place the client in a side lying position,with the head of the bed lowered.d. Clean the client’s mouth with hydrogenperoxide.35. A 77-year-old male client is admitted with adiagnosis of dehydration and change in mentalstatus. He’s being hydrated with L.V. fluids.When the nurse takes his vital signs, she noteshe has a fever of 103°F (39.4°C) a coughproducing yellow sputum and pleuritic chestpain. The nurse suspects this client may havewhich of the following conditions?a. Adult respiratory distress syndrome(ARDS)b. Myocardial infarction (MI)c. Pneumoniad. Tuberculosis36. Nurse Oliver is working in an outpatient clinic.He has been alerted that there is an outbreak oftuberculosis (TB). Which of the following clientsentering the clinic today most likely to have TB?a. A 16-year-old female high schoolstudentb. A 33-year-old day-care workerc. A 43-yesr-old homeless man with ahistory of alcoholismd. A 54-year-old businessman37. Virgie with a positive Mantoux test result will besent for a chest X-ray. The nurse is aware thatwhich of the following reasons this is done?a. To confirm the diagnosisb. To determine if a repeat skin test isneededc. To determine the extent of lesionsd. To determine if this is a primary orsecondary infection38. Kennedy with acute asthma showing inspiratoryand expiratory wheezes and a decreased forcedexpiratory volume should be treated with whichof the following classes of medication rightaway?a. Beta-adrenergic blockersb. Bronchodilatorsc. Inhaled steroidsd. Oral steroids39. Mr. Vasquez 56-year-old client with a 40-yearhistory of smoking one to two packs of cigarettesper day has a chronic cough producing thicksputum, peripheral edema and cyanotic nailbeds. Based on this information, he most likelyhas which of the following conditions?a. Adult respiratory distress syndrome(ARDS)b. Asthmac. Chronic obstructive bronchitisd. EmphysemaSituation: Francis, age 46 is admitted to the hospital withdiagnosis of Chronic Lymphocytic Leukemia.40. The treatment for patients with leukemia is bonemarrow transplantation. Which statement aboutbone marrow transplantation is not correct?a. The patient is under local anesthesiaduring the procedureb. The aspirated bone marrow is mixedwith heparin.c. The aspiration site is the posterior oranterior iliac crest.
  • 95d. The recipient receivescyclophosphamide (Cytoxan) for 4consecutive days before the procedure.41. After several days of admission, Francis becomesdisoriented and complains of frequentheadaches. The nurse in-charge first actionwould be:a. Call the physicianb. Document the patient’s status in hischarts.c. Prepare oxygen treatmentd. Raise the side rails42. During routine care, Francis asks the nurse,“How can I be anemic if this disease causesincreased my white blood cell production?” Thenurse in-charge best response would be that theincreased number of white blood cells (WBC) is:a. Crowd red blood cellsb. Are not responsible for the anemia.c. Uses nutrients from other cellsd. Have an abnormally short life span ofcells.43. Diagnostic assessment of Francis would probablynot reveal:a. Predominance of lymhoblastsb. Leukocytosisc. Abnormal blast cells in the bone marrowd. Elevated thrombocyte counts44. Robert, a 57-year-old client with acute arterialocclusion of the left leg undergoes anemergency embolectomy. Six hours later, thenurse isn’t able to obtain pulses in his left footusing Doppler ultrasound. The nurseimmediately notifies the physician, and asks herto prepare the client for surgery. As the nurseenters the client’s room to prepare him, hestates that he won’t have any more surgery.Which of the following is the best initialresponse by the nurse?a. Explain the risks of not having thesurgeryb. Notifying the physician immediatelyc. Notifying the nursing supervisord. Recording the client’s refusal in thenurses’ notes45. During the endorsement, which of the followingclients should the on-duty nurse assess first?a. The 58-year-old client who was admitted2 days ago with heart failure, bloodpressure of 126/76 mm Hg, and arespiratory rate of 22 breaths/ minute.b. The 89-year-old client with end-stageright-sided heart failure, blood pressureof 78/50 mm Hg, and a “do notresuscitate” orderc. The 62-year-old client who was admitted1 day ago with thrombophlebitis and isreceiving L.V. heparind. The 75-year-old client who was admitted1 hour ago with new-onset atrialfibrillation and is receiving L.V. dilitiazem(Cardizem)46. Honey, a 23-year old client complains ofsubsternal chest pain and states that her heartfeels like “it’s racing out of the chest”. Shereports no history of cardiac disorders. Thenurse attaches her to a cardiac monitor andnotes sinus tachycardia with a rate of136beats/minutes. Breath sounds are clear andthe respiratory rate is 26 breaths/minutes.Which of the following drugs should the nursequestion the client about using?a. Barbituratesb. Opioidsc. Cocained. Benzodiazepines47. A 51-year-old female client tells the nurse in-charge that she has found a painless lump in herright breast during her monthly self-examination. Which assessment finding wouldstrongly suggest that this clients lump iscancerous?a. Eversion of the right nipple and mobilemassb. Nonmobile mass with irregular edgesc. Mobile mass that is soft and easilydelineatedd. Nonpalpable right axillary lymph nodes48. A 35-year-old client with vaginal cancer asks thenurse, "What is the usual treatment for this typeof cancer?" Which treatment should the nursename?a. Surgeryb. Chemotherapyc. Radiationd. Immunotherapy49. Cristina undergoes a biopsy of a suspiciouslesion. The biopsy report classifies the lesion
  • 96according to the TNM staging system as follows:TIS, N0, M0. What does this classification mean?a. No evidence of primary tumor, noabnormal regional lymph nodes, and noevidence of distant metastasisb. Carcinoma in situ, no abnormal regionallymph nodes, and no evidence of distantmetastasisc. Cant assess tumor or regional lymphnodes and no evidence of metastasisd. Carcinoma in situ, no demonstrablemetastasis of the regional lymph nodes,and ascending degrees of distantmetastasis50. Lydia undergoes a laryngectomy to treatlaryngeal cancer. When teaching the client howto care for the neck stoma, the nurse shouldinclude which instruction?a. "Keep the stoma uncovered."b. "Keep the stoma dry."c. "Have a family member perform stomacare initially until you get used to theprocedure."d. "Keep the stoma moist."51. A 37-year-old client with uterine cancer asks thenurse, "Which is the most common type ofcancer in women?" The nurse replies that itsbreast cancer. Which type of cancer causes themost deaths in women?a. Breast cancerb. Lung cancerc. Brain cancerd. Colon and rectal cancer52. Antonio with lung cancer develops Hornerssyndrome when the tumor invades the ribs andaffects the sympathetic nerve ganglia. Whenassessing for signs and symptoms of thissyndrome, the nurse should note:a. miosis, partial eyelid ptosis, andanhidrosis on the affected side of theface.b. chest pain, dyspnea, cough, weight loss,and fever.c. arm and shoulder pain and atrophy ofarm and hand muscles, both on theaffected side.d. hoarseness and dysphagia.53. Vic asks the nurse what PSA is. The nurse shouldreply that it stands for:a. prostate-specific antigen, which is usedto screen for prostate cancer.b. protein serum antigen, which is used todetermine protein levels.c. pneumococcal strep antigen, which is abacteria that causes pneumonia.d. Papanicolaou-specific antigen, which isused to screen for cervical cancer.54. What is the most important postoperativeinstruction that nurse Kate must give a clientwho has just returned from the operating roomafter receiving a subarachnoid block?a. "Avoid drinking liquids until the gagreflex returns."b. "Avoid eating milk products for 24hours."c. "Notify a nurse if you experience bloodin your urine."d. "Remain supine for the time specified bythe physician."55. A male client suspected of having colorectalcancer will require which diagnostic study toconfirm the diagnosis?a. Stool Hematestb. Carcinoembryonic antigen (CEA)c. Sigmoidoscopyd. Abdominal computed tomography (CT)scan56. During a breast examination, which finding moststrongly suggests that the Luz has breast cancer?a. Slight asymmetry of the breasts.b. A fixed nodular mass with dimpling ofthe overlying skinc. Bloody discharge from the nippled. Multiple firm, round, freely movablemasses that change with the menstrualcycle57. A female client with cancer is being evaluatedfor possible metastasis. Which of the following isone of the most common metastasis sites forcancer cells?a. Liverb. Colonc. Reproductive tractd. White blood cells (WBCs)58. Nurse Mandy is preparing a client for magneticresonance imaging (MRI) to confirm or rule out a
  • 97spinal cord lesion. During the MRI scan, which ofthe following would pose a threat to the client?a. The client lies still.b. The client asks questions.c. The client hears thumping sounds.d. The client wears a watch and weddingband.59. Nurse Cecile is teaching a female client aboutpreventing osteoporosis. Which of the followingteaching points is correct?a. Obtaining an X-ray of the bones every 3years is recommended to detect boneloss.b. To avoid fractures, the client shouldavoid strenuous exercise.c. The recommended daily allowance ofcalcium may be found in a wide varietyof foods.d. Obtaining the recommended dailyallowance of calcium requires taking acalcium supplement.60. Before Jacob undergoes arthroscopy, the nursereviews the assessment findings forcontraindications for this procedure. Whichfinding is a contraindication?a. Joint painb. Joint deformityc. Joint flexion of less than 50%d. Joint stiffness61. Mr. Rodriguez is admitted with severe pain inthe knees. Which form of arthritis ischaracterized by urate deposits and joint pain,usually in the feet and legs, and occurs primarilyin men over age 30?a. Septic arthritisb. Traumatic arthritisc. Intermittent arthritisd. Gouty arthritis62. A heparin infusion at 1,500 unit/hour is orderedfor a 64-year-old client with stroke in evolution.The infusion contains 25,000 units of heparin in500 ml of saline solution. How many millilitersper hour should be given?a. 15 ml/hourb. 30 ml/hourc. 45 ml/hourd. 50 ml/hour63. A 76-year-old male client had a thromboembolicright stroke; his left arm is swollen. Which of thefollowing conditions may cause swelling after astroke?a. Elbow contracture secondary tospasticityb. Loss of muscle contraction decreasingvenous returnc. Deep vein thrombosis (DVT) due toimmobility of the ipsilateral sided. Hypoalbuminemia due to proteinescaping from an inflamed glomerulus64. Heberden’s nodes are a common sign ofosteoarthritis. Which of the following statementis correct about this deformity?a. It appears only in menb. It appears on the distal interphalangealjointc. It appears on the proximalinterphalangeal jointd. It appears on the dorsolateral aspect ofthe interphalangeal joint.65. Which of the following statements explains themain difference between rheumatoid arthritisand osteoarthritis?a. Osteoarthritis is gender-specific,rheumatoid arthritis isn’tb. Osteoarthritis is a localized diseaserheumatoid arthritis is systemicc. Osteoarthritis is a systemic disease,rheumatoid arthritis is localizedd. Osteoarthritis has dislocations andsubluxations, rheumatoid arthritisdoesn’t66. Mrs. Cruz uses a cane for assistance in walking.Which of the following statements is true abouta cane or other assistive devices?a. A walker is a better choice than a cane.b. The cane should be used on the affectedsidec. The cane should be used on theunaffected sided. A client with osteoarthritis should beencouraged to ambulate without thecane67. A male client with type 1 diabetes is scheduledto receive 30 U of 70/30 insulin. There is no70/30 insulin available. As a substitution, thenurse may give the client:
  • 98a. 9 U regular insulin and 21 U neutralprotamine Hagedorn (NPH).b. 21 U regular insulin and 9 U NPH.c. 10 U regular insulin and 20 U NPH.d. 20 U regular insulin and 10 U NPH.68. Nurse Len should expect to administer whichmedication to a client with gout?a. aspirinb. furosemide (Lasix)c. colchicinesd. calcium gluconate (Kalcinate)69. Mr. Domingo with a history of hypertension isdiagnosed with primary hyperaldosteronism.This diagnosis indicates that the clientshypertension is caused by excessive hormonesecretion from which of the following glands?a. Adrenal cortexb. Pancreasc. Adrenal medullad. Parathyroid70. For a diabetic male client with a foot ulcer, thedoctor orders bed rest, a wet-to-dry dressingchange every shift, and blood glucosemonitoring before meals and bedtime. Why arewet-to-dry dressings used for this client?a. They contain exudate and provide amoist wound environment.b. They protect the wound frommechanical trauma and promotehealing.c. They debride the wound and promotehealing by secondary intention.d. They prevent the entrance ofmicroorganisms and minimize wounddiscomfort.71. Nurse Zeny is caring for a client in acuteaddisonian crisis. Which laboratory data wouldthe nurse expect to find?a. Hyperkalemiab. Reduced blood urea nitrogen (BUN)c. Hypernatremiad. Hyperglycemia72. A client is admitted for treatment of thesyndrome of inappropriate antidiuretic hormone(SIADH). Which nursing intervention isappropriate?a. Infusing I.V. fluids rapidly as orderedb. Encouraging increased oral intakec. Restricting fluidsd. Administering glucose-containing I.V.fluids as ordered73. A female client tells nurse Nikki that she hasbeen working hard for the last 3 months tocontrol her type 2 diabetes mellitus with dietand exercise. To determine the effectiveness ofthe clients efforts, the nurse should check:a. urine glucose level.b. fasting blood glucose level.c. serum fructosamine level.d. glycosylated hemoglobin level.74. Nurse Trinity administered neutral protamineHagedorn (NPH) insulin to a diabetic client at 7a.m. At what time would the nurse expect theclient to be most at risk for a hypoglycemicreaction?a. 10:00 amb. Noonc. 4:00 pmd. 10:00 pm75. The adrenal cortex is responsible for producingwhich substances?a. Glucocorticoids and androgensb. Catecholamines and epinephrinec. Mineralocorticoids and catecholaminesd. Norepinephrine and epinephrine76. On the third day after a partial thyroidectomy,Proserfina exhibits muscle twitching andhyperirritability of the nervous system. Whenquestioned, the client reports numbness andtingling of the mouth and fingertips. Suspectinga life-threatening electrolyte disturbance, thenurse notifies the surgeon immediately. Whichelectrolyte disturbance most commonly followsthyroid surgery?a. Hypocalcemiab. Hyponatremiac. Hyperkalemiad. Hypermagnesemia77. Which laboratory test value is elevated in clientswho smoke and cant be used as a generalindicator of cancer?a. Acid phosphatase levelb. Serum calcitonin levelc. Alkaline phosphatase leveld. Carcinoembryonic antigen level
  • 9978. Francis with anemia has been admitted to themedical-surgical unit. Which assessment findingsare characteristic of iron-deficiency anemia?a. Nights sweats, weight loss, and diarrheab. Dyspnea, tachycardia, and pallorc. Nausea, vomiting, and anorexiad. Itching, rash, and jaundice79. In teaching a female client who is HIV-positiveabout pregnancy, the nurse would know moreteaching is necessary when the client says:a. The baby can get the virus from myplacenta."b. "Im planning on starting on birth controlpills."c. "Not everyone who has the virus givesbirth to a baby who has the virus."d. "Ill need to have a C-section if I becomepregnant and have a baby."80. When preparing Judy with acquiredimmunodeficiency syndrome (AIDS) fordischarge to the home, the nurse should be sureto include which instruction?a. "Put on disposable gloves beforebathing."b. "Sterilize all plates and utensils in boilingwater."c. "Avoid sharing such articles astoothbrushes and razors."d. "Avoid eating foods from serving dishesshared by other family members."81. Nurse Marie is caring for a 32-year-old clientadmitted with pernicious anemia. Which set offindings should the nurse expect when assessingthe client?a. Pallor, bradycardia, and reduced pulsepressureb. Pallor, tachycardia, and a sore tonguec. Sore tongue, dyspnea, and weight gaind. Angina, double vision, and anorexia82. After receiving a dose of penicillin, a clientdevelops dyspnea and hypotension. NurseCelestina suspects the client is experiencinganaphylactic shock. What should the nurse dofirst?a. Page an anesthesiologist immediatelyand prepare to intubate the client.b. Administer epinephrine, as prescribed,and prepare to intubate the client ifnecessary.c. Administer the antidote for penicillin, asprescribed, and continue to monitor theclients vital signs.d. Insert an indwelling urinary catheter andbegin to infuse I.V. fluids as ordered.83. Mr. Marquez with rheumatoid arthritis is aboutto begin aspirin therapy to reduce inflammation.When teaching the client about aspirin, thenurse discusses adverse reactions to prolongedaspirin therapy. These include:a. weight gain.b. fine motor tremors.c. respiratory acidosis.d. bilateral hearing loss.84. A 23-year-old client is diagnosed with humanimmunodeficiency virus (HIV). After recoveringfrom the initial shock of the diagnosis, the clientexpresses a desire to learn as much as possibleabout HIV and acquired immunodeficiencysyndrome (AIDS). When teaching the clientabout the immune system, the nurse states thatadaptive immunity is provided by which type ofwhite blood cell?a. Neutrophilb. Basophilc. Monocyted. Lymphocyte85. In an individual with Sjögrens syndrome, nursingcare should focus on:a. moisture replacement.b. electrolyte balance.c. nutritional supplementation.d. arrhythmia management.86. During chemotherapy for lymphocytic leukemia,Mathew develops abdominal pain, fever, and"horse barn" smelling diarrhea. It would be mostimportant for the nurse to advise the physicianto order:a. enzyme-linked immunosuppressantassay (ELISA) test.b. electrolyte panel and hemogram.c. stool for Clostridium difficile test.d. flat plate X-ray of the abdomen.87. A male client seeks medical evaluation forfatigue, night sweats, and a 20-lb weight loss in 6weeks. To confirm that the client has beeninfected with the human immunodeficiency virus(HIV), the nurse expects the physician to order:
  • 100a. E-rosette immunofluorescence.b. quantification of T-lymphocytes.c. enzyme-linked immunosorbent assay(ELISA).d. Western blot test with ELISA.88. A complete blood count is commonly performedbefore a Joe goes into surgery. What does thistest seek to identify?a. Potential hepatic dysfunction indicatedby decreased blood urea nitrogen (BUN)and creatinine levelsb. Low levels of urine constituents normallyexcreted in the urinec. Abnormally low hematocrit (HCT) andhemoglobin (Hb) levelsd. Electrolyte imbalance that could affectthe bloods ability to coagulate properly89. While monitoring a client for the developmentof disseminated intravascular coagulation (DIC),the nurse should take note of what assessmentparameters?a. Platelet count, prothrombin time, andpartial thromboplastin timeb. Platelet count, blood glucose levels, andwhite blood cell (WBC) countc. Thrombin time, calcium levels, andpotassium levelsd. Fibrinogen level, WBC, and plateletcount90. When taking a dietary history from a newlyadmitted female client, Nurse Len shouldremember that which of the following foods is acommon allergen?a. Breadb. Carrotsc. Oranged. Strawberries91. Nurse John is caring for clients in the outpatientclinic. Which of the following phone calls shouldthe nurse return first?a. A client with hepatitis A who states, “Myarms and legs are itching.”b. A client with cast on the right leg whostates, “I have a funny feeling in my rightleg.”c. A client with osteomyelitis of the spinewho states, “I am so nauseous that Ican’t eat.”d. A client with rheumatoid arthritis whostates, “I am having trouble sleeping.”92. Nurse Sarah is caring for clients on the surgicalfloor and has just received report from theprevious shift. Which of the following clientsshould the nurse see first?a. A 35-year-old admitted three hours agowith a gunshot wound; 1.5 cm area ofdark drainage noted on the dressing.b. A 43-year-old who had a mastectomytwo days ago; 23 ml of serosanguinousfluid noted in the Jackson-Pratt drain.c. A 59-year-old with a collapsed lung dueto an accident; no drainage noted in theprevious eight hours.d. A 62-year-old who had an abdominal-perineal resection three days ago; clientcomplaints of chills.93. Nurse Eve is caring for a client who had athyroidectomy 12 hours ago for treatment ofGrave’s disease. The nurse would be mostconcerned if which of the following wasobserved?a. Blood pressure 138/82, respirations 16,oral temperature 99 degrees Fahrenheit.b. The client supports his head and neckwhen turning his head to the right.c. The client spontaneously flexes his wristwhen the blood pressure is obtained.d. The client is drowsy and complains ofsore throat.94. Julius is admitted with complaints of severe painin the lower right quadrant of the abdomen. Toassist with pain relief, the nurse should takewhich of the following actions?a. Encourage the client to change positionsfrequently in bed.b. Administer Demerol 50 mg IM q 4 hoursand PRN.c. Apply warmth to the abdomen with aheating pad.d. Use comfort measures and pillows toposition the client.95. Nurse Tina prepares a client for peritonealdialysis. Which of the following actions shouldthe nurse take first?a. Assess for a bruit and a thrill.b. Warm the dialysate solution.c. Position the client on the left side.
  • 101d. Insert a Foley catheter96. Nurse Jannah teaches an elderly client withright-sided weakness how to use cane. Which ofthe following behaviors, if demonstrated by theclient to the nurse, indicates that the teachingwas effective?a. The client holds the cane with his righthand, moves the can forward followedby the right leg, and then moves the leftleg.b. The client holds the cane with his righthand, moves the cane forward followedby his left leg, and then moves the rightleg.c. The client holds the cane with his lefthand, moves the cane forward followedby the right leg, and then moves the leftleg.d. The client holds the cane with his lefthand, moves the cane forward followedby his left leg, and then moves the rightleg.97. An elderly client is admitted to the nursing homesetting. The client is occasionally confused andher gait is often unsteady. Which of thefollowing actions, if taken by the nurse, is mostappropriate?a. Ask the woman’s family to providepersonal items such as photos ormementos.b. Select a room with a bed by the door sothe woman can look down the hall.c. Suggest the woman eat her meals in theroom with her roommate.d. Encourage the woman to ambulate inthe halls twice a day.98. Nurse Evangeline teaches an elderly client howto use a standard aluminum walker. Which ofthe following behaviors, if demonstrated by theclient, indicates that the nurse’s teaching waseffective?a. The client slowly pushes the walkerforward 12 inches, then takes smallsteps forward while leaning on thewalker.b. The client lifts the walker, moves itforward 10 inches, and then takesseveral small steps forward.c. The client supports his weight on thewalker while advancing it forward, thentakes small steps while balancing on thewalker.d. The client slides the walker 18 inchesforward, then takes small steps whileholding onto the walker for balance.99. Nurse Deric is supervising a group of elderlyclients in a residential home setting. The nurseknows that the elderly are at greater risk ofdeveloping sensory deprivation for what reason?a. Increased sensitivity to the side effectsof medications.b. Decreased visual, auditory, andgustatory abilities.c. Isolation from their families and familiarsurroundings.d. Decrease musculoskeletal function andmobility.100. A male client with emphysema becomesrestless and confused. What step shouldnurse Jasmine take next?a. Encourage the client to perform pursedlip breathing.b. Check the client’s temperature.c. Assess the client’s potassium level.d. Increase the client’s oxygen flow rate.
  • 102Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations1. Answer: (C) Loose, bloodyRationale: Normal bowel function and soft-formed stool usually do not occur until aroundthe seventh day following surgery. The stoolconsistency is related to how much water isbeing absorbed.2. Answer: (A) On the client’s right sideRationale: The client has left visual fieldblindness. The client will see only from theright side.3. Answer: (C) Check respirations, stabilize spine,and check circulationRationale: Checking the airway would bepriority, and a neck injury should besuspected.4. Answer: (D) Decreasing venous return throughvasodilation.Rationale: The significant effect ofnitroglycerin is vasodilation and decreasedvenous return, so the heart does not have towork hard.5. Answer: (A) Call for help and note the time.Rationale: Having established, by stimulatingthe client, that the client is unconscious ratherthan sleep, the nurse should immediately callfor help. This may be done by dialing theoperator from the client’s phone and givingthe hospital code for cardiac arrest and theclient’s room number to the operator, of if thephone is not available, by pulling theemergency call button. Noting the time isimportant baseline information for cardiacarrest procedure6. Answer: (C) Make sure that the client takesfood and medications at prescribed intervals.Rationale: Food and drug therapy will preventthe accumulation of hydrochloric acid, or willneutralize and buffer the acid that doesaccumulate.7. Answer: (B) Continue treatment as ordered.Rationale: The effects of heparin aremonitored by the PTT is normally 30 to 45seconds; the therapeutic level is 1.5 to 2 timesthe normal level.8. Answer: (B) In the operating room.Rationale: The stoma drainage bag is appliedin the operating room. Drainage from theileostomy contains secretions that are rich indigestive enzymes and highly irritating to theskin. Protection of the skin from the effects ofthese enzymes is begun at once. Skin exposedto these enzymes even for a short timebecomes reddened, painful, and excoriated.9. Answer: (B) Flat on back.Rationale: To avoid the complication of apainful spinal headache that can last forseveral days, the client is kept in flat in asupine position for approximately 4 to 12hours postoperatively. Headaches arebelieved to be causes by the seepage ofcerebral spinal fluid from the puncture site. Bykeeping the client flat, cerebral spinal fluidpressures are equalized, which avoids traumato the neurons.10. Answer: (C) The client is oriented whenaroused from sleep, and goes back to sleepimmediately.Rationale: This finding suggest that the levelof consciousness is decreasing.11. Answer: (A) Altered mental status anddehydrationRationale: Fever, chills, hemortysis, dyspnea,cough, and pleuritic chest pain are thecommon symptoms of pneumonia, but elderlyclients may first appear with only an alteredlentil status and dehydration due to a bluntedimmune response.12. Answer: (B) Chills, fever, night sweats, andhemoptysisRationale: Typical signs and symptoms arechills, fever, night sweats, and hemoptysis.Chest pain may be present from coughing, butisn’t usual. Clients with TB typically have low-grade fevers, not higher than 102°F (38.9°C).Nausea, headache, and photophobia aren’tusual TB symptoms.13. Answer:(A) Acute asthmaRationale: Based on the client’s history andsymptoms, acute asthma is the most likelydiagnosis. He’s unlikely to have bronchialpneumonia without a productive cough andfever and he’s too young to have developed(COPD) and emphysema.14. Answer: (B) Respiratory arrestRationale: Narcotics can cause respiratoryarrest if given in large quantities. It’s unlikelythe client will have asthma attack or a seizureor wake up on his own.15. Answer: (D) Decreased vital capacityRationale: Reduction in vital capacity is anormal physiologic change includes decreased
  • 103elastic recoil of the lungs, fewer functionalcapillaries in the alveoli, and an increased inresidual volume.16. Answer: (C) Presence of premature ventricularcontractions (PVCs) on a cardiac monitor.Rationale: Lidocaine drips are commonly usedto treat clients whose arrhythmias haven’tbeen controlled with oral medication and whoare having PVCs that are visible on the cardiacmonitor. SaO2, blood pressure, and ICP areimportant factors but aren’t as significant asPVCs in the situation.17. Answer: (B) Avoid foods high in vitamin KRationale: The client should avoid consuminglarge amounts of vitamin K because vitamin Kcan interfere with anticoagulation. The clientmay need to report diarrhea, but isn’t effectof taking an anticoagulant. An electric razor-not a straight razor-should be used to preventcuts that cause bleeding. Aspirin may increasethe risk of bleeding; acetaminophen should beused to pain relief.18. Answer: (C) Clipping the hair in the areaRationale: Hair can be a source of infectionand should be removed by clipping. Shavingthe area can cause skin abrasions anddepilatories can irritate the skin.19. Answer: (A) Bone fractureRationale: Bone fracture is a majorcomplication of osteoporosis that resultswhen loss of calcium and phosphate increasedthe fragility of bones. Estrogen deficienciesresult from menopause-not osteoporosis.Calcium and vitamin D supplements may beused to support normal bone metabolism, Buta negative calcium balance isn’t acomplication of osteoporosis. Dowager’shump results from bone fractures. It developswhen repeated vertebral fractures increasespinal curvature.20. Answer: (C) Changes from previousexaminations.Rationale: Women are instructed to examinethemselves to discover changes that haveoccurred in the breast. Only a physician candiagnose lumps that are cancerous, areas ofthickness or fullness that signal the presenceof a malignancy, or masses that are fibrocysticas opposed to malignant.21. Answer: (C) Balance the client’s periods ofactivity and rest.Rationale: A client with hyperthyroidismneeds to be encouraged to balance periods ofactivity and rest. Many clients withhyperthyroidism are hyperactive and complainof feeling very warm.22. Answer: (B) Increase his activity level.Rationale: The client should be encouraged toincrease his activity level. aintaining an idealweight; following a low-cholesterol, lowsodium diet; and avoiding stress are allimportant factors in decreasing the risk ofatherosclerosis.23. Answer: (A) LaminectomyRationale: The client who has had spinalsurgery, such as laminectomy, must be logrolled to keep the spinal column straight whenturning. Thoracotomy and cystectomy mayturn themselves or may be assisted into acomfortable position. Under normalcircumstances, hemorrhoidectomy is anoutpatient procedure, and the client mayresume normal activities immediately aftersurgery.24. Answer: (D) Avoiding straining during bowelmovement or bending at the waist.Rationale: The client should avoid straining,lifting heavy objects, and coughing harshlybecause these activities increase intraocularpressure. Typically, the client is instructed toavoid lifting objects weighing more than 15 lb(7kg) – not 5lb. instruct the client when lyingin bed to lie on either the side or back. Theclient should avoid bright light by wearingsunglasses.25. Answer: (D) Before age 20.Rationale: Testicular cancer commonly occursin men between ages 20 and 30. A male clientshould be taught how to perform testicularself- examination before age 20, preferablywhen he enters his teens.26. Answer: (B) Place a saline-soaked steriledressing on the wound.Rationale: The nurse should first place saline-soaked sterile dressings on the open wound toprevent tissue drying and possible infection.Then the nurse should call the physician andtake the client’s vital signs. The dehiscenceneeds to be surgically closed, so the nurseshould never try to close it.27. Answer: (A) A progressively deeper breathsfollowed by shallower breaths with apneicperiods.Rationale: Cheyne-Strokes respirations arebreaths that become progressively deeperfallowed by shallower respirations with
  • 104apneas periods. Biot’s respirations are rapid,deep breathing with abrupt pauses betweeneach breath, and equal depth between eachbreath. Kussmaul’s respirationa are rapid,deep breathing without pauses. Tachypnea isshallow breathing with increased respiratoryrate.28. Answer: (B) Fine cracklesRationale: Fine crackles are caused by fluid inthe alveoli and commonly occur in clients withheart failure. Tracheal breath sounds areauscultated over the trachea. Coarse cracklesare caused by secretion accumulation in theairways. Friction rubs occur with pleuralinflammation.29. Answer: (B) The airways are so swollen that noair cannot get throughRationale: During an acute attack, wheezingmay stop and breath sounds becomeinaudible because the airways are so swollenthat air can’t get through. If the attack is overand swelling has decreased, there would beno more wheezing and less emergent concern.Crackles do not replace wheezes during anacute asthma attack.30. Answer: (D) Place the client on his side,remove dangerous objects, and protect hishead.Rationale: During the active seizure phase,initiate precautions by placing the client on hisside, removing dangerous objects, andprotecting his head from injury. A bite blockshould never be inserted during the activeseizure phase. Insertion can break the teethand lead to aspiration.31. Answer: (B) Kinked or obstructed chest tubeRationales: Kinking and blockage of the chesttube is a common cause of a tensionpneumothorax. Infection and excessivedrainage won’t cause a tensionpneumothorax. Excessive water won’t affectthe chest tube drainage.32. Answer: (D) Stay with him but not intervene atthis time.Rationale: If the client is coughing, he shouldbe able to dislodge the object or cause acomplete obstruction. If complete obstructionoccurs, the nurse should perform theabdominal thrust maneuver with the clientstanding. If the client is unconscious, sheshould lay him down. A nurse should neverleave a choking client alone.33. Answer: (B) Current health promotionactivitiesRationale: Recognizing an individual’s positivehealth measures is very useful. General healthin the previous 10 years is important,however, the current activities of an 84 yearold client are most significant in planning care.Family history of disease for a client in lateryears is of minor significance. Marital statusinformation may be important for dischargeplanning but is not as significant foraddressing the immediate medical problem.34. Answer: (C) Place the client in a side lyingposition, with the head of the bed lowered.Rationale: The client should be positioned in aside-lying position with the head of the bedlowered to prevent aspiration. A small amountof toothpaste should be used and the mouthswabbed or suctioned to remove pooledsecretions. Lemon glycerin can be drying ifused for extended periods. Brushing the teethwith the client lying supine may lead toaspiration. Hydrogen peroxide is caustic totissues and should not be used.35. Answer: (C) PneumoniaRationale: Fever productive cough andpleuritic chest pain are common signs andsymptoms of pneumonia. The client withARDS has dyspnea and hypoxia withworsening hypoxia over time, if not treatedaggressively. Pleuritic chest pain varies withrespiration, unlike the constant chest painduring an MI; so this client most likely isn’thaving an MI. the client with TB typically has acough producing blood-tinged sputum. Asputum culture should be obtained to confirmthe nurse’s suspicions.36. Answer: (C) A 43-yesr-old homeless man witha history of alcoholismRationale: Clients who are economicallydisadvantaged, malnourished, and havereduced immunity, such as a client with ahistory of alcoholism, are at extremely highrisk for developing TB. A high school student,day- care worker, and businessman probablyhave a much low risk of contracting TB.37. Answer: (C ) To determine the extent oflesionsRationale: If the lesions are large enough, thechest X-ray will show their presence in thelungs. Sputum culture confirms the diagnosis.There can be false-positive and false-negative
  • 105skin test results. A chest X-ray can’t determineif this is a primary or secondary infection.38. Answer: (B) BronchodilatorsRationale: Bronchodilators are the first line oftreatment for asthma because broncho-constriction is the cause of reduced airflow.Beta- adrenergic blockers aren’t used to treatasthma and can cause broncho- constriction.Inhaled oral steroids may be given to reducethe inflammation but aren’t used foremergency relief.39. Answer: (C) Chronic obstructive bronchitisRationale: Because of this extensive smokinghistory and symptoms the client most likelyhas chronic obstructive bronchitis. Client withARDS have acute symptoms of hypoxia andtypically need large amounts of oxygen.Clients with asthma and emphysema tend notto have chronic cough or peripheral edema.40. Answer: (A) The patient is under localanesthesia during the procedure Rationale:Before the procedure, the patient isadministered with drugs that would help toprevent infection and rejection of thetransplanted cells such as antibiotics,cytotoxic, and corticosteroids. During thetransplant, the patient is placed under generalanesthesia.41. Answer: (D) Raise the side railsRationale: A patient who is disoriented is atrisk of falling out of bed. The initial action ofthe nurse should be raising the side rails toensure patients safety.42. Answer: (A) Crowd red blood cellsRationale: The excessive production of whiteblood cells crowd out red blood cellsproduction which causes anemia to occur.43. Answer: (B) LeukocytosisRationale: Chronic Lymphocytic leukemia (CLL)is characterized by increased production ofleukocytes and lymphocytes resulting inleukocytosis, and proliferation of these cellswithin the bone marrow, spleen and liver.44. Answer: (A) Explain the risks of not having thesurgeryRationale: The best initial response is toexplain the risks of not having the surgery. Ifthe client understands the risks but stillrefuses the nurse should notify the physicianand the nurse supervisor and then record theclient’s refusal in the nurses’ notes.45. Answer: (D) The 75-year-old client who wasadmitted 1 hour ago with new-onset atrialfibrillation and is receiving L.V. dilitiazem(Cardizem)Rationale: The client with atrial fibrillation hasthe greatest potential to become unstable andis on L.V. medication that requires closemonitoring. After assessing this client, thenurse should assess the client withthrombophlebitis who is receiving a heparininfusion, and then the 58- year-old clientadmitted 2 days ago with heart failure (hissigns and symptoms are resolving and don’trequire immediate attention). The lowestpriority is the 89-year-old with end-stageright-sided heart failure, who requires time-consuming supportive measures.46. Answer: (C) CocaineRationale: Because of the client’s age andnegative medical history, the nurse shouldquestion her about cocaine use. Cocaineincreases myocardial oxygen consumption andcan cause coronary artery spasm, leading totachycardia, ventricular fibrillation, myocardialischemia, and myocardial infarction.Barbiturate overdose may trigger respiratorydepression and slow pulse. Opioids can causemarked respiratory depression, whilebenzodiazepines can cause drowsiness andconfusion.47. Answer: (B) Nonmobile mass with irregularedgesRationale: Breast cancer tumors are fixed,hard, and poorly delineated with irregularedges. A mobile mass that is soft and easilydelineated is most often a fluid-filled benigncyst. Axillary lymph nodes may or may not bepalpable on initial detection of a cancerousmass. Nipple retraction — not eversion —may be a sign of cancer.48. Answer: (C) RadiationRationale: The usual treatment for vaginalcancer is external or intravaginal radiationtherapy. Less often, surgery is performed.Chemotherapy typically is prescribed only ifvaginal cancer is diagnosed in an early stage,which is rare. Immunotherapy isnt used totreat vaginal cancer.49. Answer: (B) Carcinoma in situ, no abnormalregional lymph nodes, and no evidence ofdistant metastasisRationale: TIS, N0, M0 denotes carcinoma insitu, no abnormal regional lymph nodes, andno evidence of distant metastasis. Noevidence of primary tumor, no abnormal
  • 106regional lymph nodes, and no evidence ofdistant metastasis is classified as T0, N0, M0. Ifthe tumor and regional lymph nodes cant beassessed and no evidence of metastasis exists,the lesion is classified as TX, NX, M0. Aprogressive increase in tumor size, nodemonstrable metastasis of the regionallymph nodes, and ascending degrees ofdistant metastasis is classified as T1, T2, T3, orT4; N0; and M1, M2, or M3.50. Answer: (D) "Keep the stoma moist."Rationale: The nurse should instruct the clientto keep the stoma moist, such as by applying athin layer of petroleum jelly around the edges,because a dry stoma may become irritated.The nurse should recommend placing a stomabib over the stoma to filter and warm airbefore it enters the stoma. The client shouldbegin performing stoma care withoutassistance as soon as possible to gainindependence in self-care activities.51. Answer: (B) Lung cancerRationale: Lung cancer is the most deadly typeof cancer in both women and men. Breastcancer ranks second in women, followed (indescending order) by colon and rectal cancer,pancreatic cancer, ovarian cancer, uterinecancer, lymphoma, leukemia, liver cancer,brain cancer, stomach cancer, and multiplemyeloma.52. Answer: (A) miosis, partial eyelid ptosis, andanhidrosis on the affected side of the face.Rationale: Horners syndrome, which occurswhen a lung tumor invades the ribs andaffects the sympathetic nerve ganglia, ischaracterized by miosis, partial eyelid ptosis,and anhidrosis on the affected side of theface. Chest pain, dyspnea, cough, weight loss,and fever are associated with pleural tumors.Arm and shoulder pain and atrophy of the armand hand muscles on the affected side suggestPancoasts tumor, a lung tumor involving thefirst thoracic and eighth cervical nerves withinthe brachial plexus. Hoarseness in a clientwith lung cancer suggests that the tumor hasextended to the recurrent laryngeal nerve;dysphagia suggests that the lung tumor iscompressing the esophagus.53. 53. Answer: (A) prostate-specific antigen,which is used to screen for prostate cancer.Rationale: PSA stands for prostate-specificantigen, which is used to screen for prostatecancer. The other answers are incorrect.54. Answer: (D) "Remain supine for the timespecified by the physician." Rationale: Thenurse should instruct the client to remainsupine for the time specified by the physician.Local anesthetics used in a subarachnoid blockdont alter the gag reflex. No interactionsbetween local anesthetics and food occur.Local anesthetics dont cause hematuria.55. Answer: (C) SigmoidoscopyRationale: Used to visualize the lower GI tract,sigmoidoscopy and proctoscopy aid in thedetection of two-thirds of all colorectalcancers. Stool Hematest detects blood, whichis a sign of colorectal cancer; however, thetest doesnt confirm the diagnosis. CEA maybe elevated in colorectal cancer but isntconsidered a confirming test. An abdominal CTscan is used to stage the presence ofcolorectal cancer.56. Answer: (B) A fixed nodular mass withdimpling of the overlying skinRationale: A fixed nodular mass with dimplingof the overlying skin is common during latestages of breast cancer. Many women haveslightly asymmetrical breasts. Bloody nippledischarge is a sign of intraductal papilloma, abenign condition. Multiple firm, round, freelymovable masses that change with themenstrual cycle indicate fibrocystic breasts, abenign condition.57. Answer: (A) LiverRationale: The liver is one of the five mostcommon cancer metastasis sites. The othersare the lymph nodes, lung, bone, and brain.The colon, reproductive tract, and WBCs areoccasional metastasis sites.58. Answer: (D) The client wears a watch andwedding band.Rationale: During an MRI, the client shouldwear no metal objects, such as jewelry,because the strong magnetic field can pull onthem, causing injury to the client and (if theyfly off) to others. The client must lie stillduring the MRI but can talk to thoseperforming the test by way of the microphoneinside the scanner tunnel. The client shouldhear thumping sounds, which are caused bythe sound waves thumping on the magneticfield.59. Answer: (C) The recommended dailyallowance of calcium may be found in a widevariety of foods.
  • 107Rationale: Premenopausal women require1,000 mg of calcium per day. Postmenopausalwomen require 1,500 mg per day. Its often,though not always, possible to get therecommended daily requirement in the foodswe eat. Supplements are available but notalways necessary. Osteoporosis doesnt showup on ordinary X-rays until 30% of the boneloss has occurred. Bone densitometry candetect bone loss of 3% or less. This test issometimes recommended routinely forwomen over 35 who are at risk. Strenuousexercise wont cause fractures.60. Answer: (C) Joint flexion of less than 50%Rationale: Arthroscopy is contraindicated inclients with joint flexion of less than 50%because of technical problems in inserting theinstrument into the joint to see it clearly.Other contraindications for this procedureinclude skin and wound infections. Joint painmay be an indication, not a contraindication,for arthroscopy. Joint deformity and jointstiffness arent contraindications for thisprocedure.61. Answer: (D) Gouty arthritisRationale: Gouty arthritis, a metabolic disease,is characterized by urate deposits and pain inthe joints, especially those in the feet andlegs. Urate deposits dont occur in septic ortraumatic arthritis. Septic arthritis results frombacterial invasion of a joint and leads toinflammation of the synovial lining. Traumaticarthritis results from blunt trauma to a joint orligament. Intermittent arthritis is a rare,benign condition marked by regular, recurrentjoint effusions, especially in the knees.62. Answer: (B) 30 ml/houRationale: An infusion prepared with 25,000units of heparin in 500 ml of saline solutionyields 50 units of heparin per milliliter ofsolution. The equation is set up as 50 unitstimes X (the unknown quantity) equals 1,500units/hour, X equals 30 ml/hour.63. Answer: (B) Loss of muscle contractiondecreasing venous returnRationale: In clients with hemiplegia orhemiparesis loss of muscle contractiondecreases venous return and may causeswelling of the affected extremity.Contractures, or bony calcifications may occurwith a stroke, but don’t appear with swelling.DVT may develop in clients with a stroke but ismore likely to occur in the lower extremities.A stroke isn’t linked to protein loss.64. Answer: (B) It appears on the distalinterphalangeal jointRationale: Heberden’s nodes appear on thedistal interphalageal joint on both men andwomen. Bouchard’s node appears on thedorsolateral aspect of the proximalinterphalangeal joint.65. Answer: (B) Osteoarthritis is a localizeddisease rheumatoid arthritis is systemicRationale: Osteoarthritis is a localized disease,rheumatoid arthritis is systemic. Osteoarthritisisn’t gender-specific, but rheumatoid arthritisis. Clients have dislocations and subluxationsin both disorders.66. Answer: (C) The cane should be used on theunaffected sideRationale: A cane should be used on theunaffected side. A client with osteoarthritisshould be encouraged to ambulate with acane, walker, or other assistive device asneeded; their use takes weight and stress offjoints.67. Answer: (A) a. 9 U regular insulin and 21 Uneutral protamine Hagedorn (NPH).Rationale: A 70/30 insulin preparation is 70%NPH and 30% regular insulin. Therefore, acorrect substitution requires mixing 21 U ofNPH and 9 U of regular insulin. The otherchoices are incorrect dosages for theprescribed insulin.68. Answer: (C) colchicinesRationale: A disease characterized by jointinflammation (especially in the great toe),gout is caused by urate crystal deposits in thejoints. The physician prescribes colchicine toreduce these deposits and thus ease jointinflammation. Although aspirin is used toreduce joint inflammation and pain in clientswith osteoarthritis and rheumatoid arthritis, itisnt indicated for gout because it has noeffect on urate crystal formation. Furosemide,a diuretic, doesnt relieve gout. Calciumgluconate is used to reverse a negativecalcium balance and relieve muscle cramps,not to treat gout.69. Answer: (A) Adrenal cortexRationale: Excessive secretion of aldosteronein the adrenal cortex is responsible for theclients hypertension. This hormone acts onthe renal tubule, where it promotesreabsorption of sodium and excretion of
  • 108potassium and hydrogen ions. The pancreasmainly secretes hormones involved in fuelmetabolism. The adrenal medulla secretes thecatecholamines — epinephrine andnorepinephrine. The parathyroids secreteparathyroid hormone.70. Answer: (C) They debride the wound andpromote healing by secondary intentionRationale: For this client, wet-to-dry dressingsare most appropriate because they clean thefoot ulcer by debriding exudate and necrotictissue, thus promoting healing by secondaryintention. Moist, transparent dressingscontain exudate and provide a moist woundenvironment. Hydrocolloid dressings preventthe entrance of microorganisms and minimizewound discomfort. Dry sterile dressingsprotect the wound from mechanical traumaand promote healing.71. Answer: (A) HyperkalemiaRationale: In adrenal insufficiency, the clienthas hyperkalemia due to reduced aldosteronesecretion. BUN increases as the glomerularfiltration rate is reduced. Hyponatremia iscaused by reduced aldosterone secretion.Reduced cortisol secretion leads to impairedglyconeogenesis and a reduction of glycogenin the liver and muscle, causing hypoglycemia.72. Answer: (C) Restricting fluidsRationale: To reduce water retention in aclient with the SIADH, the nurse shouldrestrict fluids. Administering fluids by anyroute would further increase the clientsalready heightened fluid load.73. Answer: (D) glycosylated hemoglobin level.Rationale: Because some of the glucose in thebloodstream attaches to some of thehemoglobin and stays attached during the120-day life span of red blood cells,glycosylated hemoglobin levels provideinformation about blood glucose levels duringthe previous 3 months. Fasting blood glucoseand urine glucose levels only give informationabout glucose levels at the point in time whenthey were obtained. Serum fructosaminelevels provide information about bloodglucose control over the past 2 to 3 weeks.74. Answer: (C) 4:00 pmRationale: NPH is an intermediate-actinginsulin that peaks 8 to 12 hours afteradministration. Because the nurseadministered NPH insulin at 7 a.m., the clientis at greatest risk for hypoglycemia from 3p.m. to 7 p.m.75. Answer: (A) Glucocorticoids and androgensRationale: The adrenal glands have twodivisions, the cortex and medulla. The cortexproduces three types of hormones:glucocorticoids, mineralocorticoids, andandrogens. The medulla producescatecholamines— epinephrine andnorepinephrine.76. Answer: (A) HypocalcemiaRationale: Hypocalcemia may follow thyroidsurgery if the parathyroid glands wereremoved accidentally. Signs and symptoms ofhypocalcemia may be delayed for up to 7 daysafter surgery. Thyroid surgery doesnt directlycause serum sodium, potassium, ormagnesium abnormalities. Hyponatremia mayoccur if the client inadvertently received toomuch fluid; however, this can happen to anysurgical client receiving I.V. fluid therapy, notjust one recovering from thyroid surgery.Hyperkalemia and hypermagnesemia usuallyare associated with reduced renal excretion ofpotassium and magnesium, not thyroidsurgery.77. Answer: (D) Carcinoembryonic antigen levelRationale: In clients who smoke, the level ofcarcinoembryonic antigen is elevated.Therefore, it cant be used as a generalindicator of cancer. However, it is helpful inmonitoring cancer treatment because thelevel usually falls to normal within 1 month iftreatment is successful. An elevated acidphosphatase level may indicate prostatecancer. An elevated alkaline phosphatase levelmay reflect bone metastasis. An elevatedserum calcitonin level usually signals thyroidcancer.78. Answer: (B) Dyspnea, tachycardia, and pallorRationale: Signs of iron-deficiency anemiainclude dyspnea, tachycardia, and pallor aswell as fatigue, listlessness, irritability, andheadache. Night sweats, weight loss, anddiarrhea may signal acquiredimmunodeficiency syndrome (AIDS). Nausea,vomiting, and anorexia may be signs ofhepatitis B. Itching, rash, and jaundice mayresult from an allergic or hemolytic reaction.79. Answer: (D) "Ill need to have a C-section if Ibecome pregnant and have a baby."Rationale: The human immunodeficiency virus(HIV) is transmitted from mother to child via
  • 109the transplacental route, but a Cesareansection delivery isnt necessary when themother is HIV-positive. The use of birthcontrol will prevent the conception of a childwho might have HIV. Its true that a motherwhos HIV positive can give birth to a babywhos HIV negative.80. Answer: (C) "Avoid sharing such articles astoothbrushes and razors."Rationale: The human immunodeficiency virus(HIV), which causes AIDS, is mostconcentrated in the blood. For this reason, theclient shouldnt share personal articles thatmay be blood-contaminated, such astoothbrushes and razors, with other familymembers. HIV isnt transmitted by bathing orby eating from plates, utensils, or servingdishes used by a person with AIDS.81. Answer: (B) Pallor, tachycardia, and a soretongueRationale: Pallor, tachycardia, and a soretongue are all characteristic findings inpernicious anemia. Other clinicalmanifestations include anorexia; weight loss; asmooth, beefy red tongue; a wide pulsepressure; palpitations; angina; weakness;fatigue; and paresthesia of the hands and feet.Bradycardia, reduced pulse pressure, weightgain, and double vision arent characteristicfindings in pernicious anemia.82. Answer: (B) Administer epinephrine, asprescribed, and prepare to intubate the clientif necessary.Rationale: To reverse anaphylactic shock, thenurse first should administer epinephrine, apotent bronchodilator as prescribed. Thephysician is likely to order additionalmedications, such as antihistamines andcorticosteroids; if these medications dontrelieve the respiratory compromise associatedwith anaphylaxis, the nurse should prepare tointubate the client. No antidote for penicillinexists; however, the nurse should continue tomonitor the clients vital signs. A client whoremains hypotensive may need fluidresuscitation and fluid intake and outputmonitoring; however, administeringepinephrine is the first priority.83. Answer: (D) bilateral hearing loss.Rationale: Prolonged use of aspirin and othersalicylates sometimes causes bilateral hearingloss of 30 to 40 decibels. Usually, this adverseeffect resolves within 2 weeks after thetherapy is discontinued. Aspirin doesnt leadto weight gain or fine motor tremors. Large ortoxic salicylate doses may cause respiratoryalkalosis, not respiratory acidosis.84. Answer: (D) LymphocyteRationale: The lymphocyte provides adaptiveimmunity — recognition of a foreign antigenand formation of memory cells against theantigen. Adaptive immunity is mediated by Band T lymphocytes and can be acquiredactively or passively. The neutrophil is crucialto phagocytosis. The basophil plays animportant role in the release of inflammatorymediators. The monocyte functions inphagocytosis and monokine production.85. Answer: (A) moisture replacement.Rationale: Sjogrens syndrome is anautoimmune disorder leading to progressiveloss of lubrication of the skin, GI tract, ears,nose, and vagina. Moisture replacement is themainstay of therapy. Though malnutrition andelectrolyte imbalance may occur as a result ofSjogrens syndromes effect on the GI tract, itisnt the predominant problem. Arrhythmiasarent a problem associated with Sjogrenssyndrome.86. Answer: (C) stool for Clostridium difficile test.Rationale: Immunosuppressed clients — forexample, clients receiving chemotherapy, —are at risk for infection with C. difficile, whichcauses "horse barn" smelling diarrhea.Successful treatment begins with an accuratediagnosis, which includes a stool test. TheELISA test is diagnostic for humanimmunodeficiency virus (HIV) and isntindicated in this case. An electrolyte panel andhemogram may be useful in the overallevaluation of a client but arent diagnostic forspecific causes of diarrhea. A flat plate of theabdomen may provide useful informationabout bowel function but isnt indicated in thecase of "horse barn" smelling diarrhea.87. Answer: (D) Western blot test with ELISA.Rationale: HIV infection is detected byanalyzing blood for antibodies to HIV, whichform approximately 2 to 12 weeks afterexposure to HIV and denote infection. TheWestern blot test — electrophoresis ofantibody proteins — is more than 98%accurate in detecting HIV antibodies whenused in conjunction with the ELISA. It isntspecific when used alone. E-rosetteimmunofluorescence is used to detect viruses
  • 110in general; it doesnt confirm HIV infection.Quantification of T-lymphocytes is a usefulmonitoring test but isnt diagnostic for HIV.The ELISA test detects HIV antibody particlesbut may yield inaccurate results; a positiveELISA result must be confirmed by theWestern blot test.88. Answer: (C) Abnormally low hematocrit (HCT)and hemoglobin (Hb) levelsRationale: Low preoperative HCT and Hblevels indicate the client may require a bloodtransfusion before surgery. If the HCT and Hblevels decrease during surgery because ofblood loss, the potential need for atransfusion increases. Possible renal failure isindicated by elevated BUN or creatinine levels.Urine constituents arent found in the blood.Coagulation is determined by the presence ofappropriate clotting factors, not electrolytes.89. Answer: (A) Platelet count, prothrombin time,and partial thromboplastin timeRationale: The diagnosis of DIC is based on theresults of laboratory studies of prothrombintime, platelet count, thrombin time, partialthromboplastin time, and fibrinogen level aswell as client history and other assessmentfactors. Blood glucose levels, WBC count,calcium levels, and potassium levels arentused to confirm a diagnosis of DIC.90. Answer: (D) StrawberriesRationale: Common food allergens includeberries, peanuts, Brazil nuts, cashews,shellfish, and eggs. Bread, carrots, andoranges rarely cause allergic reactions.91. Answer: (B) A client with cast on the right legwho states, “I have a funny feeling in my rightleg.”Rationale: It may indicate neurovascularcompromise, requires immediate assessment.92. Answer: (D) A 62-year-old who had anabdominal-perineal resection three days ago;client complaints of chills.Rationale: The client is at risk for peritonitis;should be assessed for further symptoms andinfection.93. Answer: (C) The client spontaneously flexeshis wrist when the blood pressure is obtained.Rationale: Carpal spasms indicatehypocalcemia.94. Answer: (D) Use comfort measures andpillows to position the client.Rationale: Using comfort measures andpillows to position the client is a non-pharmacological methods of pain relief.95. Answer: (B) Warm the dialysate solution.Rationale: Cold dialysate increases discomfort.The solution should be warmed to bodytemperature in warmer or heating pad; don’tuse microwave oven.96. Answer: (C) The client holds the cane with hisleft hand, moves the cane forward followedby the right leg, and then moves the left leg.Rationale: The cane acts as a support and aidsin weight bearing for the weaker right leg.97. Answer: (A) Ask the woman’s family toprovide personal items such as photos ormementos.Rationale: Photos and mementos providevisual stimulation to reduce sensorydeprivation.98. Answer: (B) The client lifts the walker, movesit forward 10 inches, and then takes severalsmall steps forward.Rationale: A walker needs to be picked up,placed down on all legs.99. Answer: (C) Isolation from their families andfamiliar surroundings.Rationale: Gradual loss of sight, hearing, andtaste interferes with normal functioning.100. Answer: (A) Encourage the client to performpursed lip breathing.Rationale: Purse lip breathing prevents thecollapse of lung unit and helps client controlrate and depth of breathing.
  • 111TEST IV - Care of Clients with Physiologic andPsychosocial Alterations1. Randy has undergone kidney transplant, whatassessment would prompt Nurse Katrina tosuspect organ rejection?a. Sudden weight lossb. Polyuriac. Hypertensiond. Shock2. The immediate objective of nursing care for anoverweight, mildly hypertensive male client withureteral colic and hematuria is to decrease:a. Painb. Weightc. Hematuriad. Hypertension3. Matilda, with hyperthyroidism is to receiveLugol’s iodine solution before a subtotalthyroidectomy is performed. The nurse is awarethat this medication is given to:a. Decrease the total basal metabolic rate.b. Maintain the function of the parathyroidglands.c. Block the formation of thyroxine by thethyroid gland.d. Decrease the size and vascularity of thethyroid gland.4. Ricardo, was diagnosed with type I diabetes. Thenurse is aware that acute hypoglycemia also candevelop in the client who is diagnosed with:a. Liver diseaseb. Hypertensionc. Type 2 diabetesd. Hyperthyroidism5. Tracy is receiving combination chemotherapy fortreatment of metastatic carcinoma. Nurse Rubyshould monitor the client for the systemic sideeffect of:a. Ascitesb. Nystagmusc. Leukopeniad. Polycythemia6. Norma, with recent colostomy expressesconcern about the inability to control thepassage of gas. Nurse Oliver should suggest thatthe client plan to:a. Eliminate foods high in cellulose.b. Decrease fluid intake at meal times.c. Avoid foods that in the past causedflatus.d. Adhere to a bland diet prior to socialevents.7. Nurse Ron begins to teach a male client how toperform colostomy irrigations. The nurse wouldevaluate that the instructions were understoodwhen the client states, “I should:a. Lie on my left side while instilling theirrigating solution.”b. Keep the irrigating container less than18 inches above the stoma.”c. Instill a minimum of 1200 ml of irrigatingsolution to stimulate evacuation of thebowel.”d. Insert the irrigating catheter deeper intothe stoma if cramping occurs during theprocedure.”8. Patrick is in the oliguric phase of acute tubularnecrosis and is experiencing fluid and electrolyteimbalances. The client is somewhat confusedand complains of nausea and muscle weakness.As part of the prescribed therapy to correct thiselectrolyte imbalance, the nurse would expectto:a. Administer Kayexalateb. Restrict foods high in proteinc. Increase oral intake of cheese and milk.d. Administer large amounts of normalsaline via I.V.9. Mario has burn injury. After Forty48 hours, thephysician orders for Mario 2 liters of IV fluid tobe administered q12 h. The drop factor of thetubing is 10 gtt/ml. The nurse should set theflow to provide:a. 18 gtt/minb. 28 gtt/minc. 32 gtt/mind. 36 gtt/min10. Terence suffered from burn injury. Using the ruleof nines, which has the largest percent of burns?a. Face and neckb. Right upper arm and penisc. Right thigh and penisd. Upper trunk11. Herbert, a 45 year old construction engineer isbrought to the hospital unconscious after falling
  • 112from a 2-story building. When assessing theclient, the nurse would be most concerned if theassessment revealed:a. Reactive pupilsb. A depressed fontanelc. Bleeding from earsd. An elevated temperature12. Nurse Sherry is teaching male client regardinghis permanent artificial pacemaker. Whichinformation given by the nurse shows herknowledge deficit about the artificial cardiacpacemaker?a. take the pulse rate once a day, in themorning upon awakeningb. May be allowed to use electricalappliancesc. Have regular follow up cared. May engage in contact sports13. The nurse is ware that the most relevantknowledge about oxygen administration to amale client with COPD isa. Oxygen at 1-2L/min is given to maintainthe hypoxic stimulus for breathing.b. Hypoxia stimulates the centralchemoreceptors in the medulla thatmakes the client breath.c. Oxygen is administered best using a non-rebreathing maskd. Blood gases are monitored using a pulseoximeter.14. Tonny has undergoes a left thoracotomy and apartial pneumonectomy. Chest tubes areinserted, and one-bottle water-seal drainage isinstituted in the operating room. In thepostanesthesia care unit Tonny is placed inFowlers position on either his right side or onhis back. The nurse is aware that this position:a. Reduce incisional pain.b. Facilitate ventilation of the left lung.c. Equalize pressure in the pleural space.d. Increase venous return15. Kristine is scheduled for a bronchoscopy. Whenteaching Kristine what to expect afterward, thenurses highest priority of information would be:a. Food and fluids will be withheld for atleast 2 hours.b. Warm saline gargles will be done q 2h.c. Coughing and deep-breathing exerciseswill be done q2h.d. Only ice chips and cold liquids will beallowed initially.16. Nurse Tristan is caring for a male client in acuterenal failure. The nurse should expect hypertonicglucose, insulin infusions, and sodiumbicarbonate to be used to treat:a. hypernatremia.b. hypokalemia.c. hyperkalemia.d. hypercalcemia.17. Ms. X has just been diagnosed with condylomataacuminata (genital warts). What information isappropriate to tell this client?a. This condition puts her at a higher riskfor cervical cancer; therefore, she shouldhave a Papanicolaou (Pap) smearannually.b. The most common treatment ismetronidazole (Flagyl), which shoulderadicate the problem within 7 to 10days.c. The potential for transmission to hersexual partner will be eliminated ifcondoms are used every time they havesexual intercourse.d. The human papillomavirus (HPV), whichcauses condylomata acuminata, cant betransmitted during oral sex.18. Maritess was recently diagnosed with agenitourinary problem and is being examined inthe emergency department. When palpating herkidneys, the nurse should keep which anatomicalfact in mind?a. The left kidney usually is slightly higherthan the right one.b. The kidneys are situated just above theadrenal glands.c. The average kidney is approximately 5cm (2") long and 2 to 3 cm (¾" to 1-1/8")wide.d. The kidneys lie between the 10th and12th thoracic vertebrae.19. Jestoni with chronic renal failure (CRF) isadmitted to the urology unit. The nurse is awarethat the diagnostic test are consistent with CRF ifthe result is:a. Increased pH with decreased hydrogenions.
  • 113b. Increased serum levels of potassium,magnesium, and calcium.c. Blood urea nitrogen (BUN) 100 mg/dland serum creatinine 6.5 mg/ dl.d. Uric acid analysis 3.5 mg/dl andphenolsulfonphthalein (PSP) excretion75%.20. Katrina has an abnormal result on aPapanicolaou test. After admitting that she readher chart while the nurse was out of the room,Katrina asks what dysplasia means. Whichdefinition should the nurse provide?a. Presence of completely undifferentiatedtumor cells that dont resemble cells ofthe tissues of their origin.b. Increase in the number of normal cells ina normal arrangement in a tissue or anorgan.c. Replacement of one type of fullydifferentiated cell by another in tissueswhere the second type normally isntfound.d. Alteration in the size, shape, andorganization of differentiated cells.21. During a routine checkup, Nurse Marianeassesses a male client with acquiredimmunodeficiency syndrome (AIDS) for signs andsymptoms of cancer. What is the most commonAIDS-related cancer?a. Squamous cell carcinomab. Multiple myelomac. Leukemiad. Kaposis sarcoma22. Ricardo is scheduled for a prostatectomy, andthe anesthesiologist plans to use a spinal(subarachnoid) block during surgery. In theoperating room, the nurse positions the clientaccording to the anesthesiologists instructions.Why does the client require special positioningfor this type of anesthesia?a. To prevent confusionb. To prevent seizuresc. To prevent cerebrospinal fluid (CSF)leakaged. To prevent cardiac arrhythmias23. A male client had a nephrectomy 2 days ago andis now complaining of abdominal pressure andnausea. The first nursing action should be to:a. Auscultate bowel sounds.b. Palpate the abdomen.c. Change the clients position.d. Insert a rectal tube.24. Wilfredo with a recent history of rectal bleedingis being prepared for a colonoscopy. How shouldthe nurse Patricia position the client for this testinitially?a. Lying on the right side with legs straightb. Lying on the left side with knees bentc. Prone with the torso elevatedd. Bent over with hands touching the floor25. A male client with inflammatory bowel diseaseundergoes an ileostomy. On the first day aftersurgery, Nurse Oliver notes that the clientsstoma appears dusky. How should the nurseinterpret this finding?a. Blood supply to the stoma has beeninterrupted.b. This is a normal finding 1 day aftersurgery.c. The ostomy bag should be adjusted.d. An intestinal obstruction has occurred.26. Anthony suffers burns on the legs, which nursingintervention helps prevent contractures?a. Applying knee splintsb. Elevating the foot of the bedc. Hyperextending the clients palmsd. Performing shoulder range-of-motionexercises27. Nurse Ron is assessing a client admitted withsecond- and third-degree burns on the face,arms, and chest. Which finding indicates apotential problem?a. Partial pressure of arterial oxygen(PaO2) value of 80 mm Hg.b. Urine output of 20 ml/hour.c. White pulmonary secretions.d. Rectal temperature of 100.6° F (38° C).28. Mr. Mendoza who has suffered acerebrovascular accident (CVA) is too weak tomove on his own. To help the client avoidpressure ulcers, Nurse Celia should:a. Turn him frequently.b. Perform passive range-of-motion (ROM)exercises.c. Reduce the clients fluid intake.d. Encourage the client to use a footboard.
  • 11429. Nurse Maria plans to administer dexamethasonecream to a female client who has dermatitis overthe anterior chest. How should the nurse applythis topical agent?a. With a circular motion, to enhanceabsorption.b. With an upward motion, to increaseblood supply to the affected areac. In long, even, outward, and downwardstrokes in the direction of hair growthd. In long, even, outward, and upwardstrokes in the direction opposite hairgrowth30. Nurse Kate is aware that one of the followingclasses of medication protects the ischemicmyocardium by blocking catecholamines andsympathetic nerve stimulation is:a. Beta -adrenergic blockersb. Calcium channel blockerc. Narcoticsd. Nitrates31. A male client has jugular distention. On whatposition should the nurse place the head of thebed to obtain the most accurate reading ofjugular vein distention?a. High Fowler’sb. Raised 10 degreesc. Raised 30 degreesd. Supine position32. The nurse is aware that one of the followingclasses of medications maximizes cardiacperformance in clients with heart failure byincreasing ventricular contractility?a. Beta-adrenergic blockersb. Calcium channel blockerc. Diureticsd. Inotropic agents33. A male client has a reduced serum high-densitylipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of thefollowing dietary modifications is notappropriate for this client?a. Fiber intake of 25 to 30 g dailyb. Less than 30% of calories from fatc. Cholesterol intake of less than 300 mgdailyd. Less than 10% of calories from saturatedfat34. A 37-year-old male client was admitted to thecoronary care unit (CCU) 2 days ago with anacute myocardial infarction. Which of thefollowing actions would breach the clientconfidentiality?a. The CCU nurse gives a verbal report tothe nurse on the telemetry unit beforetransferring the client to that unitb. The CCU nurse notifies the on-callphysician about a change in the client’sconditionc. The emergency department nurse callsup the latest electrocardiogram resultsto check the client’s progress.d. At the client’s request, the CCU nurseupdates the client’s wife on his condition35. A male client arriving in the emergencydepartment is receiving cardiopulmonaryresuscitation from paramedics who are givingventilations through an endotracheal (ET) tubethat they placed in the client’s home. During apause in compressions, the cardiac monitorshows narrow QRS complexes and a heart rateof beats/minute with a palpable pulse. Which ofthe following actions should the nurse take first?a. Start an L.V. line and administeramiodarone (Cardarone), 300 mg L.V.over 10 minutes.b. Check endotracheal tube placement.c. Obtain an arterial blood gas (ABG)sample.d. Administer atropine, 1 mg L.V.36. After cardiac surgery, a client’s blood pressuremeasures 126/80 mm Hg. Nurse Katrinadetermines that mean arterial pressure (MAP) iswhich of the following?a. 46 mm Hgb. 80 mm Hgc. 95 mm Hgd. 90 mm Hg37. A female client arrives at the emergencydepartment with chest and stomach pain and areport of black tarry stool for several months.Which of the following order should the nurseOliver anticipate?a. Cardiac monitor, oxygen, creatine kinaseand lactate dehydrogenase levelsb. Prothrombin time, partialthromboplastin time, fibrinogen andfibrin split product values.
  • 115c. Electrocardiogram, complete bloodcount, testing for occult blood,comprehensive serum metabolic panel.d. Electroencephalogram, alkalinephosphatase and aspartateaminotransferase levels, basic serummetabolic panel38. Macario had coronary artery bypass graft (CABG)surgery 3 days ago. Which of the followingconditions is suspected by the nurse when adecrease in platelet count from 230,000 ul to5,000 ul is noted?a. Pancytopeniab. Idiopathic thrombocytopemic purpura(ITP)c. Disseminated intravascular coagulation(DIC)d. Heparin-associated thrombosis andthrombocytopenia (HATT)39. Which of the following drugs would be orderedby the physician to improve the platelet count ina male client with idiopathic thrombocytopenicpurpura (ITP)?a. Acetylsalicylic acid (ASA)b. Corticosteroidsc. Methotrezated. Vitamin K40. A female client is scheduled to receive a heartvalve replacement with a porcine valve. Whichof the following types of transplant is this?a. Allogeneicb. Autologousc. Syngeneicd. Xenogeneic41. Marco falls off his bicycle and injuries his ankle.Which of the following actions shows the initialresponse to the injury in the extrinsic pathway?a. Release of Calciumb. Release of tissue thromboplastinc. Conversion of factors XII to factor XIIad. Conversion of factor VIII to factor VIIIa42. Instructions for a client with systemic lupuserythematosus (SLE) would include informationabout which of the following blood dyscrasias?a. Dressler’s syndromeb. Polycythemiac. Essential thrombocytopeniad. Von Willebrand’s disease43. The nurse is aware that the following symptomis most commonly an early indication of stage 1Hodgkin’s disease?a. Pericarditisb. Night sweatc. Splenomegalyd. Persistent hypothermia44. Francis with leukemia has neutropenia. Which ofthe following functions must frequentlyassessed?a. Blood pressureb. Bowel soundsc. Heart soundsd. Breath sounds45. The nurse knows that neurologic complicationsof multiple myeloma (MM) usually involve whichof the following body system?a. Brainb. Muscle spasmc. Renal dysfunctiond. Myocardial irritability46. Nurse Patricia is aware that the average lengthof time from human immunodeficiency virus(HIV) infection to the development of acquiredimmunodeficiency syndrome (AIDS)?a. Less than 5 yearsb. 5 to 7 yearsc. 10 yearsd. More than 10 years47. An 18-year-old male client admitted with heatstroke begins to show signs of disseminatedintravascular coagulation (DIC). Which of thefollowing laboratory findings is most consistentwith DIC?a. Low platelet countb. Elevated fibrinogen levelsc. Low levels of fibrin degradation productsd. Reduced prothrombin time48. Mario comes to the clinic complaining of fever,drenching night sweats, and unexplained weightloss over the past 3 months. Physicalexamination reveals a single enlargedsupraclavicular lymph node. Which of thefollowing is the most probable diagnosis?a. Influenzab. Sickle cell anemiac. Leukemiad. Hodgkin’s disease
  • 11649. A male client with a gunshot wound requires anemergency blood transfusion. His blood type isAB negative. Which blood type would be thesafest for him to receive?a. AB Rh-positiveb. A Rh-positivec. A Rh-negatived. O Rh-positiveSituation: Stacy is diagnosed with acute lymphoidleukemia (ALL) and beginning chemotherapy.50. Stacy is discharged from the hospital followingher chemotherapy treatments. Which statementof Stacy’s mother indicated that she understandswhen she will contact the physician?a. “I should contact the physician if Stacyhas difficulty in sleeping”.b. “I will call my doctor if Stacy haspersistent vomiting and diarrhea”.c. “My physician should be called if Stacy isirritable and unhappy”.d. “Should Stacy have continued hair loss, Ineed to call the doctor”.51. Stacy’s mother states to the nurse that it is hardto see Stacy with no hair. The best response forthe nurse is:a. “Stacy looks very nice wearing a hat”.b. “You should not worry about her hair,just be glad that she is alive”.c. “Yes it is upsetting. But try to cover upyour feelings when you are with her orelse she may be upset”.d. “This is only temporary; Stacy will re-grow new hair in 3-6 months, but maybe different in texture”.52. Stacy has beginning stomatitis. To promote oralhygiene and comfort, the nurse in-chargeshould:a. Provide frequent mouthwash withnormal saline.b. Apply viscous Lidocaine to oral ulcers asneeded.c. Use lemon glycerine swabs every 2hours.d. Rinse mouth with Hydrogen Peroxide.53. During the administration of chemotherapyagents, Nurse Oliver observed that the IV site isred and swollen, when the IV is touched Stacyshouts in pain. The first nursing action to take is:a. Notify the physicianb. Flush the IV line with saline solutionc. Immediately discontinue the infusiond. Apply an ice pack to the site, followed bywarm compress.54. The term “blue bloater” refers to a male clientwhich of the following conditions?a. Adult respiratory distress syndrome(ARDS)b. Asthmac. Chronic obstructive bronchitisd. Emphysema55. The term “pink puffer” refers to the femaleclient with which of the following conditions?a. Adult respiratory distress syndrome(ARDS)b. Asthmac. Chronic obstructive bronchitisd. Emphysema56. Jose is in danger of respiratory arrest followingthe administration of a narcotic analgesic. Anarterial blood gas value is obtained. Nurse Oliverwould expect the paco2 to be which of thefollowing values?a. 15 mm Hgb. 30 mm Hgc. 40 mm Hgd. 80 mm Hg57. Timothy’s arterial blood gas (ABG) results are asfollows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mmHg; HCO3- 24mEq/L; Sao2 81%. This ABG resultrepresents which of the following conditions?a. Metabolic acidosisb. Metabolic alkalosisc. Respiratory acidosisd. Respiratory alkalosis58. Norma has started a new drug for hypertension.Thirty minutes after she takes the drug, shedevelops chest tightness and becomes short ofbreath and tachypneic. She has a decreased levelof consciousness. These signs indicate which ofthe following conditions?a. Asthma attackb. Pulmonary embolismc. Respiratory failured. Rheumatoid arthritis
  • 117Situation: Mr. Gonzales was admitted to the hospitalwith ascites and jaundice. To rule out cirrhosis of theliver:59. Which laboratory test indicates liver cirrhosis?a. Decreased red blood cell countb. Decreased serum acid phosphate levelc. Elevated white blood cell countd. Elevated serum aminotransferase60. 60.The biopsy of Mr. Gonzales confirms thediagnosis of cirrhosis. Mr. Gonzales is atincreased risk for excessive bleeding primarilybecause of:a. Impaired clotting mechanismb. Varix formationc. Inadequate nutritiond. Trauma of invasive procedure61. Mr. Gonzales develops hepatic encephalopathy.Which clinical manifestation is most commonwith this condition?a. Increased urine outputb. Altered level of consciousnessc. Decreased tendon reflexd. Hypotension62. When Mr. Gonzales regained consciousness, thephysician orders 50 ml of Lactose p.o. every 2hours. Mr. Gozales develops diarrhea. The nursebest action would be:a. “I’ll see if your physician is in thehospital”.b. “Maybe you’re reacting to the drug; Iwill withhold the next dose”.c. “I’ll lower the dosage as ordered so thedrug causes only 2 to 4 stools a day”.d. “Frequently, bowel movements areneeded to reduce sodium level”.63. Which of the following groups of symptomsindicates a ruptured abdominal aorticaneurysm?a. Lower back pain, increased bloodpressure, decreased red blood cell (RBC)count, increased white blood (WBC)count.b. Severe lower back pain, decreased bloodpressure, decreased RBC count,increased WBC count.c. Severe lower back pain, decreased bloodpressure, decreased RBC count,decreased RBC count, decreased WBCcount.d. Intermitted lower back pain, decreasedblood pressure, decreased RBC count,increased WBC count.64. After undergoing a cardiac catheterization, Tracyhas a large puddle of blood under his buttocks.Which of the following steps should the nursetake first?a. Call for help.b. Obtain vital signsc. Ask the client to “lift up”d. Apply gloves and assess the groin site65. Which of the following treatment is a suitablesurgical intervention for a client with unstableangina?a. Cardiac catheterizationb. Echocardiogramc. Nitroglycerind. Percutaneous transluminal coronaryangioplasty (PTCA)66. The nurse is aware that the following terms usedto describe reduced cardiac output andperfusion impairment due to ineffectivepumping of the heart is:a. Anaphylactic shockb. Cardiogenic shockc. Distributive shockd. Myocardial infarction (MI)67. A client with hypertension asks the nurse whichfactors can cause blood pressure to drop tonormal levels?a. Kidneys’ excretion to sodium only.b. Kidneys’ retention of sodium and waterc. Kidneys’ excretion of sodium and waterd. Kidneys’ retention of sodium andexcretion of water68. Nurse Rose is aware that the statement thatbest explains why furosemide (Lasix) isadministered to treat hypertension is:a. It dilates peripheral blood vessels.b. It decreases sympatheticcardioacceleration.c. It inhibits the angiotensin-covertingenzymesd. It inhibits reabsorption of sodium andwater in the loop of Henle.
  • 11869. Nurse Nikki knows that laboratory resultssupports the diagnosis of systemic lupuserythematosus (SLE) is:a. Elavated serum complement levelb. Thrombocytosis, elevated sedimentationratec. Pancytopenia, elevated antinuclearantibody (ANA) titerd. Leukocysis, elevated blood urea nitrogen(BUN) and creatinine levels70. Arnold, a 19-year-old client with a mildconcussion is discharged from the emergencydepartment. Before discharge, he complains of aheadache. When offered acetaminophen, hismother tells the nurse the headache is severeand she would like her son to have somethingstronger. Which of the following responses bythe nurse is appropriate?a. “Your son had a mild concussion,acetaminophen is strong enough.”b. “Aspirin is avoided because of thedanger of Reye’s syndrome in children oryoung adults.”c. “Narcotics are avoided after a headinjury because they may hide aworsening condition.”d. Stronger medications may lead tovomiting, which increases theintracarnial pressure (ICP).”71. When evaluating an arterial blood gas from amale client with a subdural hematoma, thenurse notes the Paco2 is 30 mm Hg. Which ofthe following responses best describes theresult?a. Appropriate; lowering carbon dioxide(CO2) reduces intracranial pressure (ICP)b. Emergent; the client is poorlyoxygenatedc. Normald. Significant; the client has alveolarhypoventilation72. When prioritizing care, which of the followingclients should the nurse Olivia assess first?a. A 17-year-old client’s 24-hourspostappendectomyb. A 33-year-old client with a recentdiagnosis of Guillain-Barre syndromec. A 50-year-old client 3 dayspostmyocardial infarctiond. A 50-year-old client with diverticulitis73. JP has been diagnosed with gout and wants toknow why colchicine is used in the treatment ofgout. Which of the following actions ofcolchicines explains why it’s effective for gout?a. Replaces estrogenb. Decreases infectionc. Decreases inflammationd. Decreases bone demineralization74. Norma asks for information about osteoarthritis.Which of the following statements aboutosteoarthritis is correct?a. Osteoarthritis is rarely debilitatingb. Osteoarthritis is a rare form of arthritisc. Osteoarthritis is the most common formof arthritisd. Osteoarthritis afflicts people over 6075. Ruby is receiving thyroid replacement therapydevelops the flu and forgets to take her thyroidreplacement medicine. The nurse understandsthat skipping this medication will put the clientat risk for developing which of the following life-threatening complications?a. Exophthalmosb. Thyroid stormc. Myxedema comad. Tibial myxedema76. Nurse Sugar is assessing a client with Cushingssyndrome. Which observation should the nursereport to the physician immediately?a. Pitting edema of the legsb. An irregular apical pulsec. Dry mucous membranesd. Frequent urination77. Cyrill with severe head trauma sustained in a caraccident is admitted to the intensive care unit.Thirty-six hours later, the clients urine outputsuddenly rises above 200 ml/hour, leading thenurse to suspect diabetes insipidus. Whichlaboratory findings support the nurses suspicionof diabetes insipidus?a. Above-normal urine and serumosmolality levelsb. Below-normal urine and serumosmolality levelsc. Above-normal urine osmolality level,below-normal serum osmolality leveld. Below-normal urine osmolality level,above-normal serum osmolality level
  • 11978. Jomari is diagnosed with hyperosmolarhyperglycemic nonketotic syndrome (HHNS) isstabilized and prepared for discharge. Whenpreparing the client for discharge and homemanagement, which of the following statementsindicates that the client understands hercondition and how to control it?a. "I can avoid getting sick by not becomingdehydrated and by paying attention tomy need to urinate, drink, or eat morethan usual."b. "If I experience trembling, weakness,and headache, I should drink a glass ofsoda that contains sugar."c. "I will have to monitor my blood glucoselevel closely and notify the physician ifits constantly elevated."d. "If I begin to feel especially hungry andthirsty, Ill eat a snack high incarbohydrates."79. A 66-year-old client has been complaining ofsleeping more, increased urination, anorexia,weakness, irritability, depression, and bone painthat interferes with her going outdoors. Basedon these assessment findings, the nurse wouldsuspect which of the following disorders?a. Diabetes mellitusb. Diabetes insipidusc. Hypoparathyroidismd. Hyperparathyroidism80. Nurse Lourdes is teaching a client recoveringfrom addisonian crisis about the need to takefludrocortisone acetate and hydrocortisone athome. Which statement by the client indicatesan understanding of the instructions?a. "Ill take my hydrocortisone in the lateafternoon, before dinner."b. "Ill take all of my hydrocortisone in themorning, right after I wake up."c. "Ill take two-thirds of the dose when Iwake up and one-third in the lateafternoon."d. "Ill take the entire dose at bedtime."81. Which of the following laboratory test resultswould suggest to the nurse Len that a client hasa corticotropin-secreting pituitary adenoma?a. High corticotropin and low cortisol levelsb. Low corticotropin and high cortisol levelsc. High corticotropin and high cortisollevelsd. Low corticotropin and low cortisol levels82. A male client is scheduled for a transsphenoidalhypophysectomy to remove a pituitary tumor.Preoperatively, the nurse should assess forpotential complications by doing which of thefollowing?a. Testing for ketones in the urineb. Testing urine specific gravityc. Checking temperature every 4 hoursd. Performing capillary glucose testingevery 4 hours83. Capillary glucose monitoring is being performedevery 4 hours for a client diagnosed withdiabetic ketoacidosis. Insulin is administeredusing a scale of regular insulin according toglucose results. At 2 p.m., the client has acapillary glucose level of 250 mg/dl for which hereceives 8 U of regular insulin. Nurse Marinershould expect the doses:a. onset to be at 2 p.m. and its peak to beat 3 p.m.b. onset to be at 2:15 p.m. and its peak tobe at 3 p.m.c. onset to be at 2:30 p.m. and its peak tobe at 4 p.m.d. onset to be at 4 p.m. and its peak to beat 6 p.m.84. The physician orders laboratory tests to confirmhyperthyroidism in a female client with classicsigns and symptoms of this disorder. Which testresult would confirm the diagnosis?a. No increase in the thyroid-stimulatinghormone (TSH) level after 30 minutesduring the TSH stimulation testb. A decreased TSH levelc. An increase in the TSH level after 30minutes during the TSH stimulation testd. Below-normal levels of serumtriiodothyronine (T3) and serumthyroxine (T4) as detected byradioimmunoassay85. Rico with diabetes mellitus must learn how toself-administer insulin. The physician hasprescribed 10 U of U-100 regular insulin and 35U of U-100 isophane insulin suspension (NPH) tobe taken before breakfast. When teaching theclient how to select and rotate insulin injectionsites, the nurse should provide whichinstruction?
  • 120a. "Inject insulin into healthy tissue withlarge blood vessels and nerves."b. "Rotate injection sites within the sameanatomic region, not among differentregions."c. "Administer insulin into areas of scartissue or hypotrophy wheneverpossible."d. "Administer insulin into sites abovemuscles that you plan to exercise heavilylater that day."86. Nurse Sarah expects to note an elevated serumglucose level in a client with hyperosmolarhyperglycemic nonketotic syndrome (HHNS).Which other laboratory finding should the nurseanticipate?a. Elevated serum acetone levelb. Serum ketone bodiesc. Serum alkalosisd. Below-normal serum potassium level87. For a client with Graves disease, which nursingintervention promotes comfort?a. Restricting intake of oral fluidsb. Placing extra blankets on the clients bedc. Limiting intake of high-carbohydratefoodsd. Maintaining room temperature in thelow-normal range88. Patrick is treated in the emergency departmentfor a Colles fracture sustained during a fall.What is a Colles fracture?a. Fracture of the distal radiusb. Fracture of the olecranonc. Fracture of the humerusd. Fracture of the carpal scaphoid89. Cleo is diagnosed with osteoporosis. Whichelectrolytes are involved in the development ofthis disorder?a. Calcium and sodiumb. Calcium and phosphorousc. Phosphorous and potassiumd. Potassium and sodium90. Johnny a firefighter was involved inextinguishing a house fire and is being treated tosmoke inhalation. He develops severe hypoxia48 hours after the incident, requiring intubationand mechanical ventilation. He most likely hasdeveloped which of the following conditions?a. Adult respiratory distress syndrome(ARDS)b. Atelectasisc. Bronchitisd. Pneumonia91. A 67-year-old client develops acute shortness ofbreath and progressive hypoxia requiring rightfemur. The hypoxia was probably caused bywhich of the following conditions?a. Asthma attackb. Atelectasisc. Bronchitisd. Fat embolism92. A client with shortness of breath has decreasedto absent breath sounds on the right side, fromthe apex to the base. Which of the followingconditions would best explain this?a. Acute asthmab. Chronic bronchitisc. Pneumoniad. Spontaneous pneumothorax93. A 62-year-old male client was in a motor vehicleaccident as an unrestrained driver. He’s now inthe emergency department complaining ofdifficulty of breathing and chest pain. Onauscultation of his lung field, no breath soundsare present in the upper lobe. This client mayhave which of the following conditions?a. Bronchitisb. Pneumoniac. Pneumothoraxd. Tuberculosis (TB)94. If a client requires a pneumonectomy, what fillsthe area of the thoracic cavity?a. The space remains filled with air onlyb. The surgeon fills the space with a gelc. Serous fluids fills the space andconsolidates the regiond. The tissue from the other lung growsover to the other side95. Hemoptysis may be present in the client with apulmonary embolism because of which of thefollowing reasons?a. Alveolar damage in the infracted areab. Involvement of major blood vessels inthe occluded areac. Loss of lung parenchymad. Loss of lung tissue
  • 12196. Aldo with a massive pulmonary embolism willhave an arterial blood gas analysis performed todetermine the extent of hypoxia. The acid-basedisorder that may be present is?a. Metabolic acidosisb. Metabolic alkalosisc. Respiratory acidosisd. 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 itto a chest drainage system. Bubbling soonappears in the water seal chamber. Which of thefollowing is the most likely cause of thebubbling?a. Air leakb. Adequate suctionc. Inadequate suctiond. Kinked chest tube98. Nurse Michelle calculates the IV flow rate for apostoperative client. The client receives 3,000 mlof Ringer’s lactate solution IV to run over 24hours. The IV infusion set has a drop factor of 10drops per milliliter. The nurse should regulatethe client’s IV to deliver how many drops perminute?a. 18b. 21c. 35d. 4099. Mickey, a 6-year-old child with a congenitalheart disorder is admitted with congestive heartfailure. Digoxin (lanoxin) 0.12 mg is ordered forthe child. The bottle of Lanoxin contains .05 mgof Lanoxin in 1 ml of solution. What amountshould the nurse administer to the child?a. 1.2 mlb. 2.4 mlc. 3.5 mld. 4.2 ml100. Nurse Alexandra teaches a client about elasticstockings. Which of the following statements,if made by the client, indicates to the nursethat the teaching was successful?a. “I will wear the stockings until thephysician tells me to remove them.”b. “I should wear the stockings even when Iam sleep.”c. “Every four hours I should remove thestockings for a half hour.”d. “I should put on the stockings beforegetting out of bed in the morning.”
  • 122Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations1. Answer: (C) HypertensionRationale: Hypertension, along with fever,and tenderness over the grafted kidney,reflects acute rejection.2. Answer: (A) PainRationale: Sharp, severe pain (renal colic)radiating toward the genitalia and thigh iscaused by uretheral distention andsmooth muscle spasm; relief form pain isthe priority.3. Answer: (D) Decrease the size andvascularity of the thyroid gland.Rationale: Lugol’s solution providesiodine, which aids in decreasing thevascularity of the thyroid gland, whichlimits the risk of hemorrhage whensurgery is performed.4. Answer: (A) Liver DiseaseRationale: The client with liver disease hasa decreased ability to metabolizecarbohydrates because of a decreasedability to form glycogen (glycogenesis) andto form glucose from glycogen.5. Answer: (C) LeukopeniaRationale: Leukopenia, a reduction inWBCs, is a systemic effect ofchemotherapy as a result ofmyelosuppression.6. Answer: (C) Avoid foods that in the pastcaused flatus.Rationale: Foods that bothered a personpreoperatively will continue to do so aftera colostomy.7. Answer: (B) Keep the irrigating containerless than 18 inches above the stoma.”Rationale: This height permits the solutionto flow slowly with little force so thatexcessive peristalsis is not immediatelyprecipitated.8. Answer: (A) Administer KayexalateRationale: Kayexalate,a potassiumexchange resin, permits sodium to beexchanged for potassium in the intestine,reducing the serum potassium level.9. Answer:(B) 28 gtt/minRationale: This is the correct flow rate;multiply the amount to be infused (2000ml) by the drop factor (10) and divide theresult by the amount of time in minutes(12 hours x 60 minutes)10. Answer: (D) Upper trunkRationale: The percentage designated foreach burned part of the body using therule of nines: Head and neck 9%; Rightupper extremity 9%; Left upper extremity9%; Anterior trunk 18%; Posterior trunk18%; Right lower extremity 18%; Leftlower extremity 18%; Perineum 1%.11. Answer: (C) Bleeding from earsRationale: The nurse needs to perform athorough assessment that could indicatealterations in cerebral function, increasedintracranial pressures, fractures andbleeding. Bleeding from the ears occursonly with basal skull fractures that caneasily contribute to increased intracranialpressure and brain herniation.12. Answer: (D) may engage in contact sportsRationale: The client should be advised bythe nurse to avoid contact sports. This willprevent trauma to the area of thepacemaker generator.13. Answer: (A) Oxygen at 1-2L/min is given tomaintain the hypoxic stimulus forbreathing.Rationale: COPD causes a chronic CO2retention that renders the medullainsensitive to the CO2 stimulation forbreathing. The hypoxic state of the clientthen becomes the stimulus for breathing.Giving the client oxygen in lowconcentrations will maintain the client’shypoxic drive.14. Answer: (B) Facilitate ventilation of theleft lung.Rationale: Since only a partialpneumonectomy is done, there is a needto promote expansion of this remainingLeft lung by positioning the client on theopposite unoperated side.15. Answer: (A) Food and fluids will bewithheld for at least 2 hours.Rationale: Prior to bronchoscopy, thedoctors sprays the back of the throat withanesthetic to minimize the gag reflex andthus facilitate the insertion of thebronchoscope. Giving the client food anddrink after the procedure withoutchecking on the return of the gag reflexcan cause the client to aspirate. The gagreflex usually returns after two hours.16. Answer: (C) hyperkalemia.
  • 123Rationale: Hyperkalemia is a commoncomplication of acute renal failure. Itslife-threatening if immediate action isnttaken to reverse it. The administration ofglucose and regular insulin, with sodiumbicarbonate if necessary, can temporarilyprevent cardiac arrest by movingpotassium into the cells and temporarilyreducing serum potassium levels.Hypernatremia, hypokalemia, andhypercalcemia dont usually occur withacute renal failure and arent treated withglucose, insulin, or sodium bicarbonate.17. Answer: (A) This condition puts her at ahigher risk for cervical cancer; therefore,she should have a Papanicolaou (Pap)smear annually.Rationale: Women with condylomataacuminata are at risk for cancer of thecervix and vulva. Yearly Pap smears arevery important for early detection.Because condylomata acuminata is avirus, there is no permanent cure.Because condylomata acuminata canoccur on the vulva, a condom wontprotect sexual partners. HPV can betransmitted to other parts of the body,such as the mouth, oropharynx, andlarynx.18. Answer: (A) The left kidney usually isslightly higher than the right one.Rationale: The left kidney usually isslightly higher than the right one. Anadrenal gland lies atop each kidney. Theaverage kidney measures approximately11 cm (4-3/8") long, 5 to 5.8 cm (2" to2¼") wide, and 2.5 cm (1") thick. Thekidneys are located retroperitoneally, inthe posterior aspect of the abdomen, oneither side of the vertebral column. Theylie between the 12th thoracic and 3rdlumbar vertebrae.19. Answer: (C) Blood urea nitrogen (BUN)100 mg/dl and serum creatinine 6.5mg/dl.Rationale: The normal BUN level ranges 8to 23 mg/dl; the normal serum creatininelevel ranges from 0.7 to 1.5 mg/dl. Thetest results in option C are abnormallyelevated, reflecting CRF and the kidneysdecreased ability to remove nonproteinnitrogen waste from the blood. CRFcauses decreased pH and increasedhydrogen ions — not vice versa. CRF alsoincreases serum levels of potassium,magnesium, and phosphorous, anddecreases serum levels of calcium. A uricacid analysis of 3.5 mg/dl falls within thenormal range of 2.7 to 7.7 mg/dl; PSPexcretion of 75% also falls with the normalrange of 60% to 75%.20. Answer: (D) Alteration in the size, shape,and organization of differentiated cellsRationale: Dysplasia refers to an alterationin the size, shape, and organization ofdifferentiated cells. The presence ofcompletely undifferentiated tumor cellsthat dont resemble cells of the tissues oftheir origin is called anaplasia. An increasein the number of normal cells in a normalarrangement in a tissue or an organ iscalled hyperplasia. Replacement of onetype of fully differentiated cell by anotherin tissues where the second type normallyisnt found is called metaplasia.21. Answer: (D) Kaposis sarcomaRationale: Kaposis sarcoma is the mostcommon cancer associated with AIDS.Squamous cell carcinoma, multiplemyeloma, and leukemia may occur inanyone and arent associated specificallywith AIDS.22. Answer: (C) To prevent cerebrospinal fluid(CSF) leakageRationale: The client receiving asubarachnoid block requires specialpositioning to prevent CSF leakage andheadache and to ensure proper anestheticdistribution. Proper positioning doesnthelp prevent confusion, seizures, orcardiac arrhythmias.23. Answer: (A) Auscultate bowel sounds.Rationale: If abdominal distention isaccompanied by nausea, the nurse mustfirst auscultate bowel sounds. If bowelsounds are absent, the nurse shouldsuspect gastric or small intestine dilationand these findings must be reported tothe physician. Palpation should beavoided postoperatively with abdominaldistention. If peristalsis is absent,changing positions and inserting a rectaltube wont relieve the clients discomfort.24. Answer: (B) Lying on the left side withknees bentRationale: For a colonoscopy, the nurseinitially should position the client on the
  • 124left side with knees bent. Placing theclient on the right side with legs straight,prone with the torso elevated, or bentover with hands touching the floorwouldnt allow proper visualization of thelarge intestine.25. Answer: (A) Blood supply to the stoma hasbeen interruptedRationale: An ileostomy stoma forms asthe ileum is brought through theabdominal wall to the surface skin,creating an artificial opening for wasteelimination. The stoma should appearcherry red, indicating adequate arterialperfusion. A dusky stoma suggestsdecreased perfusion, which may resultfrom interruption of the stomas bloodsupply and may lead to tissue damage ornecrosis. A dusky stoma isnt a normalfinding. Adjusting the ostomy bagwouldnt affect stoma color, whichdepends on blood supply to the area. Anintestinal obstruction also wouldntchange stoma color.26. Answer: (A) Applying knee splintsRationale: Applying knee splints preventsleg contractures by holding the joints in aposition of function. Elevating the foot ofthe bed cant prevent contracturesbecause this action doesnt hold the jointsin a position of function. Hyperextending abody part for an extended time isinappropriate because it can causecontractures. Performing shoulder range-of-motion exercises can preventcontractures in the shoulders, but not inthe legs.27. Answer: (B) Urine output of 20 ml/hour.Rationale: A urine output of less than 40ml/hour in a client with burns indicates afluid volume deficit. This clients PaO2value falls within the normal range (80 to100 mm Hg). White pulmonary secretionsalso are normal. The clients rectaltemperature isnt significantly elevatedand probably results from the fluidvolume deficit.28. Answer: (A) Turn him frequently.Rationale: The most importantintervention to prevent pressure ulcers isfrequent position changes, which relievepressure on the skin and underlyingtissues. If pressure isnt relieved,capillaries become occluded, reducingcirculation and oxygenation of the tissuesand resulting in cell death and ulcerformation. During passive ROM exercises,the nurse moves each joint through itsrange of movement, which improves jointmobility and circulation to the affectedarea but doesnt prevent pressure ulcers.Adequate hydration is necessary tomaintain healthy skin and ensure tissuerepair. A footboard prevents plantarflexion and footdrop by maintaining thefoot in a dorsiflexed position.29. Answer: (C) In long, even, outward, anddownward strokes in the direction of hairgrowthRationale: When applying a topical agent,the nurse should begin at the midline anduse long, even, outward, and downwardstrokes in the direction of hair growth.This application pattern reduces the riskof follicle irritation and skin inflammation.30. Answer: (A) Beta -adrenergic blockersRationale: Beta-adrenergic blockers workby blocking beta receptors in themyocardium, reducing the response tocatecholamines and sympathetic nervestimulation. They protect themyocardium, helping to reduce the risk ofanother infraction by decreasingmyocardial oxygen demand. Calciumchannel blockers reduce the workload ofthe heart by decreasing the heart rate.Narcotics reduce myocardial oxygendemand, promote vasodilation, anddecrease anxiety. Nitrates reducemyocardial oxygen consumption btdecreasing left ventricular end diastolicpressure (preload) and systemic vascularresistance (afterload).31. Answer: (C) Raised 30 degreesRationale: Jugular venous pressure ismeasured with a centimeter ruler toobtain the vertical distance between thesternal angle and the point of highestpulsation with the head of the bedinclined between 15 to 30 degrees.Increased pressure can’t be seen whenthe client is supine or when the head ofthe bed is raised 10 degrees because thepoint that marks the pressure level isabove the jaw (therefore, not visible). In
  • 125high Fowler’s position, the veins would bebarely discernible above the clavicle.32. Answer: (D) Inotropic agentsRationale: Inotropic agents areadministered to increase the force of theheart’s contractions, thereby increasingventricular contractility and ultimatelyincreasing cardiac output. Beta-adrenergicblockers and calcium channel blockersdecrease the heart rate and ultimatelydecreased the workload of the heart.Diuretics are administered to decrease theoverall vascular volume, also decreasingthe workload of the heart.33. Answer: (B) Less than 30% of calories fromfatRationale: A client with low serum HDLand high serum LDL levels should get lessthan 30% of daily calories from fat. Theother modifications are appropriate forthis client.34. Answer: (C) The emergency departmentnurse calls up the latest electrocardiogramresults to check the client’s progressRationale: The emergency departmentnurse is no longer directly involved withthe client’s care and thus has no legalright to information about his presentcondition. Anyone directly involved in hiscare (such as the telemetry nurse and theon-call physician) has the right toinformation about his condition. Becausethe client requested that the nurse updatehis wife on his condition, doing so doesn’tbreach confidentiality.35. Answer: (B) Check endotracheal tubeplacement.Rationale: ET tube placement should beconfirmed as soon as the client arrives inthe emergency department. Once theairways is secured, oxygenation andventilation should be confirmed using anend-tidal carbon dioxide monitor andpulse oximetry. Next, the nurse shouldmake sure L.V. access is established. If theclient experiences symptomaticbradycardia, atropine is administered asordered 0.5 to 1 mg every 3 to 5 minutesto a total of 3 mg. Then the nurse shouldtry to find the cause of the client’s arrestby obtaining an ABG sample. Amiodaroneis indicated for ventricular tachycardia,ventricular fibrillation and atrial flutter –not symptomatic bradycardia.36. Answer: (C) 95 mm HgRationale: Use the following formula tocalculate MAPMAP = systolic + 2 (diastolic)3MAP=126 mm Hg + 2 (80 mm Hg)3MAP=286 mm HG3MAP=95 mm Hg37. Answer: (C) Electrocardiogram, completeblood count, testing for occult blood,comprehensive serum metabolic panel.Rationale: An electrocardiogram evaluatesthe complaints of chest pain, laboratorytests determines anemia, and the stooltest for occult blood determines blood inthe stool. Cardiac monitoring, oxygen, andcreatine kinase and lactatedehydrogenase levels are appropriate fora cardiac primary problem. A basicmetabolic panel and alkaline phosphataseand aspartate aminotransferase levelsassess liver function. Prothrombin time,partial thromboplastin time, fibrinogenand fibrin split products are measured toverify bleeding dyscrasias; anelectroencephalogram evaluates brainelectrical activity.38. Answer: (D) Heparin-associatedthrombosis and thrombocytopenia (HATT)Rationale: HATT may occur after CABGsurgery due to heparin use during surgery.Although DIC and ITP cause plateletaggregation and bleeding, neither iscommon in a client after revascularizationsurgery. Pancytopenia is a reduction in allblood cells.39. Answer: (B) CorticosteroidsRationale: Corticosteroid therapy candecrease antibody production andphagocytosis of the antibody-coatedplatelets, retaining more functioningplatelets. Methotrexate can causethrombocytopenia. Vitamin K is used totreat an excessive anticoagulate statefrom warfarin overload, and ASAdecreases platelet aggregation.40. Answer: (D) XenogeneicRationale: An xenogeneic transplant isbetween is between human and another
  • 126species. A syngeneic transplant is betweenidentical twins, allogeneic transplant isbetween two humans, and autologous is atransplant from the same individual.41. Answer: (B)Rationale: Tissue thromboplastin isreleased when damaged tissue comes incontact with clotting factors. Calcium isreleased to assist the conversion offactors X to Xa. Conversion of factors XII toXIIa and VIII to IIIa are part of the intrinsicpathway.42. Answer: (C) Essential thrombocytopeniaRationale: Essential thrombocytopenia islinked to immunologic disorders, such asSLE and human immunodeficiency virus.The disorder known as von Willebrand’sdisease is a type of hemophilia and isn’tlinked to SLE. Moderate to severe anemiais associated with SLE, not polycythemia.Dressler’s syndrome is pericarditis thatoccurs after a myocardial infarction andisn’t linked to SLE.43. Answer: (B) Night sweatRationale: In stage 1, symptoms include asingle enlarged lymph node (usually),unexplained fever, night sweats, malaise,and generalized pruritis. Althoughsplenomegaly may be present in someclients, night sweats are generally moreprevalent. Pericarditis isn’t associatedwith Hodgkin’s disease, nor ishypothermia. Moreover, splenomegalyand pericarditis aren’t symptoms.Persistent hypothermia is associated withHodgkin’s but isn’t an early sign of thedisease.44. Answer: (D) Breath soundsRationale: Pneumonia, both viral andfungal, is a common cause of death inclients with neutropenia, so frequentassessment of respiratory rate and breathsounds is required. Although assessingblood pressure, bowel sounds, and heartsounds is important, it won’t help detectpneumonia.45. Answer: (B) Muscle spasmRationale: Back pain or paresthesia in thelower extremities may indicate impendingspinal cord compression from a spinaltumor. This should be recognized andtreated promptly as progression of thetumor may result in paraplegia. The otheroptions, which reflect parts of the nervoussystem, aren’t usually affected by MM.46. Answer: (C) 10 yearsRationale: Epidermiologic studies showthe average time from initial contact withHIV to the development of AIDS is 10years.47. Answer: (A) Low platelet countRationale: In DIC, platelets and clottingfactors are consumed, resulting inmicrothrombi and excessive bleeding. Asclots form, fibrinogen levels decrease andthe prothrombin time increases. Fibrindegeneration products increase asfibrinolysis takes places.48. Answer: (D) Hodgkin’s diseaseRationale: Hodgkin’s disease typicallycauses fever night sweats, weight loss,and lymph mode enlargement. Influenzadoesn’t last for months. Clients with sicklecell anemia manifest signs and symptomsof chronic anemia with pallor of themucous membrane, fatigue, anddecreased tolerance for exercise; theydon’t show fever, night sweats, weightloss or lymph node enlargement.Leukemia doesn’t cause lymph nodeenlargement.49. Answer: (C) A Rh-negativeRationale: Human blood can sometimescontain an inherited D antigen. Personswith the D antigen have Rh-positive bloodtype; those lacking the antigen have Rh-negative blood. It’s important that aperson with Rh- negative blood receivesRh-negative blood. If Rh-positive blood isadministered to an Rh-negative person,the recipient develops anti-Rh agglutinins,and sub sequent transfusions with Rh-positive blood may cause seriousreactions with clumping and hemolysis ofred blood cells.50. Answer: (B) “I will call my doctor if Stacyhas persistent vomiting and diarrhea”.Rationale: Persistent (more than 24 hours)vomiting, anorexia, and diarrhea are signsof toxicity and the patient should stop themedication and notify the health careprovider. The other manifestations areexpected side effects of chemotherapy.51. Answer: (D) “This is only temporary; Stacywill re-grow new hair in 3-6 months, butmay be different in texture”.
  • 127Rationale: This is the appropriateresponse. The nurse should help themother how to cope with her own feelingsregarding the child’s disease so as not toaffect the child negatively. When the hairgrows back, it is still of the same color andtexture.52. Answer: (B) Apply viscous Lidocaine tooral ulcers as needed.Rationale: Stomatitis can cause pain andthis can be relieved by applying topicalanesthetics such as lidocaine beforemouth care. When the patient is alreadycomfortable, the nurse can proceed withproviding the patient with oral rinses ofsaline solution mixed with equal part ofwater or hydrogen peroxide mixed waterin 1:3 concentrations to promote oralhygiene. Every 2-4 hours.53. Answer: (C) Immediately discontinue theinfusionRationale: Edema or swelling at the IV siteis a sign that the needle has beendislodged and the IV solution is leakinginto the tissues causing the edema. Thepatient feels pain as the nerves areirritated by pressure and the IV solution.The first action of the nurse would be todiscontinue the infusion right away toprevent further edema and othercomplication.54. Answer: (C) Chronic obstructive bronchitisRationale: Clients with chronic obstructivebronchitis appear bloated; they have largebarrel chest and peripheral edema,cyanotic nail beds, and at times,circumoral cyanosis. Clients with ARDS areacutely short of breath and frequentlyneed intubation for mechanical ventilationand large amount of oxygen. Clients withasthma don’t exhibit characteristics ofchronic disease, and clients withemphysema appear pink and cachectic.55. Answer: (D) EmphysemaRationale: Because of the large amount ofenergy it takes to breathe, clients withemphysema are usually cachectic. They’repink and usually breathe through pursedlips, hence the term “puffer.” Clients withARDS are usually acutely short of breath.Clients with asthma don’t have anyparticular characteristics, and clients withchronic obstructive bronchitis are bloatedand cyanotic in appearance.56. Answer: D 80 mm HgRationale: A client about to go intorespiratory arrest will have inefficientventilation and will be retaining carbondioxide. The value expected would bearound 80 mm Hg. All other values arelower than expected.57. Answer: (C) Respiratory acidosisRationale: Because Paco2 is high at 80 mmHg and the metabolic measure, HCO3- isnormal, the client has respiratory acidosis.The pH is less than 7.35, academic, whicheliminates metabolic and respiratoryalkalosis as possibilities. If the HCO3- wasbelow 22 mEq/L the client would havemetabolic acidosis.58. Answer: (C) Respiratory failureRationale: The client was reacting to thedrug with respiratory signs of impendinganaphylaxis, which could lead toeventually respiratory failure. Althoughthe signs are also related to an asthmaattack or a pulmonary embolism, considerthe new drug first. Rheumatoid arthritisdoesn’t manifest these signs.59. Answer: (D) Elevated serumaminotransferaseRationale: Hepatic cell death causesrelease of liver enzymes alanineaminotransferase (ALT), aspartateaminotransferase (AST) and lactatedehydrogenase (LDH) into the circulation.Liver cirrhosis is a chronic and irreversibledisease of the liver characterized bygeneralized inflammation and fibrosis ofthe liver tissues.60. Answer: (A) Impaired clotting mechanismRationale: Cirrhosis of the liver results indecreased Vitamin K absorption andformation of clotting factors resulting inimpaired clotting mechanism.61. Answer: (B) Altered level of consciousnessRationale: Changes in behavior and levelof consciousness are the first sins ofhepatic encephalopathy. Hepaticencephalopathy is caused by liver failureand develops when the liver is unable toconvert protein metabolic productammonia to urea. This results inaccumulation of ammonia and other toxicin the blood that damages the cells.
  • 12862. Answer: (C) “I’ll lower the dosage asordered so the drug causes only 2 to 4stools a day”.Rationale: Lactulose is given to a patientswith hepatic encephalopathy to reduceabsorption of ammonia in the intestinesby binding with ammonia and promotingmore frequent bowel movements. If thepatient experience diarrhea, it indicatesover dosage and the nurse must reducethe amount of medication given to thepatient. The stool will be mashy or soft.Lactulose is also very sweet and maycause cramping and bloating.63. Answer: (B) Severe lower back pain,decreased blood pressure, decreased RBCcount, increased WBC count.Rationale: Severe lower back painindicates an aneurysm rupture, secondaryto pressure being applied within theabdominal cavity. When ruptured occurs,the pain is constant because it can’t bealleviated until the aneurysm is repaired.Blood pressure decreases due to the lossof blood. After the aneurysm ruptures, thevasculature is interrupted and bloodvolume is lost, so blood pressure wouldn’tincrease. For the same reason, the RBCcount is decreased – not increased. TheWBC count increases as cell migrate to thesite of injury.64. Answer: (D) Apply gloves and assess thegroin siteRationale: Observing standard precautionsis the first priority when dealing with anyblood fluid. Assessment of the groin site isthe second priority. This establishes wherethe blood is coming from and determineshow much blood has been lost. The goal inthis situation is to stop the bleeding. Thenurse would call for help if it werewarranted after the assessment of thesituation. After determining the extent ofthe bleeding, vital signs assessment isimportant. The nurse should never movethe client, in case a clot has formed.Moving can disturb the clot and causerebleeding.65. Answer: (D) Percutaneous transluminalcoronary angioplasty (PTCA)Rationale: PTCA can alleviate the blockageand restore blood flow and oxygenation.An echocardiogram is a noninvasivediagnosis test. Nitroglycerin is an oralsublingual medication. Cardiaccatheterization is a diagnostic tool – not atreatment.66. Answer: (B) Cardiogenic shockRationale: Cardiogenic shock is shockrelated to ineffective pumping of theheart. Anaphylactic shock results from anallergic reaction. Distributive shock resultsfrom changes in the intravascular volumedistribution and is usually associated withincreased cardiac output. MI isn’t a shockstate, though a severe MI can lead toshock.67. Answer: (C) Kidneys’ excretion of sodiumand waterRationale: The kidneys respond to rise inblood pressure by excreting sodium andexcess water. This response ultimatelyaffects sysmolic blood pressure byregulating blood volume. Sodium or waterretention would only further increaseblood pressure. Sodium and water traveltogether across the membrane in thekidneys; one can’t travel without theother.68. Answer: (D) It inhibits reabsorption ofsodium and water in the loop of Henle.Rationale: Furosemide is a loop diureticthat inhibits sodium and waterreabsorption in the loop Henle, therebycausing a decrease in blood pressure.Vasodilators cause dilation of peripheralblood vessels, directly relaxing vascularsmooth muscle and decreasing bloodpressure. Adrenergic blockers decreasesympathetic cardioacceleration anddecrease blood pressure. Angiotensin-converting enzyme inhibitors decreaseblood pressure due to their action onangiotensin.69. Answer: (C) Pancytopenia, elevatedantinuclear antibody (ANA) titerRationale: Laboratory findings for clientswith SLE usually show pancytopenia,elevated ANA titer, and decreased serumcomplement levels. Clients may haveelevated BUN and creatinine levels fromnephritis, but the increase does notindicate SLE.70. Answer: (C) Narcotics are avoided after ahead injury because they may hide aworsening condition.
  • 129Rationale: Narcotics may mask changes inthe level of consciousness that indicateincreased ICP and shouldn’tacetaminophen is strong enough ignoresthe mother’s question and therefore isn’tappropriate. Aspirin is contraindicated inconditions that may have bleeding, suchas trauma, and for children or youngadults with viral illnesses due to thedanger of Reye’s syndrome. Strongermedications may not necessarily lead tovomiting but will sedate the client,thereby masking changes in his level ofconsciousness.71. Answer: (A) Appropriate; lowering carbondioxide (CO2) reduces intracranialpressure (ICP)Rationale: A normal Paco2 value is 35 to45 mm Hg CO2 has vasodilatingproperties; therefore, lowering Paco2through hyperventilation will lower ICPcaused by dilated cerebral vessels.Oxygenation is evaluated through Pao2and oxygen saturation. Alveolarhypoventilation would be reflected in anincreased Paco2.72. Answer: (B) A 33-year-old client with arecent diagnosis of Guillain-BarresyndromeRationale: Guillain-Barre syndrome ischaracterized by ascending paralysis andpotential respiratory failure. The order ofclient assessment should follow clientpriorities, with disorder of airways,breathing, and then circulation. There’s noinformation to suggest the postmyocardialinfarction client has an arrhythmia orother complication. There’s no evidenceto suggest hemorrhage or perforation forthe remaining clients as a priority of care.73. Answer: (C) Decreases inflammationRationale: Then action of colchicines is todecrease inflammation by reducing themigration of leukocytes to synovial fluid.Colchicine doesn’t replace estrogen,decrease infection, or decrease bonedemineralization.74. Answer: (C) Osteoarthritis is the mostcommon form of arthritisRationale: Osteoarthritis is the mostcommon form of arthritis and can beextremely debilitating. It can afflict peopleof any age, although most are elderly.75. Answer: (C) Myxedema comaRationale: Myxedema coma, severehypothyroidism, is a life-threateningcondition that may develop if thyroidreplacement medication isnt taken.Exophthalmos, protrusion of the eyeballs,is seen with hyperthyroidism. Thyroidstorm is life-threatening but is caused bysevere hyperthyroidism. Tibial myxedema,peripheral mucinous edema involving thelower leg, is associated withhypothyroidism but isnt life-threatening.76. Answer: (B) An irregular apical pulseRationale: Because Cushings syndromecauses aldosterone overproduction, whichincreases urinary potassium loss, thedisorder may lead to hypokalemia.Therefore, the nurse should immediatelyreport signs and symptoms ofhypokalemia, such as an irregular apicalpulse, to the physician. Edema is anexpected finding because aldosteroneoverproduction causes sodium and fluidretention. Dry mucous membranes andfrequent urination signal dehydration,which isnt associated with Cushingssyndrome.77. Answer: (D) Below-normal urineosmolality level, above-normal serumosmolality levelRationale: In diabetes insipidus, excessivepolyuria causes dilute urine, resulting in abelow-normal urine osmolality level. Atthe same time, polyuria depletes the bodyof water, causing dehydration that leadsto an above-normal serum osmolalitylevel. For the same reasons, diabetesinsipidus doesnt cause above-normalurine osmolality or below-normal serumosmolality levels.78. Answer: (A) "I can avoid getting sick by notbecoming dehydrated and by payingattention to my need to urinate, drink, oreat more than usual."Rationale: Inadequate fluid intake duringhyperglycemic episodes often leads toHHNS. By recognizing the signs ofhyperglycemia (polyuria, polydipsia, andpolyphagia) and increasing fluid intake,the client may prevent HHNS. Drinking aglass of nondiet soda would beappropriate for hypoglycemia. A clientwhose diabetes is controlled with oral
  • 130antidiabetic agents usually doesnt needto monitor blood glucose levels. A high-carbohydrate diet would exacerbate theclients condition, particularly if fluidintake is low.79. Answer: (D) HyperparathyroidismRationale: Hyperparathyroidism is mostcommon in older women and ischaracterized by bone pain and weaknessfrom excess parathyroid hormone (PTH).Clients also exhibit hypercaliuria-causingpolyuria. While clients with diabetesmellitus and diabetes insipidus also havepolyuria, they dont have bone pain andincreased sleeping. Hypoparathyroidism ischaracterized by urinary frequency ratherthan polyuria.80. Answer: (C) "Ill take two-thirds of thedose when I wake up and one-third in thelate afternoon."Rationale: Hydrocortisone, aglucocorticoid, should be administeredaccording to a schedule that closelyreflects the bodies own secretion of thishormone; therefore, two-thirds of thedose of hydrocortisone should be taken inthe morning and one-third in the lateafternoon. This dosage schedule reducesadverse effects.81. Answer: (C) High corticotropin and highcortisol levelsRationale: A corticotropin-secretingpituitary tumor would cause highcorticotropin and high cortisol levels. Ahigh corticotropin level with a low cortisollevel and a low corticotropin level with alow cortisol level would be associatedwith hypocortisolism. Low corticotropinand high cortisol levels would be seen ifthere was a primary defect in the adrenalglands.82. Answer: (D) Performing capillary glucosetesting every 4 hoursRationale: The nurse should performcapillary glucose testing every 4 hoursbecause excess cortisol may cause insulinresistance, placing the client at risk forhyperglycemia. Urine ketone testing isntindicated because the client does secreteinsulin and, therefore, isnt at risk forketosis. Urine specific gravity isntindicated because although fluid balancecan be compromised, it usually isntdangerously imbalanced. Temperatureregulation may be affected by excesscortisol and isnt an accurate indicator ofinfection.83. Answer: (C) onset to be at 2:30 p.m. andits peak to be at 4 p.m.Rationale: Regular insulin, which is ashort-acting insulin, has an onset of 15 to30 minutes and a peak of 2 to 4 hours.Because the nurse gave the insulin at 2p.m., the expected onset would be from2:15 p.m. to 2:30 p.m. and the peak from4 p.m. to 6 p.m.84. Answer: (A) No increase in the thyroid-stimulating hormone (TSH) level after 30minutes during the TSH stimulation testRationale: In the TSH test, failure of theTSH level to rise after 30 minutes confirmshyperthyroidism. A decreased TSH levelindicates a pituitary deficiency of thishormone. Below-normal levels of T3 andT4, as detected by radioimmunoassay,signal hypothyroidism. A below-normal T4level also occurs in malnutrition and liverdisease and may result fromadministration of phenytoin and certainother drugs.85. Answer: (B) "Rotate injection sites withinthe same anatomic region, not amongdifferent regions."Rationale: The nurse should instruct theclient to rotate injection sites within thesame anatomic region. Rotating sitesamong different regions may causeexcessive day-to-day variations in theblood glucose level; also, insulinabsorption differs from one region to thenext. Insulin should be injected only intohealthy tissue lacking large blood vessels,nerves, or scar tissue or other deviations.Injecting insulin into areas of hypertrophymay delay absorption. The client shouldntinject insulin into areas of lipodystrophy(such as hypertrophy or atrophy); toprevent lipodystrophy, the client shouldrotate injection sites systematically.Exercise speeds drug absorption, so theclient shouldnt inject insulin into sitesabove muscles that will be exercisedheavily.86. Answer: (D) Below-normal serumpotassium level
  • 131Rationale: A client with HHNS has anoverall body deficit of potassium resultingfrom diuresis, which occurs secondary tothe hyperosmolar, hyperglycemic statecaused by the relative insulin deficiency.An elevated serum acetone level andserum ketone bodies are characteristic ofdiabetic ketoacidosis. Metabolic acidosis,not serum alkalosis, may occur in HHNS.87. Answer: (D) Maintaining roomtemperature in the low-normal rangeRationale: Graves disease causes signsand symptoms of hypermetabolism, suchas heat intolerance, diaphoresis, excessivethirst and appetite, and weight loss. Toreduce heat intolerance and diaphoresis,the nurse should keep the clients roomtemperature in the low-normal range. Toreplace fluids lost via diaphoresis, thenurse should encourage, not restrict,intake of oral fluids. Placing extra blanketson the bed of a client with heatintolerance would cause discomfort. Toprovide needed energy and calories, thenurse should encourage the client to eathigh-carbohydrate foods.88. Answer: (A) Fracture of the distal radiusRationale: Colles fracture is a fracture ofthe distal radius, such as from a fall on anoutstretched hand. Its most common inwomen. Colles fracture doesnt refer to afracture of the olecranon, humerus, orcarpal scaphoid.89. Answer: (B) Calcium and phosphorousRationale: In osteoporosis, bones losecalcium and phosphate salts, becomingporous, brittle, and abnormally vulnerableto fracture. Sodium and potassium arentinvolved in the development ofsteoporosis.90. Answer: (A) Adult respiratory distresssyndrome (ARDS)Rationale: Severe hypoxia after smokeinhalation is typically related to ARDS. Theother conditions listed aren’t typicallyassociated with smoke inhalation andsevere hypoxia.91. Answer: (D) Fat embolismRationale: Long bone fractures arecorrelated with fat emboli, which causeshortness of breath and hypoxia. It’sunlikely the client has developed asthmaor bronchitis without a previous history.He could develop atelectasis but ittypically doesn’t produce progressivehypoxia.92. Answer: (D) Spontaneous pneumothoraxRationale: A spontaneous pneumothoraxoccurs when the client’s lung collapses,causing an acute decreased in the amountof functional lung used in oxygenation.The sudden collapse was the cause of hischest pain and shortness of breath. Anasthma attack would show wheezingbreath sounds, and bronchitis would haverhonchi. Pneumonia would have bronchialbreath sounds over the area ofconsolidation.93. Answer: (C) PneumothoraxRationale: From the trauma the clientexperienced, it’s unlikely he hasbronchitis, pneumonia, or TB; rhonchiwith bronchitis, bronchial breath soundswith TB would be heard.94. Answer: (C) Serous fluids fills the spaceand consolidates the regionRationale: Serous fluid fills the space andeventually consolidates, preventingextensive mediastinal shift of the heartand remaining lung. Air can’t be left in thespace. There’s no gel that can be placed inthe pleural space. The tissue from theother lung can’t cross the mediastinum,although a temporary mediastinal shiftexits until the space is filled.95. Answer: (A) Alveolar damage in theinfracted areaRationale: The infracted area producesalveolar damage that can lead to theproduction of bloody sputum, sometimesin massive amounts. Clot formationusually occurs in the legs. There’s a loss oflung parenchyma and subsequent scartissue formation.96. Answer: (D) Respiratory alkalosisRationale: A client with massivepulmonary embolism will have a largeregion and blow off large amount ofcarbon dioxide, which crosses theunaffected alveolar-capillary membranemore readily than does oxygen and resultsin respiratory alkalosis.97. Answer: (A) Air leakRationale: Bubbling in the water sealchamber of a chest drainage system stemsfrom an air leak. In pneumothorax an air
  • 132leak can occur as air is pulled from thepleural space. Bubbling doesn’t normallyoccur with either adequate or inadequatesuction or any preexisting bubbling in thewater seal chamber.98. Answer: (B) 21Rationale: 3000 x 10 divided by 24 x 60.99. Answer: (B) 2.4 mlRationale: .05 mg/ 1 ml = .12mg/ x ml,.05x = .12, x = 2.4 ml.100. Answer: (D) “I should put on the stockingsbefore getting out of bed in the morning.Rationale: Promote venous return byapplying external pressure on veins.
  • 133TEST V - Care of Clients with Physiologic andPsychosocial Alterations1. Mr. Marquez reports of losing his job, not beingable to sleep at night, and feeling upset with hiswife. Nurse John responds to the client, “Youmay want to talk about your employmentsituation in group today.” The Nurse is usingwhich therapeutic technique?a. Observationsb. Restatingc. Exploringd. Focusing2. Tony refuses his evening dose of Haloperidol(Haldol), then becomes extremely agitated in thedayroom while other clients are watchingtelevision. He begins cursing and throwingfurniture. Nurse Oliver first action is to:a. Check the client’s medical record for anorder for an as-needed I.M. dose ofmedication for agitation.b. Place the client in full leather restraints.c. Call the attending physician and reportthe behavior.d. Remove all other clients from thedayroom.3. Tina who is manic, but not yet on medication,comes to the drug treatment center. The nursewould not let this client join the group sessionbecause:a. The client is disruptive.b. The client is harmful to self.c. The client is harmful to others.d. The client needs to be on medicationfirst.4. Dervid, an adolescent boy was admitted forsubstance abuse and hallucinations. The client’smother asks Nurse Armando to talk with hishusband when he arrives at the hospital. Themother says that she is afraid of what the fathermight say to the boy. The most appropriatenursing intervention would be to:a. Inform the mother that she and thefather can work through this problemthemselves.b. Refer the mother to the hospital socialworker.c. Agree to talk with the mother and thefather together.d. Suggest that the father and son workthings out.5. What is Nurse John likely to note in a male clientbeing admitted for alcohol withdrawal?a. Perceptual disorders.b. Impending coma.c. Recent alcohol intake.d. Depression with mutism.6. Aira has taken amitriptyline HCL (Elavil) for 3days, but now complains that it “doesn’t help”and refuses to take it. What should the nurse sayor do?a. Withhold the drug.b. Record the client’s response.c. Encourage the client to tell the doctor.d. Suggest that it takes a while beforeseeing the results.7. Dervid, an adolescent has a history of truancyfrom school, running away from home and“barrowing” other people’s things without theirpermission. The adolescent denies stealing,rationalizing instead that as long as no one wasusing the items, it was all right to borrow them.It is important for the nurse to understand thepsychodynamically, this behavior may be largelyattributed to a developmental defect related tothe:a. Idb. Egoc. Superegod. Oedipal complex8. In preparing a female client for electroconvulsivetherapy (ECT), Nurse Michelle knows thatsuccinylcoline (Anectine) will be administeredfor which therapeutic effect?a. Short-acting anesthesiab. Decreased oral and respiratorysecretions.c. Skeletal muscle paralysis.d. Analgesia.9. Nurse Gina is aware that the dietary implicationsfor a client in manic phase of bipolar disorder is:a. Serve the client a bowl of soup, butteredFrench bread, and apple slices.b. Increase calories, decrease fat, anddecrease protein.c. Give the client pieces of cut-up steak,carrots, and an apple.
  • 134d. Increase calories, carbohydrates, andprotein.10. What parental behavior toward a child during anadmission procedure should cause Nurse Ron tosuspect child abuse?a. Flat affectb. Expressing guiltc. Acting overly solicitous toward the child.d. Ignoring the child.11. Nurse Lynnette notices that a female client withobsessive-compulsive disorder washes her handsfor long periods each day. How should the nurserespond to this compulsive behavior?a. By designating times during which theclient can focus on the behavior.b. By urging the client to reduce thefrequency of the behavior as rapidly aspossible.c. By calling attention to or attempting toprevent the behavior.d. By discouraging the client fromverbalizing anxieties.12. After seeking help at an outpatient mentalhealth clinic, Ruby who was raped while walkingher dog is diagnosed with posttraumatic stressdisorder (PTSD). Three months later, Rubyreturns to the clinic, complaining of fear, loss ofcontrol, and helpless feelings. Which nursingintervention is most appropriate for Ruby?a. Recommending a high-protein, low-fatdiet.b. Giving sleep medication, as prescribed,to restore a normal sleep- wake cycle.c. Allowing the client time to heal.d. Exploring the meaning of the traumaticevent with the client.13. Meryl, age 19, is highly dependent on herparents and fears leaving home to go away tocollege. Shortly before the semester starts, shecomplains that her legs are paralyzed and isrushed to the emergency department. Whenphysical examination rules out a physical causefor her paralysis, the physician admits her to thepsychiatric unit where she is diagnosed withconversion disorder. Meryl asks the nurse, "Whyhas this happened to me?" What is the nursesbest response?a. "Youve developed this paralysis so youcan stay with your parents. You mustdeal with this conflict if you want to walkagain."b. "It must be awful not to be able to moveyour legs. You may feel better if yourealize the problem is psychological, notphysical."c. "Your problem is real but there is nophysical basis for it. Well work on whatis going on in your life to find out whyits happened."d. "It isnt uncommon for someone withyour personality to develop a conversiondisorder during times of stress."14. Nurse Krina knows that the following drugs havebeen known to be effective in treatingobsessive-compulsive disorder (OCD):a. benztropine (Cogentin) anddiphenhydramine (Benadryl).b. chlordiazepoxide (Librium) anddiazepam (Valium)c. fluvoxamine (Luvox) and clomipramine(Anafranil)d. divalproex (Depakote) and lithium(Lithobid)15. Alfred was newly diagnosed with anxietydisorder. The physician prescribed buspirone(BuSpar). The nurse is aware that the teachinginstructions for newly prescribed buspironeshould include which of the following?a. A warning about the drugs delayedtherapeutic effect, which is from 14 to30 days.b. A warning about the incidence ofneuroleptic malignant syndrome (NMS).c. A reminder of the need to scheduleblood work in 1 week to check bloodlevels of the drug.d. A warning that immediate sedation canoccur with a resultant drop in pulse.16. Richard with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms ofphobias include:a. Insomnia and an inability to concentrate.b. Severe anxiety and fear.c. Depression and weight loss.d. Withdrawal and failure to distinguishreality from fantasy.17. Which medications have been found to helpreduce or eliminate panic attacks?
  • 135a. Antidepressantsb. Anticholinergicsc. Antipsychoticsd. Mood stabilizers18. A client seeks care because she feels depressedand has gained weight. To treat her atypicaldepression, the physician prescribestranylcypromine sulfate (Parnate), 10 mg bymouth twice per day. When this drug is used totreat atypical depression, what is its onset ofaction?a. 1 to 2 daysb. 3 to 5 daysc. 6 to 8 daysd. 10 to 14 days19. A 65 years old client is in the first stage ofAlzheimers disease. Nurse Patricia should planto focus this clients care on:a. Offering nourishing finger foods to helpmaintain the clients nutritional status.b. Providing emotional support andindividual counseling.c. Monitoring the client to prevent minorillnesses from turning into majorproblems.d. Suggesting new activities for the clientand family to do together.20. The nurse is assessing a client who has just beenadmitted to the emergency department. Whichsigns would suggest an overdose of anantianxiety agent?a. Combativeness, sweating, and confusionb. Agitation, hyperactivity, and grandioseideationc. Emotional lability, euphoria, andimpaired memoryd. Suspiciousness, dilated pupils, andincreased blood pressure21. The nurse is caring for a client diagnosed withantisocial personality disorder. The client has ahistory of fighting, cruelty to animals, andstealing. Which of the following traits would thenurse be most likely to uncover duringassessment?a. History of gainful employmentb. Frequent expression of guilt regardingantisocial behaviorc. Demonstrated ability to maintain close,stable relationshipsd. A low tolerance for frustration22. Nurse Amy is providing care for a male clientundergoing opiate withdrawal. Opiatewithdrawal causes severe physical discomfortand can be life-threatening. To minimize theseeffects, opiate users are commonly detoxifiedwith:a. Barbituratesb. Amphetaminesc. Methadoned. Benzodiazepines23. Nurse Cristina is caring for a client whoexperiences false sensory perceptions with nobasis in reality. These perceptions are known as:a. Delusionsb. Hallucinationsc. Loose associationsd. Neologisms24. Nurse Marco is developing a plan of care for aclient with anorexia nervosa. Which actionshould the nurse include in the plan?a. Restricts visits with the family andfriends until the client begins to eat.b. Provide privacy during meals.c. Set up a strict eating plan for the client.d. Encourage the client to exercise, whichwill reduce her anxiety.25. Tim is admitted with a diagnosis of delusions ofgrandeur. The nurse is aware that this diagnosisreflects a belief that one is:a. Highly important or famous.b. Being persecutedc. Connected to events unrelated tooneselfd. Responsible for the evil in the world.26. Nurse Jen is caring for a male client with manicdepression. The plan of care for a client in amanic state would include:a. Offering a high-calorie meals andstrongly encouraging the client to finishall food.b. Insisting that the client remain activethrough the day so that he’ll sleep atnight.c. Allowing the client to exhibithyperactive, demanding, manipulativebehavior without setting limits.
  • 136d. Listening attentively with a neutralattitude and avoiding power struggles.27. Ramon is admitted for detoxification after acocaine overdose. The client tells the nurse thathe frequently uses cocaine but that he cancontrol his use if he chooses. Which copingmechanism is he using?a. Withdrawalb. Logical thinkingc. Repressiond. Denial28. Richard is admitted with a diagnosis ofschizotypal personality disorder. hich signswould this client exhibit during social situations?a. Aggressive behaviorb. Paranoid thoughtsc. Emotional affectd. Independence needs29. Nurse Mickey is caring for a client diagnosedwith bulimia. The most appropriate initial goalfor a client diagnosed with bulimia is to:a. Avoid shopping for large amounts offood.b. Control eating impulses.c. Identify anxiety-causing situationsd. Eat only three meals per day.30. Rudolf is admitted for an overdose ofamphetamines. When assessing the client, thenurse should expect to see:a. Tension and irritabilityb. Slow pulsec. Hypotensiond. Constipation31. Nicolas is experiencing hallucinations tells thenurse, “The voices are telling me I’m no good.”The client asks if the nurse hears the voices. Themost appropriate response by the nurse wouldbe:a. “It is the voice of your conscience, whichonly you can control.”b. “No, I do not hear your voices, but Ibelieve you can hear them”.c. “The voices are coming from within youand only you can hear them.”d. “Oh, the voices are a symptom of yourillness; don’t pay any attention to them.”32. The nurse is aware that the side effect ofelectroconvulsive therapy that a client mayexperience:a. Loss of appetiteb. Postural hypotensionc. Confusion for a time after treatmentd. Complete loss of memory for a time33. A dying male client gradually moves towardresolution of feelings regarding impendingdeath. Basing care on the theory of Kubler-Ross,Nurse Trish plans to use nonverbal interventionswhen assessment reveals that the client is in the:a. Anger stageb. Denial stagec. Bargaining staged. Acceptance stage34. The outcome that is unrelated to a crisis state is:a. Learning more constructive coping skillsb. Decompensation to a lower level offunctioning.c. Adaptation and a return to a prior levelof functioning.d. A higher level of anxiety continuing formore than 3 months.35. Miranda a psychiatric client is to be dischargedwith orders for haloperidol (haldol) therapy.When developing a teaching plan for discharge,the nurse should include cautioning the clientagainst:a. Driving at nightb. Staying in the sunc. Ingesting wines and cheesesd. Taking medications containing aspirin36. Jen a nursing student is anxious about theupcoming board examination but is able to studyintently and does not become distracted by aroommate’s talking and loud music. Thestudent’s ability to ignore distractions and tofocus on studying demonstrates:a. Mild-level anxietyb. Panic-level anxietyc. Severe-level anxietyd. Moderate-level anxiety37. When assessing a premorbid personalitycharacteristic of a client with a majordepression, it would be unusual for the nurse tofind that this client demonstrated:a. Rigidityb. Stubbornness
  • 137c. Diverse interestd. Over meticulousness38. Nurse Krina recognizes that the suicidal risk fordepressed client is greatest:a. As their depression begins to improveb. When their depression is most severec. Before any type of treatment is startedd. As they lose interest in the environment39. Nurse Kate would expect that a client withvascular dementis would experience:a. Loss of remote memory related toanoxiab. Loss of abstract thinking related toemotional statec. Inability to concentrate related todecreased stimulid. Disturbance in recalling recent eventsrelated to cerebral hypoxia.40. Josefina is to be discharged on a regimen oflithium carbonate. In the teaching plan fordischarge the nurse should include:a. Advising the client to watch the dietcarefullyb. Suggesting that the client take the pillswith milkc. Reminding the client that a CBC must bedone once a month.d. Encouraging the client to have bloodlevels checked as ordered.41. The psychiatrist orders lithium carbonate 600mg p.o t.i.d for a female client. Nurse Katrinawould be aware that the teachings about theside effects of this drug were understood whenthe client state, “I will call my doctorimmediately if I notice any:a. Sensitivity to bright light or sunb. Fine hand tremors or slurred speechc. Sexual dysfunction or breastenlargementd. Inability to urinate or difficulty whenurinating42. Nurse Mylene recognizes that the mostimportant factor necessary for the establishmentof trust in a critical care area is:a. Privacyb. Respectc. Empathyd. Presence43. When establishing an initial nurse-clientrelationship, Nurse Hazel should explore withthe client the:a. Client’s perception of the presentingproblem.b. Occurrence of fantasies the client mayexperience.c. Details of any ritualistic acts carried outby the clientd. Client’s feelings when external; controlsare instituted.44. Tranylcypromine sulfate (Parnate) is prescribedfor a depressed client who has not responded tothe tricyclic antidepressants. After teaching theclient about the medication, Nurse Marianevaluates that learning has occurred when theclient states, “I will avoid:a. Citrus fruit, tuna, and yellowvegetables.”b. Chocolate milk, aged cheese, andyogurt’”c. Green leafy vegetables, chicken, andmilk.”d. Whole grains, red meats, andcarbonated soda.”45. Nurse John is a aware that most crisis situationsshould resolve in about:a. 1 to 2 weeksb. 4 to 6 weeksc. 4 to 6 monthsd. 6 to 12 months46. Nurse Judy knows that statistics show that inadolescent suicide behavior:a. Females use more dramatic methodsthan malesb. Males account for more attempts thando femalesc. Females talk more about suicide beforeattempting itd. Males are more likely to use lethalmethods than are females47. Dervid with paranoid schizophrenia repeatedlyuses profanity during an activity therapy session.Which response by the nurse would be mostappropriate?a. "Your behavior wont be tolerated. Go toyour room immediately."
  • 138b. "Youre just doing this to get back at mefor making you come to therapy."c. "Your cursing is interrupting the activity.Take time out in your room for 10minutes."d. "Im disappointed in you. You cantcontrol yourself even for a few minutes."48. Nurse Maureen knows that the nonantipsychoticmedication used to treat some clients withschizoaffective disorder is:a. phenelzine (Nardil)b. chlordiazepoxide (Librium)c. lithium carbonate (Lithane)d. imipramine (Tofranil)49. Which information is most important for thenurse Trinity to include in a teaching plan for amale schizophrenic client taking clozapine(Clozaril)?a. Monthly blood tests will be necessary.b. Report a sore throat or fever to thephysician immediately.c. Blood pressure must be monitored forhypertension.d. Stop the medication when symptomssubside.50. Ricky with chronic schizophrenia takesneuroleptic medication is admitted to thepsychiatric unit. Nursing assessment revealsrigidity, fever, hypertension, and diaphoresis.These findings suggest which life- threateningreaction:a. Tardive dyskinesia.b. Dystonia.c. Neuroleptic malignant syndrome.d. Akathisia.51. Which nursing intervention would be mostappropriate if a male client develop orthostatichypotension while taking amitriptyline (Elavil)?a. Consulting with the physician aboutsubstituting a different type ofantidepressant.b. Advising the client to sit up for 1 minutebefore getting out of bed.c. Instructing the client to double thedosage until the problem resolves.d. Informing the client that this adversereaction should disappear within 1week.52. Mr. Cruz visits the physicians office to seektreatment for depression, feelings ofhopelessness, poor appetite, insomnia, fatigue,low self- esteem, poor concentration, anddifficulty making decisions. The client states thatthese symptoms began at least 2 years ago.Based on this report, the nurse Tyfany suspects:a. Cyclothymic disorder.b. Atypical affective disorder.c. Major depression.d. Dysthymic disorder.53. After taking an overdose of phenobarbital(Barbita), Mario is admitted to the emergencydepartment. Dr. Trinidad prescribes activatedcharcoal (Charcocaps) to be administered bymouth immediately. Before administering thedose, the nurse verifies the dosage ordered.What is the usual minimum dose of activatedcharcoal?a. 5 g mixed in 250 ml of waterb. 15 g mixed in 500 ml of waterc. 30 g mixed in 250 ml of waterd. 60 g mixed in 500 ml of water54. What herbal medication for depression, widelyused in Europe, is now being prescribed in theUnited States?a. Ginkgo bilobab. Echinaceac. St. Johns wortd. Ephedra55. Cely with manic episodes is taking lithium.Which electrolyte level should the nurse checkbefore administering this medication?a. Clciumb. Sodiumc. Chlorided. Potassium56. Nurse Josefina is caring for a client who has beendiagnosed with delirium. Which statement aboutdelirium is true?a. Its characterized by an acute onset andlasts about 1 month.b. Its characterized by a slowly evolvingonset and lasts about 1 week.c. Its characterized by a slowly evolvingonset and lasts about 1 month.d. Its characterized by an acute onset andlasts hours to a number of days.
  • 13957. Edward, a 66 year old client with slight memoryimpairment and poor concentration is diagnosedwith primary degenerative dementia of theAlzheimers type. Early signs of this dementiainclude subtle personality changes andwithdrawal from social interactions. To assessfor progression to the middle stage ofAlzheimers disease, the nurse should observethe client for:a. Occasional irritable outbursts.b. Impaired communication.c. Lack of spontaneity.d. Inability to perform self-care activities.58. Isabel with a diagnosis of depression is startedon imipramine (Tofranil), 75 mg by mouth atbedtime. The nurse should tell the client that:a. This medication may be habit formingand will be discontinued as soon as theclient feels better.b. This medication has no serious adverseeffects.c. The client should avoid eating suchfoods as aged cheeses, yogurt, andchicken livers while taking themedication.d. This medication may initially causetiredness, which should become lessbothersome over time.59. Kathleen is admitted to the psychiatric clinic fortreatment of anorexia nervosa. To promote theclients physical health, the nurse should plan to:a. Severely restrict the clients physicalactivities.b. Weigh the client daily, after the eveningmeal.c. Monitor vital signs, serum electrolytelevels, and acid-base balance.d. Instruct the client to keep an accuraterecord of food and fluid intake.60. Celia with a history of polysubstance abuse isadmitted to the facility. She complains of nauseaand vomiting 24 hours after admission. Thenurse assesses the client and notes piloerection,pupillary dilation, and lacrimation. The nursesuspects that the client is going through which ofthe following withdrawals?a. Alcohol withdrawalb. Cannibis withdrawalc. Cocaine withdrawald. Opioid withdrawal61. Mr. Garcia, an attorney who throws books andfurniture around the office after losing a case isreferred to the psychiatric nurse in the law firmsemployee assistance program. Nurse Beatrizknows that the clients behavior most likelyrepresents the use of which defensemechanism?a. Regressionb. Projectionc. Reaction-formationd. Intellectualization62. Nurse Anne is caring for a client who has beentreated long term with antipsychotic medication.During the assessment, Nurse Anne checks theclient for tardive dyskinesia. If tardive dyskinesiais present, Nurse Anne would most likelyobserve:a. Abnormal movements and involuntarymovements of the mouth, tongue, andface.b. Abnormal breathing through the nostrilsaccompanied by a “thrill.”c. Severe headache, flushing, tremors, andataxia.d. Severe hypertension, migraineheadache,63. Dennis has a lithium level of 2.4 mEq/L. Thenurse immediately would assess the client forwhich of the following signs or symptoms?a. Weaknessb. Diarrheac. Blurred visiond. Fecal incontinence64. Nurse Jannah is monitoring a male client whohas been placed inrestraints because of violentbehavior. Nurse determines that it will be safe toremove the restraints when:a. The client verbalizes the reasons for theviolent behavior.b. The client apologizes and tells the nursethat it will never happen again.c. No acts of aggression have beenobserved within 1 hour after the releaseof two of the extremity restraints.d. The administered medication has takeneffect.
  • 14065. Nurse Irish is aware that Ritalin is the drug ofchoice for a child with ADHD. The side effects ofthe following may be noted by the nurse:a. Increased attention span andconcentrationb. Increase in appetitec. Sleepiness and lethargyd. Bradycardia and diarrhea66. Kitty, a 9 year old child has very limitedvocabulary and interaction skills. She has an I.Q.of 45. She is diagnosed to have Mentalretardation of this classification:a. Profoundb. Mildc. Moderated. Severe67. The therapeutic approach in the care of Armandan autistic child include the following EXCEPT:a. Engage in diversionary activities whenacting -outb. Provide an atmosphere of acceptancec. Provide safety measuresd. Rearrange the environment to activatethe child68. Jeremy is brought to the emergency room byfriends who state that he took something anhour ago. He is actively hallucinating, agitated,with irritated nasal septum.a. Heroinb. Cocainec. LSDd. Marijuana69. Nurse Pauline is aware that Dementia unlikedelirium is characterized by:a. Slurred speechb. Insidious onsetc. Clouding of consciousnessd. Sensory perceptual change70. A 35 year old female has intense fear of riding anelevator. She claims “ As if I will die inside.” Theclient is suffering from:a. Agoraphobiab. Social phobiac. Claustrophobiad. Xenophobia71. Nurse Myrna develops a counter-transferencereaction. This is evidenced by:a. Revealing personal information to theclientb. Focusing on the feelings of the client.c. Confronting the client aboutdiscrepancies in verbal or non-verbalbehaviord. The client feels angry towards the nursewho resembles his mother.72. Tristan is on Lithium has suffered from diarrheaand vomiting. What should the nurse in-chargedo first:a. Recognize this as a drug interactionb. Give the client Cogentinc. Reassure the client that these arecommon side effects of lithium therapyd. Hold the next dose and obtain an orderfor a stat serum lithium level73. Nurse Sarah ensures a therapeutic environmentfor all the client. Which of the following bestdescribes a therapeutic milieu?a. A therapy that rewards adaptivebehaviorb. A cognitive approach to change behaviorc. A living, learning or workingenvironment.d. A permissive and congenial environment74. Anthony is very hostile toward one of the stafffor no apparent reason. He is manifesting:a. Splittingb. Transferencec. Countertransferenced. Resistance75. Marielle, 17 years old was sexually attackedwhile on her way home from school. She isbrought to the hospital by her mother. Rape isan example of which type of crisis:a. Situationalb. Adventitiousc. Developmentald. Internal76. Nurse Greta is aware that the following isclassified as an Axis I disorder by the Diagnosisand Statistical Manual of Mental Disorders, TextRevision (DSM-IV-TR) is:a. Obesityb. Borderline personality disorderc. Major depressiond. Hypertension
  • 14177. Katrina, a newly admitted is extremely hostiletoward a staff member she has just met, withoutapparent reason. According to Freudian theory,the nurse should suspect that the client isexperiencing which of the followingphenomena?a. Intellectualizationb. Transferencec. Triangulationd. Splitting78. An 83year-old male client is in extended carefacility is anxious most of the time andfrequently complains of a number of vaguesymptoms that interfere with his ability to eat.These symptoms indicate which of the followingdisorders?a. Conversion disorderb. Hypochondriasisc. Severe anxietyd. Sublimation79. Charina, a college student who frequently visitedthe health center during the past year withmultiple vague complaints of GI symptomsbefore course examinations. Although physicalcauses have been eliminated, the studentcontinues to express her belief that she has aserious illness. These symptoms are typically ofwhich of the following disorders?a. Conversion disorderb. Depersonalizationc. Hypochondriasisd. Somatization disorder80. Nurse Daisy is aware that the followingpharmacologic agents are sedative- hypnoticmedication is used to induce sleep for a clientexperiencing a sleep disorder is:a. Triazolam (Halcion)b. Paroxetine (Paxil)c. Fluoxetine (Prozac)d. Risperidone (Risperdal)81. Aldo, with a somatoform pain disorder mayobtain secondary gain. Which of the followingstatement refers to a secondary gain?a. It brings some stability to the familyb. It decreases the preoccupation with thephysical illnessc. It enables the client to avoid someunpleasant activityd. It promotes emotional support orattention for the client82. Dervid is diagnosed with panic disorder withagoraphobia is talking with the nurse in-chargeabout the progress made in treatment. Which ofthe following statements indicates a positiveclient response?a. “I went to the mall with my friends lastSaturday”b. “I’m hyperventilating only when I have apanic attack”c. “Today I decided that I can stop takingmy medication”d. “Last night I decided to eat more than abowl of cereal”83. The effectiveness of monoamine oxidase (MAO)inhibitor drug therapy in a client withposttraumatic stress disorder can bedemonstrated by which of the following clientself –reports?a. “I’m sleeping better and don’t havenightmares”b. “I’m not losing my temper as much”c. “I’ve lost my craving for alcohol”d. I’ve lost my phobia for water”84. Mark, with a diagnosis of generalized anxietydisorder wants to stop taking his lorazepam(Ativan). Which of the following important factsshould nurse Betty discuss with the client aboutdiscontinuing the medication?a. Stopping the drug may cause depressionb. Stopping the drug increases cognitiveabilitiesc. Stopping the drug decreases sleepingdifficultiesd. Stopping the drug can cause withdrawalsymptoms85. Jennifer, an adolescent who is depressed andreported by his parents as having difficulty inschool is brought to the community mentalhealth center to be evaluated. Which of thefollowing other health problems would the nursesuspect?a. Anxiety disorderb. Behavioral difficultiesc. Cognitive impairmentd. Labile moods
  • 14286. Ricardo, an outpatient in psychiatric facility isdiagnosed with dysthymic disorder. Which of thefollowing statement about dysthymic disorder istrue?a. It involves a mood range from moderatedepression to hypomaniab. It involves a single manic depressionc. It’s a form of depression that occurs inthe fall and winterd. It’s a mood disorder similar to majordepression but of mild to moderateseverity87. The nurse is aware that the following ways invascular dementia different from Alzheimer’sdisease is:a. Vascular dementia has more abruptonsetb. The duration of vascular dementia isusually briefc. Personality change is common invascular dementiad. The inability to perform motor activitiesoccurs in vascular dementia88. Loretta, a newly admitted client was diagnosedwith delirium and has history of hypertensionand anxiety. She had been taking digoxin,furosemide (Lasix), and diazepam (Valium) foranxiety. This client’s impairment may be relatedto which of the following conditions?a. Infectionb. Metabolic acidosisc. Drug intoxicationd. Hepatic encephalopathy89. Nurse Ron enters a client’s room, the client says,“They’re crawling on my sheets! Get them offmy bed!” Which of the following assessment isthe most accurate?a. The client is experiencing aphasiab. The client is experiencing dysarthriac. The client is experiencing a flight of ideasd. The client is experiencing visualhallucination90. Which of the following descriptions of a client’sexperience and behavior can be assessed as anillusion?a. The client tries to hit the nurse whenvital signs must be takenb. The client says, “I keep hearing a voicetelling me to run away”c. The client becomes anxious wheneverthe nurse leaves the bedsided. The client looks at the shadow on a walland tells the nurse she sees frighteningfaces on the wall.91. During conversation of Nurse John with a client,he observes that the client shift from one topicto the next on a regular basis. Which of thefollowing terms describes this disorder?a. Flight of ideasb. Concrete thinkingc. Ideas of referenced. Loose association92. Francis tells the nurse that her coworkers aresabotaging the computer. When the nurse asksquestions, the client becomes argumentative.This behavior shows personality traits associatedwith which of the following personality disorder?a. Antisocialb. Histrionicc. Paranoidd. Schizotypal93. Which of the following interventions isimportant for a Cely experiencing with paranoidpersonality disorder taking olanzapine(Zyprexa)?a. Explain effects of serotonin syndromeb. Teach the client to watch forextrapyramidal adverse reactionc. Explain that the drug is less affective ifthe client smokesd. Discuss the need to report paradoxicaleffects such as euphoria94. Nurse Alexandra notices other clients on the unitavoiding a client diagnosed with antisocialpersonality disorder. When discussingappropriate behavior in group therapy, which ofthe following comments is expected about thisclient by his peers?a. Lack of honestyb. Belief in superstitionc. Show of temper tantrumsd. Constant need for attention95. Tommy, with dependent personality disorder isworking to increase his self- esteem. Which ofthe following statements by the Tommy showsteaching was successful?
  • 143a. “I’m not going to look just at thenegative things about myself”b. “I’m most concerned about my level ofcompetence and progress”c. “I’m not as envious of the things otherpeople have as I used to be”d. “I find I can’t stop myself from takingover things other should be doing”96. Norma, a 42-year-old client with a diagnosis ofchronic undifferentiated schizophrenia lives in arooming house that has a weekly nursing clinic.She scratches while she tells the nurse she feelscreatures eating away at her skin. Which of thefollowing interventions should be done first?a. Talk about his hallucinations and fearsb. Refer him for anticholinergic adversereactionsc. Assess for possible physical problemssuch as rashd. Call his physician to get his medicationincreased to control his psychosis97. Ivy, who is on the psychiatric unit is copying andimitating the movements of her primary nurse.During recovery, she says, “I thought the nursewas my mirror. I felt connected only when I sawmy nurse.” This behavior is known by which ofthe following terms?a. Modelingb. Echopraxiac. Ego-syntonicityd. Ritualism98. Jun approaches the nurse and tells that he hearsa voice telling him that he’s evil and deserves todie. Which of the following terms describes theclient’s perception?a. Delusionb. Disorganized speechc. Hallucinationd. Idea of reference99. Mike is admitted to a psychiatric unit with adiagnosis of undifferentiated schizophrenia.Which of the following defense mechanisms isprobably used by mike?a. Projectionb. Rationalizationc. Regressiond. Repression100. Rocky has started taking haloperidol (Haldol).Which of the following instructions is mostappropriate for Ricky before takinghaloperidol?a. Should report feelings of restlessness oragitation at onceb. Use a sunscreen outdoors on a year-round basisc. Be aware you’ll feel increased energytaking this drugd. This drug will indirectly control essentialhypertension
  • 144Answers and Rationale – Care of Clients withPhysiologic and Psychosocial Alterations1. Answer: (D) FocusingRationale: The nurse is using focusing bysuggesting that the client discuss a specific issue.The nurse didn’t restate the question, makeobservation, or ask further question (exploring).2. Answer: (D) Remove all other clients from thedayroom.Rationale: The nurse’s first priority is to considerthe safety of the clients in the therapeuticsetting. The other actions are appropriateresponses after ensuring the safety of otherclients.3. Answer: (A) The client is disruptive.Rationale: Group activity provides too muchstimulation, which the client will not be able tohandle (harmful to self) and as a result will bedisruptive to others.4. Answer: (C) Agree to talk with the mother andthe father together.Rationale: By agreeing to talk with both parents,the nurse can provide emotional support andfurther assess and validate the family’s needs.5. Answer: (A) Perceptual disorders.Rationale: Frightening visual hallucinations areespecially common in clients experiencingalcohol withdrawal.6. Answer: (D) Suggest that it takes a while beforeseeing the results.Rationale: The client needs a specific response;that it takes 2 to 3 weeks (a delayed effect) untilthe therapeutic blood level is reached.7. Answer: (C) SuperegoRationale: This behavior shows a weak sense ofmoral consciousness. According to Freudiantheory, personality disorders stem from a weaksuperego.8. Answer: (C) Skeletal muscle paralysis.Rationale: Anectine is a depolarizing musclerelaxant causing paralysis. It is used to reducethe intensity of muscle contractions during theconvulsive stage, thereby reducing the risk ofbone fractures or dislocation.9. Answer: (D) Increase calories, carbohydrates,and protein.Rationale: This client increased protein for tissuebuilding and increased calories to replace what isburned up (usually via carbohydrates).10. Answer: (C) Acting overly solicitous toward thechild.Rationale: This behavior is an example ofreaction formation, a coping mechanism.11. Answer: (A) By designating times during whichthe client can focus on the behavior.Rationale: The nurse should designate timesduring which the client can focus on thecompulsive behavior or obsessive thoughts. Thenurse should urge the client to reduce thefrequency of the compulsive behavior gradually,not rapidly. She shouldnt call attention to or tryto prevent the behavior. Trying to prevent thebehavior may cause pain and terror in the client.The nurse should encourage the client toverbalize anxieties to help distract attentionfrom the compulsive behavior.12. Answer: (D) Exploring the meaning of thetraumatic event with the client.Rationale: The client with PTSD needsencouragement to examine and understand themeaning of the traumatic event and consequentlosses. Otherwise, symptoms may worsen andthe client may become depressed or engage inself-destructive behavior such as substanceabuse. The client must explore the meaning ofthe event and wont heal without this, no matterhow much time passes. Behavioral techniques,such as relaxation therapy, may help decreasethe clients anxiety and induce sleep. Thephysician may prescribe antianxiety agents orantidepressants cautiously to avoid dependence;sleep medication is rarely appropriate. A specialdiet isnt indicated unless the client also has aneating disorder or a nutritional problem.13. Answer: (C) "Your problem is real but there is nophysical basis for it. Well work on what is goingon in your life to find out why its happened."Rationale: The nurse must be honest with theclient by telling her that the paralysis has nophysiologic cause while also conveying empathyand acknowledging that her symptoms are real.The client will benefit from psychiatrictreatment, which will help her understand theunderlying cause of her symptoms. After thepsychological conflict is resolved, her symptomswill disappear. Saying that it must be awful notto be able to move her legs wouldnt answer theclients question; knowing that the cause ispsychological wouldnt necessarily make her feelbetter. Telling her that she has developedparalysis to avoid leaving her parents or that herpersonality caused her disorder wouldnt helpher understand and resolve the underlyingconflict.
  • 14514. Answer: (C) fluvoxamine (Luvox) andclomipramine (Anafranil)Rationale: The antidepressants fluvoxamine andclomipramine have been effective in thetreatment of OCD. Librium and Valium may behelpful in treating anxiety related to OCD butarent drugs of choice to treat the illness. Theother medications mentioned arent effective inthe treatment of OCD.15. Answer: (A) A warning about the drugs delayedtherapeutic effect, which is from 14 to 30 days.Rationale: The client should be informed thatthe drugs therapeutic effect might not bereached for 14 to 30 days. The client must beinstructed to continue taking the drug asdirected. Blood level checks arent necessary.NMS hasnt been reported with this drug, buttachycardia is frequently reported.16. Answer: (B) Severe anxiety and fear.Rationale: Phobias cause severe anxiety (such asa panic attack) that is out of proportion to thethreat of the feared object or situation. Physicalsigns and symptoms of phobias include profusesweating, poor motor control, tachycardia, andelevated blood pressure. Insomnia, an inabilityto concentrate, and weight loss are common indepression. Withdrawal and failure todistinguish reality from fantasy occur inschizophrenia.17. Answer: (A) AntidepressantsRationale: Tricyclic and monoamine oxidase(MAO) inhibitor antidepressants have beenfound to be effective in treating clients withpanic attacks. Why these drugs help controlpanic attacks isnt clearly understood.Anticholinergic agents, which are smooth-muscle relaxants, relieve physical symptoms ofanxiety but dont relieve the anxiety itself.Antipsychotic drugs are inappropriate becauseclients who experience panic attacks arentpsychotic. Mood stabilizers arent indicatedbecause panic attacks are rarely associated withmood changes.18. Answer: (B) 3 to 5 daysRationale: Monoamine oxidase inhibitors, suchas tranylcypromine, have an onset of action ofapproximately 3 to 5 days. A full clinicalresponse may be delayed for 3 to 4 weeks. Thetherapeutic effects may continue for 1 to 2weeks after discontinuation.19. Answer: (B) Providing emotional support andindividual counseling.Rationale: Clients in the first stage of Alzheimersdisease are aware that something is happeningto them and may become overwhelmed andfrightened. Therefore, nursing care typicallyfocuses on providing emotional support andindividual counseling. The other options areappropriate during the second stage ofAlzheimers disease, when the client needscontinuous monitoring to prevent minorillnesses from progressing into major problemsand when maintaining adequate nutrition maybecome a challenge. During this stage, offeringnourishing finger foods helps clients to feedthemselves and maintain adequate nutrition.20. Answer: (C) Emotional lability, euphoria, andimpaired memoryRationale: Signs of antianxiety agent overdoseinclude emotional lability, euphoria, andimpaired memory. Phencyclidine overdose cancause combativeness, sweating, and confusion.Amphetamine overdose can result in agitation,hyperactivity, and grandiose ideation.Hallucinogen overdose can producesuspiciousness, dilated pupils, and increasedblood pressure.21. Answer: (D) A low tolerance for frustrationRationale: Clients with an antisocial personalitydisorder exhibit a low tolerance for frustration,emotional immaturity, and a lack of impulsecontrol. They commonly have a history ofunemployment, miss work repeatedly, and quitwork without other plans for employment. Theydont feel guilt about their behavior andcommonly perceive themselves as victims. Theyalso display a lack of responsibility for theoutcome of their actions. Because of a lack oftrust in others, clients with antisocial personalitydisorder commonly have difficulty developingstable, close relationships.22. Answer: (C) MethadoneRationale: Methadone is used to detoxify opiateusers because it binds with opioid receptors atmany sites in the central nervous system butdoesn’t have the same deterious effects as otheropiates, such as cocaine, heroin, and morphine.Barbiturates, amphetamines, andbenzodiazepines are highly addictive and wouldrequire detoxification treatment.23. Answer: (B) HallucinationsRationale: Hallucinations are visual, auditory,gustatory, tactile, or olfactory perceptions thathave no basis in reality. Delusions are falsebeliefs, rather than perceptions, that the client
  • 146accepts as real. Loose associations are rapidshifts among unrelated ideas. Neologisms arebizarre words that have meaning only to theclient.24. Answer: (C) Set up a strict eating plan for theclient.Rationale: Establishing a consistent eating planand monitoring the client’s weight are veryimportant in this disorder. The family and friendsshould be included in the client’s care. The clientshould be monitored during meals-not givenprivacy. Exercise must be limited and supervised.25. Answer: (A) Highly important or famous.Rationale: A delusion of grandeur is a false beliefthat one is highly important or famous. Adelusion of persecution is a false belief that oneis being persecuted. A delusion of reference is afalse belief that one is connected to eventsunrelated to oneself or a belief that one isresponsible for the evil in the world.26. Answer: (D) Listening attentively with a neutralattitude and avoiding power struggles.Rationale: The nurse should listen to the client’srequests, express willingness to seriouslyconsider the request, and respond later. Thenurse should encourage the client to take shortdaytime naps because he expends so muchenergy. The nurse shouldn’t try to restrain theclient when he feels the need to move around aslong as his activity isn’t harmful. High caloriefinger foods should be offered to supplementthe client’s diet, if he can’t remain seated longenough to eat a complete meal. The nurseshouldn’t be forced to stay seated at the table tofinid=sh a meal. The nurse should set limits in acalm, clear, and self-confident tone of voice.27. Answer: (D) DenialRationale: Denial is unconscious defensemechanism in which emotional conflict andanxiety is avoided by refusing to acknowledgefeelings, desires, impulses, or external facts thatare consciously intolerable. Withdrawal is acommon response to stress, characterized byapathy. Logical thinking is the ability to thinkrationally and make responsible decisions, whichwould lead the client admitting the problem andseeking help. Repression is suppressing pastevents from the consciousness because of guiltyassociation.28. Answer: (B) Paranoid thoughtsRationale: Clients with schizotypal personalitydisorder experience excessive social anxiety thatcan lead to paranoid thoughts. Aggressivebehavior is uncommon, although these clientsmay experience agitation with anxiety. Theirbehavior is emotionally cold with a flattenedaffect, regardless of the situation. These clientsdemonstrate a reduced capacity for close ordependent relationships.29. Answer: (C) Identify anxiety-causing situationsRationale: Bulimic behavior is generally amaladaptive coping response to stress andunderlying issues. The client must identifyanxiety-causing situations that stimulate thebulimic behavior and then learn new ways ofcoping with the anxiety.30. Answer: (A) Tension and irritabilityRationale: An amphetamine is a nervous systemstimulant that is subject to abuse because of itsability to produce wakefulness and euphoria. Anoverdose increases tension and irritability.Options B and C are incorrect becauseamphetamines stimulate norepinephrine, whichincrease the heart rate and blood flow. Diarrheais a common adverse effect so option D isincorrect.31. Answer: (B) “No, I do not hear your voices, but Ibelieve you can hear them”.Rationale: The nurse, demonstrating knowledgeand understanding, accepts the client’sperceptions even though they are hallucinatory.32. Answer: (C) Confusion for a time after treatmentRationale: The electrical energy passing throughthe cerebral cortex during ECT results in atemporary state of confusion after treatment.33. Answer: (D) Acceptance stageRationale: Communication and interventionduring this stage are mainly nonverbal, as whenthe client gestures to hold the nurse’s hand.34. Answer: (D) A higher level of anxiety continuingfor more than 3 months.Rationale: This is not an expected outcome of acrisis because by definition a crisis would beresolved in 6 weeks.35. Answer: (B) Staying in the sunRationale: Haldol causes photosensitivity. Severesunburn can occur on exposure to the sun.36. Answer: (D) Moderate-level anxietyRationale: A moderately anxious person canignore peripheral events and focuses on centralconcerns.37. Answer: (C) Diverse interestRationale: Before onset of depression, theseclients usually have very narrow, limitedinterest.
  • 14738. Answer: (A) As their depression begins toimproveRationale: At this point the client may haveenough energy to plan and execute an attempt.39. Answer: (D) Disturbance in recalling recentevents related to cerebral hypoxia.Rationale: Cell damage seems to interfere withregistering input stimuli, which affects the abilityto register and recall recent events; vasculardementia is related to multiple vascular lesionsof the cerebral cortex and subcortical structure.40. Answer: (D) Encouraging the client to have bloodlevels checked as ordered.Rationale: Blood levels must be checked monthlyor bimonthly when the client is on maintenancetherapy because there is only a small rangebetween therapeutic and toxic levels.41. Answer: (B) Fine hand tremors or slurred speechRationale: These are common side effects oflithium carbonate.42. Answer: (D) PresenceRationale: The constant presence of a nurseprovides emotional support because the clientknows that someone is attentive and available incase of an emergency.43. Answer: (A) Client’s perception of the presentingproblem.Rationale: The nurse can be most therapeutic bystarting where the client is, because it is theclient’s concept of the problem that serves asthe starting point of the relationship.44. Answer: (B) Chocolate milk, aged cheese, andyogurt’”Rationale: These high-tyramine foods, wheningested in the presence of an MAO inhibitor,cause a severe hypertensive response.45. Answer: (B) 4 to 6 weeksRationale: Crisis is self-limiting and lasts from 4to 6 weeks.46. Answer: (D) Males are more likely to use lethalmethods than are femalesRationale: This finding is supported by research;females account for 90% of suicide attempts butmales are three times more successful becauseof methods used.47. Answer: (C) "Your cursing is interrupting theactivity. Take time out in your room for 10minutes."Rationale: The nurse should set limits on clientbehavior to ensure a comfortable environmentfor all clients. The nurse should accept hostile orquarrelsome client outbursts within limitswithout becoming personally offended, as inoption A. Option B is incorrect because it impliesthat the client’s actions reflect feelings towardthe staff instead of the clients own misery.Judgmental remarks, such as option D, maydecrease the clients self-esteem.48. Answer: (C) lithium carbonate (Lithane)Rationale: Lithium carbonate, an antimania drug,is used to treat clients with cyclicalschizoaffective disorder, a psychotic disorderonce classified under schizophrenia that causesaffective symptoms, including maniclike activity.Lithium helps control the affective component ofthis disorder. Phenelzine is a monoamineoxidase inhibitor prescribed for clients who dontrespond to other antidepressant drugs such asimipramine. Chlordiazepoxide, an antianxietyagent, generally is contraindicated in psychoticclients. Imipramine, primarily considered anantidepressant agent, is also used to treat clientswith agoraphobia and that undergoing cocainedetoxification.49. Answer: (B) Report a sore throat or fever to thephysician immediately.Rationale: A sore throat and fever areindications of an infection caused byagranulocytosis, a potentially life-threateningcomplication of clozapine. Because of the risk ofagranulocytosis, white blood cell (WBC) countsare necessary weekly, not monthly. If the WBCcount drops below 3,000/μl, the medicationmust be stopped. Hypotension may occur inclients taking this medication. Warn the client tostand up slowly to avoid dizziness fromorthostatic hypotension. The medication shouldbe continued, even when symptoms have beencontrolled. If the medication must be stopped, itshould be slowly tapered over 1 to 2 weeks andonly under the supervision of a physician.50. Answer: (C) Neuroleptic malignant syndrome.Rationale: The clients signs and symptomssuggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medicationthat requires immediate treatment. Tardivedyskinesia causes involuntary movements of thetongue, mouth, facial muscles, and arm and legmuscles. Dystonia is characterized by crampsand rigidity of the tongue, face, neck, and backmuscles. Akathisia causes restlessness, anxiety,and jitteriness.51. Answer: (B) Advising the client to sit up for 1minute before getting out of bed.Rationale: To minimize the effects ofamitriptyline-induced orthostatic hypotension,
  • 148the nurse should advise the client to sit up for 1minute before getting out of bed. Orthostatichypotension commonly occurs with tricyclicantidepressant therapy. In these cases, thedosage may be reduced or the physician mayprescribe nortriptyline, another tricyclicantidepressant. Orthostatic hypotensiondisappears only when the drug is discontinued.52. Answer: (D) Dysthymic disorder.Rationale: Dysthymic disorder is marked byfeelings of depression lasting at least 2 years,accompanied by at least two of the followingsymptoms: sleep disturbance, appetitedisturbance, low energy or fatigue, low self-esteem, poor concentration, difficulty makingdecisions, and hopelessness. These symptomsmay be relatively continuous or separated byintervening periods of normal mood that last afew days to a few weeks. Cyclothymic disorder isa chronic mood disturbance of at least 2 yearsduration marked by numerous periods ofdepression and hypomania. Atypical affectivedisorder is characterized by manic signs andsymptoms. Major depression is a recurring,persistent sadness or loss of interest or pleasurein almost all activities, with signs and symptomsrecurring for at least 2 weeks.53. Answer: (C) 30 g mixed in 250 ml of waterRationale: The usual adult dosage of activatedcharcoal is 5 to 10 times the estimated weight ofthe drug or chemical ingested, or a minimumdose of 30 g, mixed in 250 ml of water. Dosesless than this will be ineffective; doses greaterthan this can increase the risk of adversereactions, although toxicity doesnt occur withactivated charcoal, even at the maximum dose.54. Answer: (C) St. Johns wortRationale: St. Johns wort has been found tohave serotonin-elevating properties, similar toprescription antidepressants. Ginkgo biloba isprescribed to enhance mental acuity. Echinaceahas immune-stimulating properties. Ephedra is anaturally occurring stimulant that is similar toephedrine.55. Answer: (B) SodiumRationale: Lithium is chemically similar tosodium. If sodium levels are reduced, such asfrom sweating or diuresis, lithium will bereabsorbed by the kidneys, increasing the risk oftoxicity. Clients taking lithium shouldnt restricttheir intake of sodium and should drinkadequate amounts of fluid each day. The otherelectrolytes are important for normal bodyfunctions but sodium is most important to theabsorption of lithium.56. Answer: (D) Its characterized by an acute onsetand lasts hours to a number of daysRationale: Delirium has an acute onset andtypically can last from several hours to severaldays.57. Answer: (B) Impaired communication.Rationale: Initially, memory impairment may bethe only cognitive deficit in a client withAlzheimers disease. During the early stage ofthis disease, subtle personality changes may alsobe present. However, other than occasionalirritable outbursts and lack of spontaneity, theclient is usually cooperative and exhibits sociallyappropriate behavior. Signs of advancement tothe middle stage of Alzheimers disease includeexacerbated cognitive impairment with obviouspersonality changes and impairedcommunication, such as inappropriateconversation, actions, and responses. During thelate stage, the client cant perform self-careactivities and may become mute.58. Answer: (D) This medication may initially causetiredness, which should become lessbothersome over time.Rationale: Sedation is a common early adverseeffect of imipramine, a tricyclic antidepressant,and usually decreases as tolerance develops.Antidepressants arent habit forming and dontcause physical or psychological dependence.However, after a long course of high-dosetherapy, the dosage should be decreasedgradually to avoid mild withdrawal symptoms.Serious adverse effects, although rare, includemyocardial infarction, heart failure, andtachycardia. Dietary restrictions, such asavoiding aged cheeses, yogurt, and chickenlivers, are necessary for a client taking amonoamine oxidase inhibitor, not a tricyclicantidepressant.59. Answer: (C) Monitor vital signs, serumelectrolyte levels, and acid-base balance.Rationale: An anorexic client who requireshospitalization is in poor physical condition fromstarvation and may die as a result ofarrhythmias, hypothermia, malnutrition,infection, or cardiac abnormalities secondary toelectrolyte imbalances. Therefore, monitoringthe clients vital signs, serum electrolyte level,and acid base balance is crucial. Option A mayworsen anxiety. Option B is incorrect because aweight obtained after breakfast is more accurate
  • 149than one obtained after the evening meal.Option D would reward the client with attentionfor not eating and reinforce the control issuesthat are central to the underlying psychologicalproblem; also, the client may record food andfluid intake inaccurately.60. Answer: (D) Opioid withdrawalRationale: The symptoms listed are specific toopioid withdrawal. Alcohol withdrawal wouldshow elevated vital signs. There is no realwithdrawal from cannibis. Symptoms of cocainewithdrawal include depression, anxiety, andagitation.61. Answer: (A) RegressionRationale: An adult who throws tempertantrums, such as this one, is displayingregressive behavior, or behavior that isappropriate at a younger age. In projection, theclient blames someone or something other thanthe source. In reaction formation, the client actsin opposition to his feelings. Inintellectualization, the client overuses rationalexplanations or abstract thinking to decrease thesignificance of a feeling or event.62. Answer: (A) Abnormal movements andinvoluntary movements of the mouth, tongue,and face.Rationale: Tardive dyskinesia is a severe reactionassociated with long term use of antipsychoticmedication. The clinical manifestations includeabnormal movements (dyskinesia) andinvoluntary movements of the mouth, tongue(fly catcher tongue), and face.63. Answer: (C) Blurred visionRationale: At lithium levels of 2 to 2.5 mEq/L theclient will experienced blurred vision, muscletwitching, severe hypotension, and persistentnausea and vomiting. With levels between 1.5and 2 mEq/L the client experiencing vomiting,diarrhea, muscle weakness, ataxia, dizziness,slurred speech, and confusion. At lithium levelsof 2.5 to 3 mEq/L or higher, urinary and fecalincontinence occurs, as well as seizures, cardiacdysrythmias, peripheral vascular collapse, anddeath.64. Answer: (C) No acts of aggression have beenobserved within 1 hour after the release of twoof the extremity restraints.Rationale: The best indicator that the behavior iscontrolled, if the client exhibits no signs ofaggression after partial release of restraints.Options , B, and D do not ensure that the clienthas controlled the behavior.65. Answer: (A) increased attention span andconcentrationRationale: The medication has a paradoxic effectthat decreases hyperactivity and impulsivityamong children with ADHD. B, C, D. Side effectsof Ritalin include anorexia, insomnia, diarrheaand irritability.66. Answer: (C) ModerateRationale: The child with moderate mentalretardation has an I.Q. of 35- 50 ProfoundMental retardation has an I.Q. of below 20; Mildmental retardation 50-70 and Severe mentalretardation has an I.Q. of 20-35.67. Answer: (D) Rearrange the environment toactivate the childRationale: The child with autistic disorder doesnot want change. Maintaining a consistentenvironment is therapeutic. A. Angry outburstcan be re-channeling through safe activities. B.Acceptance enhances a trusting relationship. C.Ensure safety from self-destructive behaviorslike head banging and hair pulling.68. Answer: (B) cocaineRationale: The manifestations indicateintoxication with cocaine, a CNS stimulant. A.Intoxication with heroine is manifested byeuphoria then impairment in judgment,attention and the presence of papillaryconstriction. C. Intoxication with hallucinogenlike LSD is manifested by grandiosity,hallucinations, synesthesia and increase in vitalsigns D. Intoxication with Marijuana, acannabinoid is manifested by sensation ofslowed time, conjunctival redness, socialwithdrawal, impaired judgment andhallucinations.69. Answer: (B) insidious onsetRationale: Dementia has a gradual onset andprogressive deterioration. It causes pronouncedmemory and cognitive disturbances. A,C and Dare all characteristics of delirium.70. Answer: (C) ClaustrophobiaRationale: Claustrophobia is fear of closed space.A. Agoraphobia is fear of open space or being asituation where escape is difficult. B. Socialphobia is fear of performing in the presence ofothers in a way that will be humiliating orembarrassing. D. Xenophobia is fear ofstrangers.71. Answer: (A) Revealing personal information tothe clientRationale: Counter-transference is an emotionalreaction of the nurse on the client based on her
  • 150unconscious needs and conflicts. B and C. Theseare therapeutic approaches. D. This istransference reaction where a client has anemotional reaction towards the nurse based onher past.72. Answer: (D) Hold the next dose and obtain anorder for a stat serum lithium levelRationale: Diarrhea and vomiting aremanifestations of Lithium toxicity. The next doseof lithium should be withheld and test is done tovalidate the observation. A. The manifestationsare not due to drug interaction. B. Cogentin isused to manage the extra pyramidal symptomside effects of antipsychotics. C. The commonside effects of Lithium are fine hand tremors,nausea, polyuria and polydipsia.73. Answer: (C) A living, learning or workingenvironment.Rationale: A therapeutic milieu refers to a broadconceptual approach in which all aspects of theenvironment are channeled to provide atherapeutic environment for the client. The sixenvironmental elements include structure,safety, norms; limit setting, balance and unitmodification. A. Behavioral approach inpsychiatric care is based on the premise thatbehavior can be learned or unlearned throughthe use of reward and punishment. B. Cognitiveapproach to change behavior is done bycorrecting distorted perceptions and irrationalbeliefs to correct maladaptive behaviors. D. Thisis not congruent with therapeutic milieu.74. Answer: (B) TransferenceRationale: Transference is a positive or negativefeeling associated with a significant person inthe client’s past that are unconsciously assignedto another A. Splitting is a defense mechanismcommonly seen in a client with personalitydisorder in which the world is perceived as allgood or all bad C. Countert-transference is aphenomenon where the nurse shifts feelingsassigned to someone in her past to the patientD. Resistance is the client’s refusal to submithimself to the care of the nurse75. Answer: (B) AdventitiousRationale: Adventitious crisis is a crisis involvinga traumatic event. It is not part of everyday life.A. Situational crisis is from an external sourcethat upset ones psychological equilibrium C andD. are the same. They are transitional ordevelopmental periods in life76. Answer: (C) Major depressionRationale: The DSM-IV-TR classifies majordepression as an Axis I disorder. Borderlinepersonality disorder as an Axis II; obesity andhypertension, Axis III.77. Answer: (B) TransferenceRationale: Transference is the unconsciousassignment of negative or positive feelingsevoked by a significant person in the client’s pastto another person. Intellectualization is adefense mechanism in which the client avoidsdealing with emotions by focusing on facts.Triangulation refers to conflicts involving threefamily members. Splitting is a defensemechanism commonly seen in clients withpersonality disorder in which the world isperceived as all good or all bad.78. Answer: (B) HypochondriasisRationale: Complains of vague physicalsymptoms that have no apparent medical causesare characteristic of clients withhypochondriasis. In many cases, the GI system isaffected. Conversion disorders are characterizedby one or more neurologic symptoms. Theclient’s symptoms don’t suggest severe anxiety.A client experiencing sublimation channelsmaladaptive feelings or impulses into sociallyacceptable behavior79. Answer: (C) HypochondriasisRationale: Hypochodriasis in this case is shownby the client’s belief that she has a seriousillness, although pathologic causes have beeneliminated. The disturbance usually lasts at least6 with identifiable life stressor such as, in thiscase, course examinations. Conversion disordersare characterized by one or more neurologicsymptoms. Depersonalization refers topersistent recurrent episodes of feelingdetached from one’s self or body. Somatoformdisorders generally have a chronic course withfew remissions.80. Answer: (A) Triazolam (Halcion)Rationale: Triazolam is one of a group ofsedative hypnotic medication that can be usedfor a limited time because of the risk ofdependence. Paroxetine is a scrotonin-specificreutake inhibitor used for treatment ofdepression panic disorder, and obsessive-compulsive disorder. Fluoxetine is a scrotonin-specific reuptake inhibitor used for depressivedisorders and obsessive-compulsive disorders.Risperidome is indicated for psychotic disorders.81. Answer: (D) It promotes emotional support orattention for the client
  • 151Rationale: Secondary gain refers to the benefitsof the illness that allow the client to receiveemotional support or attention. Primary gainenables the client to avoid some unpleasantactivity. A dysfunctional family may disregardthe real issue, although some conflict is relieved.Somatoform pain disorder is a preoccupationwith pain in the absence of physical disease.82. Answer: (A) “I went to the mall with my friendslast Saturday”Rationale: Clients with panic disorder tent to besocially withdrawn. Going to the mall is a sign ofworking on avoidance behaviors.Hyperventilating is a key symptom of panicdisorder. Teaching breathing control is a majorintervention for clients with panic disorder. Theclient taking medications for panic disorder; suchas tricylic antidepressants and benzodiazepinesmust be weaned off these drugs. Most clientswith panic disorder with agoraphobia don’t havenutritional problems.83. Answer: (A) “I’m sleeping better and don’t havenightmares”Rationale: MAO inhibitors are used to treat sleepproblems, nightmares, and intrusive daytimethoughts in individual with posttraumatic stressdisorder. MAO inhibitors aren’t used to helpcontrol flashbacks or phobias or to decrease thecraving for alcohol.84. Answer: (D) Stopping the drug can causewithdrawal symptomsRationale: Stopping antianxiety drugs such asbenzodiazepines can cause the client to havewithdrawal symptoms. Stopping abenzodiazepine doesn’t tend to causedepression, increase cognitive abilities, ordecrease sleeping difficulties.85. Answer: (B) Behavioral difficultiesRationale: Adolescents tend to demonstratesevere irritability and behavioral problemsrather than simply a depressed mood. Anxietydisorder is more commonly associated withsmall children rather than with adolescents.Cognitive impairment is typically associated withdelirium or dementia. Labile mood is morecharacteristic of a client with cognitiveimpairment or bipolar disorder.86. Answer: (D) It’s a mood disorder similar to majordepression but of mild to moderate severityRationale: Dysthymic disorder is a mood disordersimilar to major depression but it remains mildto moderate in severity. Cyclothymic disorder isa mood disorder characterized by a mood rangefrom moderate depression to hypomania.Bipolar I disorder is characterized by a singlemanic episode with no past major depressiveepisodes. Seasonal- affective disorder is a formof depression occurring in the fall and winter.87. Answer: (A) Vascular dementia has more abruptonsetRationale: Vascular dementia differs fromAlzheimer’s disease in that it has a more abruptonset and runs a highly variable course.Personally change is common in Alzheimer’sdisease. The duration of delirium is usually brief.The inability to carry out motor activities iscommon in Alzheimer’s disease.88. Answer: (C) Drug intoxicationRationale: This client was taking severalmedications that have a propensity forproducing delirium; digoxin (a digitalisglycoxide), furosemide (a thiazide diuretic), anddiazepam (a benzodiazepine). Sufficientsupporting data don’t exist to suspect the otheroptions as causes.89. Answer: (D) The client is experiencing visualhallucinationRationale: The presence of a sensory stimuluscorrelates with the definition of a hallucination,which is a false sensory perception. Aphasiarefers to a communication problem. Dysarthria isdifficulty in speech production. Flight of ideas israpid shifting from one topic to another.90. Answer: (D) The client looks at the shadow on awall and tells the nurse she sees frighteningfaces on the wall.Rationale: Minor memory problems aredistinguished from dementia by their minorseverity and their lack of significant interferencewith the client’s social or occupational lifestyle.Other options would be included in the historydata but don’t directly correlate with the client’slifestyle.91. Answer: (D) Loose associationRationale: Loose associations are conversationsthat constantly shift in topic. Concrete thinkingimplies highly definitive thought processes.Flight of ideas is characterized by conversationthat’s disorganized from the onset. Looseassociations don’t necessarily start in a cogently,then becomes loose.92. Answer: (C) ParanoidRationale: Because of their suspiciousness,paranoid personalities ascribe malevolentactivities to others and tent to be defensive,becoming quarrelsome and argumentative.
  • 152Clients with antisocial personality disorder canalso be antagonistic and argumentative but areless suspicious than paranoid personalities.Clients with histrionic personality disorder aredramatic, not suspicious and argumentative.Clients with schizoid personality disorder areusually detached from other and tend to haveeccentric behavior.93. Answer: (C) Explain that the drug is less affectiveif the client smokesRationale: Olanzapine (Zyprexa) is less effectivefor clients who smoke cigarettes. Serotoninsyndrome occurs with clients who take acombination of antidepressant medications.Olanzapine doesn’t cause euphoria, andextrapyramidal adverse reactions aren’t aproblem. However, the client should be aware ofadverse effects such as tardive dyskinesia.94. Answer: (A) Lack of honestyRationale: Clients with antisocial personalitydisorder tent to engage in acts of dishonesty,shown by lying. Clients with schizotypalpersonality disorder tend to be superstitious.Clients with histrionic personality disorders tendto overreact to frustrations anddisappointments, have temper tantrums, andseek attention.95. Answer: (A) “I’m not going to look just at thenegative things about myself”Rationale: As the client makes progress onimproving self-esteem, self- blame and negativeself-evaluation will decrease. Clients withdependent personality disorder tend to feelfragile and inadequate and would be extremelyunlikely to discuss their level of competence andprogress. These clients focus on self and aren’tenvious or jealous. Individuals with dependentpersonality disorders don’t take over situationsbecause they see themselves as inept andinadequate.96. Answer: (C) Assess for possible physicalproblems such as rashRationale: Clients with schizophrenia generallyhave poor visceral recognition because they liveso fully in their fantasy world. They need to haveas in-depth assessment of physical complaintsthat may spill over into their delusionalsymptoms. Talking with the client won’t provideas assessment of his itching, and itching isn’t asadverse reaction of antipsychotic drugs, callingthe physician to get the client’s medicationincreased doesn’t address his physicalcomplaints.97. Answer: (B) EchopraxiaRationale: Echopraxia is the copying of another’sbehaviors and is the result of the loss of egoboundaries. Modeling is the conscious copyingof someone’s behaviors. Ego-syntonicity refersto behaviors that correspond with theindividual’s sense of self. Ritualism behaviors arerepetitive and compulsive.98. Answer: (C) HallucinationRationale: Hallucinations are sensoryexperiences that are misrepresentations ofreality or have no basis in reality. Delusions arebeliefs not based in reality. Disorganized speechis characterized by jumping from one topic tothe next or using unrelated words. An idea ofreference is a belief that an unrelated situationholds special meaning for the client.99. Answer: (C) RegressionRationale: Regression, a return to earlierbehavior to reduce anxiety, is the basic defensemechanism in schizophrenia. Projection is adefense mechanism in which one blames othersand attempts to justify actions; it’s usedprimarily by people with paranoid schizophreniaand delusional disorder. Rationalization is adefense mechanism used to justify one’s action.Repression is the basic defense mechanism inthe neuroses; it’s an involuntary exclusion ofpainful thoughts, feelings, or experiences fromawareness.100. Answer: (A) Should report feelings ofrestlessness or agitation at onceRationale: Agitation and restlessness are adverseeffect of haloperidol and can be treated withantocholinergic drugs. Haloperidol isn’t likely tocause photosensitivity or control essentialhypertension. Although the client mayexperience increased concentration and activity,these effects are due to a decreased insymptoms, not the drug itself.
  • 153PART III PRACTICE TEST I FOUNDATION OFNURSING1. Which element in the circular chain of infectioncan be eliminated by preserving skin integrity?a. Hostb. Reservoirc. Mode of transmissiond. Portal of entry2. Which of the following will probably result in abreak in sterile technique for respiratoryisolation?a. Opening the patient’s window to theoutside environmentb. Turning on the patient’s room ventilatorc. Opening the door of the patient’s roomleading into the hospital corridord. Failing to wear gloves whenadministering a bed bath3. Which of the following patients is at greater riskfor contracting an infection?a. A patient with leukopeniab. A patient receiving broad-spectrumantibioticsc. A postoperative patient who hasundergone orthopedic surgeryd. A newly diagnosed diabetic patient4. Effective hand washing requires the use of:a. Soap or detergent to promoteemulsificationb. Hot water to destroy bacteriac. A disinfectant to increase surfacetensiond. All of the above5. After routine patient contact, hand washingshould last at least:a. 30 secondsb. 1 minutec. 2 minuted. 3 minutes6. Which of the following procedures alwaysrequires surgical asepsis?a. Vaginal instillation of conjugatedestrogenb. Urinary catheterizationc. Nasogastric tube insertiond. Colostomy irrigation7. Sterile technique is used whenever:a. Strict isolation is requiredb. Terminal disinfection is performedc. Invasive procedures are performedd. Protective isolation is necessary8. Which of the following constitutes a break insterile technique while preparing a sterile fieldfor a dressing change?a. Using sterile forceps, rather than sterilegloves, to handle a sterile itemb. Touching the outside wrapper ofsterilized material without sterile glovesc. Placing a sterile object on the edge ofthe sterile fieldd. Pouring out a small amount of solution(15 to 30 ml) before pouring the solutioninto a sterile container9. A natural body defense that plays an active rolein preventing infection is:a. Yawningb. Body hairc. Hiccuppingd. Rapid eye movements10. All of the following statement are true aboutdonning sterile gloves except:a. The first glove should be picked up bygrasping the inside of the cuff.b. The second glove should be picked up byinserting the gloved fingers under thecuff outside the glove.c. The gloves should be adjusted by slidingthe gloved fingers under the sterile cuffand pulling the glove over the wristd. The inside of the glove is consideredsterile11. When removing a contaminated gown, the nurseshould be careful that the first thing she touchesis the:a. Waist tie and neck tie at the back of thegownb. Waist tie in front of the gownc. Cuffs of the gownd. Inside of the gown12. Which of the following nursing interventions isconsidered the most effective form or universalprecautions?a. Cap all used needles before removingthem from their syringes
  • 154b. Discard all used uncapped needles andsyringes in an impenetrable protectivecontainerc. Wear gloves when administering IMinjectionsd. Follow enteric precautions13. All of the following measures are recommendedto prevent pressure ulcers except:a. Massaging the reddened are with lotionb. Using a water or air mattressc. Adhering to a schedule for positioningand turningd. Providing meticulous skin care14. Which of the following blood tests should beperformed before a blood transfusion?a. Prothrombin and coagulation timeb. Blood typing and cross-matchingc. Bleeding and clotting timed. Complete blood count (CBC) andelectrolyte levels.15. The primary purpose of a platelet count is toevaluate the:a. Potential for clot formationb. Potential for bleedingc. Presence of an antigen-antibodyresponsed. Presence of cardiac enzymes16. Which of the following white blood cell (WBC)counts clearly indicates leukocytosis?a. 4,500/mm³b. 7,000/mm³c. 10,000/mm³d. 25,000/mm³17. After 5 days of diuretic therapy with 20mg offurosemide (Lasix) daily, a patient begins toexhibit fatigue, muscle cramping and muscleweakness. These symptoms probably indicatethat the patient is experiencing:a. Hypokalemiab. Hyperkalemiac. Anorexiad. Dysphagia18. Which of the following statements about chestX-ray is false?a. No contradictions exist for this testb. Before the procedure, the patient shouldremove all jewelry, metallic objects, andbuttons above the waistc. A signed consent is not requiredd. Eating, drinking, and medications areallowed before this test19. The most appropriate time for the nurse toobtain a sputum specimen for culture is:a. Early in the morningb. After the patient eats a light breakfastc. After aerosol therapyd. After chest physiotherapy20. A patient with no known allergies is to receivepenicillin every 6 hours.21. When administering the medication, the nurseobserves a fine rash on the patient’s skin. Themost appropriate nursing action would be to:a. Withhold the moderation and notify thephysicianb. Administer the medication and notifythe physicianc. Administer the medication with anantihistamined. Apply corn starch soaks to the rash22. All of the following nursing interventions arecorrect when using the Z- track method of druginjection except:a. Prepare the injection site with alcoholb. Use a needle that’s a least 1” longc. Aspirate for blood before injectiond. Rub the site vigorously after theinjection to promote absorption23. The correct method for determining the vastuslateralis site for I.M. injection is to:a. Locate the upper aspect of the upperouter quadrant of the buttock about 5 to8 cm below the iliac crestb. Palpate the lower edge of the acromionprocess and the midpoint lateral aspectof the armc. Palpate a 1” circular area anterior to theumbilicusd. Divide the area between the greaterfemoral trochanter and the lateralfemoral condyle into thirds, and selectthe middle third on the anterior of thethigh
  • 15524. The mid-deltoid injection site is seldom used forI.M. injections because it:a. Can accommodate only 1 ml or less ofmedicationb. Bruises too easilyc. Can be used only when the patient islying downd. Does not readily parenteral medication25. The appropriate needle size for insulin injectionis:a. 18G, 1 ½” longb. 22G, 1” longc. 22G, 1 ½” longd. 25G, 5/8” long26. The appropriate needle gauge for intradermalinjection is:a. 20Gb. 22Gc. 25Gd. 26G27. Parenteral penicillin can be administered as an:a. IM injection or an IV solutionb. IV or an intradermal injectionc. Intradermal or subcutaneous injectiond. IM or a subcutaneous injection28. The physician orders gr 10 of aspirin for apatient. The equivalent dose in milligrams is:a. 0.6 mgb. 10 mgc. 60 mgd. 600 mg29. The physician orders an IV solution of dextrose5% in water at 100ml/hour. What would theflow rate be if the drop factor is 15 gtt = 1 ml?a. 5 gtt/minuteb. 13 gtt/minutec. 25 gtt/minuted. 50 gtt/minute30. Which of the following is a sign or symptom of ahemolytic reaction to blood transfusion?a. Hemoglobinuriab. Chest painc. Urticariad. Distended neck veins31. Which of the following conditions may requirefluid restriction?a. Feverb. Chronic Obstructive Pulmonary Diseasec. Renal Failured. Dehydration32. All of the following are common signs andsymptoms of phlebitis except:a. Pain or discomfort at the IV insertion siteb. Edema and warmth at the IV insertionsitec. A red streak exiting the IV insertion sited. Frank bleeding at the insertion site33. The best way of determining whether a patienthas learned to instill ear medication properly isfor the nurse to:a. Ask the patient if he/she has used eardrops beforeb. Have the patient repeat the nurse’sinstructions using her own wordsc. Demonstrate the procedure to thepatient and encourage to ask questionsd. Ask the patient to demonstrate theprocedure34. Which of the following types of medications canbe administered via gastrostomy tube?a. Any oral medicationsb. Capsules whole contents are dissolve inwaterc. Enteric-coated tablets that arethoroughly dissolved in waterd. Most tablets designed for oral use,except for extended-durationcompounds35. A patient who develops hives after receiving anantibiotic is exhibiting drug:a. Toleranceb. Idiosyncrasyc. Synergismd. Allergy36. A patient has returned to his room after femoralarteriography. All of the following areappropriate nursing interventions except:a. Assess femoral, popliteal, and pedalpulses every 15 minutes for 2 hoursb. Check the pressure dressing forsanguineous drainagec. Assess vital signs every 15 minutes for 2hours
  • 156d. Order a hemoglobin and hematocritcount 1 hour after the arteriography37. The nurse explains to a patient that a cough:a. Is a protective response to clear therespiratory tract of irritantsb. Is primarily a voluntary actionc. Is induced by the administration of anantitussive drugd. Can be inhibited by “splinting” theabdomen38. An infected patient has chills and beginsshivering. The best nursing intervention is to:a. Apply iced alcohol spongesb. Provide increased cool liquidsc. Provide additional bedclothesd. Provide increased ventilation39. A clinical nurse specialist is a nurse who has:a. Been certified by the National League forNursingb. Received credentials from the PhilippineNurses’ Associationc. Graduated from an associate degreeprogram and is a registered professionalnursed. Completed a master’s degree in theprescribed clinical area and is aregistered professional nurse.40. The purpose of increasing urine acidity throughdietary means is to:a. Decrease burning sensationsb. Change the urine’s colorc. Change the urine’s concentrationd. Inhibit the growth of microorganisms41. Clay colored stools indicate:a. Upper GI bleedingb. Impending constipationc. An effect of medicationd. Bile obstruction42. In which step of the nursing process would thenurse ask a patient if the medication sheadministered relieved his pain?a. Assessmentb. Analysisc. Planningd. Evaluation43. All of the following are good sources of vitamin Aexcept:a. White potatoesb. Carrotsc. Apricotsd. Egg yolks44. Which of the following is a primary nursingintervention necessary for all patients with aFoley Catheter in place?a. Maintain the drainage tubing andcollection bag level with the patient’sbladderb. Irrigate the patient with 1% Neosporinsolution three times a dailyc. Clamp the catheter for 1 hour every 4hours to maintain the bladder’s elasticityd. Maintain the drainage tubing andcollection bag below bladder level tofacilitate drainage by gravity45. The ELISA test is used to:a. Screen blood donors for antibodies tohuman immunodeficiency virus (HIV)b. Test blood to be used for transfusion forHIV antibodiesc. Aid in diagnosing a patient with AIDSd. All of the above46. The two blood vessels most commonly used forTPN infusion are the:a. Subclavian and jugular veinsb. Brachial and subclavian veinsc. Femoral and subclavian veinsd. Brachial and femoral veins47. Effective skin disinfection before a surgicalprocedure includes which of the followingmethods?a. Shaving the site on the day beforesurgeryb. Applying a topical antiseptic to the skinon the evening before surgeryc. Having the patient take a tub bath onthe morning of surgeryd. Having the patient shower with anantiseptic soap on the evening v=beforeand the morning of surgery48. When transferring a patient from a bed to achair, the nurse should use which muscles toavoid back injury?a. Abdominal muscles
  • 157b. Back musclesc. Leg musclesd. Upper arm muscles49. Thrombophlebitis typically develops in patientswith which of the following conditions?a. Increases partial thromboplastin timeb. Acute pulsus paradoxusc. An impaired or traumatized blood vesselwalld. Chronic Obstructive Pulmonary Disease(COPD)50. In a recumbent, immobilized patient, lungventilation can become altered, leading to suchrespiratory complications as:a. Respiratory acidosis, ateclectasis, andhypostatic pneumoniab. Appneustic breathing, atypicalpneumonia and respiratory alkalosisc. Cheyne-Strokes respirations andspontaneous pneumothoraxd. Kussmail’s respirations andhypoventilation51. Immobility impairs bladder elimination, resultingin such disorders asa. Increased urine acidity and relaxation ofthe perineal muscles, causingincontinenceb. Urine retention, bladder distention, andinfectionc. Diuresis, natriuresis, and decreasedurine specific gravityd. Decreased calcium and phosphate levelsin the urine
  • 158ANSWERS AND RATIONALE – FOUNDATION OFNURSING1. D. In the circular chain of infection, pathogensmust be able to leave their reservoir and betransmitted to a susceptible host through aportal of entry, such as broken skin.2. C. Respiratory isolation, like strict isolation,requires that the door to the door patient’sroom remain closed. However, the patient’sroom should be well ventilated, so opening thewindow or turning on the ventricular isdesirable. The nurse does not need to weargloves for respiratory isolation, but good handwashing is important for all types of isolation.3. A. Leukopenia is a decreased number ofleukocytes (white blood cells), which areimportant in resisting infection. None of theother situations would put the patient at risk forcontracting an infection; taking broad- spectrumantibiotics might actually reduce the infectionrisk.4. A. Soaps and detergents are used to helpremove bacteria because of their ability to lowerthe surface tension of water and act asemulsifying agents. Hot water may lead to skinirritation or burns.5. A. Depending on the degree of exposure topathogens, hand washing may last from 10seconds to 4 minutes. After routine patientcontact, hand washing for 30 seconds effectivelyminimizes the risk of pathogen transmission.6. B. The urinary system is normally free ofmicroorganisms except at the urinary meatus.Any procedure that involves entering this systemmust use surgically aseptic measures to maintaina bacteria-free state.7. C. All invasive procedures, including surgery,catheter insertion, and administration ofparenteral therapy, require sterile technique tomaintain a sterile environment. All equipmentmust be sterile, and the nurse and the physicianmust wear sterile gloves and maintain surgicalasepsis. In the operating room, the nurse andphysician are required to wear sterile gowns,gloves, masks, hair covers, and shoe covers forall invasive procedures. Strict isolation requiresthe use of clean gloves, masks, gowns andequipment to prevent the transmission of highlycommunicable diseases by contact or byairborne routes. Terminal disinfection is thedisinfection of all contaminated supplies andequipment after a patient has been dischargedto prepare them for reuse by another patient.The purpose of protective (reverse) isolation isto prevent a person with seriously impairedresistance from coming into contact whopotentially pathogenic organisms.8. C. The edges of a sterile field are consideredcontaminated. When sterile items are allowed tocome in contact with the edges of the field, thesterile items also become contaminated.9. B. Hair on or within body areas, such as thenose, traps and holds particles that containmicroorganisms. Yawning and hiccupping do notprevent microorganisms from entering orleaving the body. Rapid eye movement marksthe stage of sleep during which dreaming occurs.10. D. The inside of the glove is always considered tobe clean, but not sterile.11. A. The back of the gown is considered clean, thefront is contaminated. So, after removing glovesand washing hands, the nurse should untie theback of the gown; slowly move backward awayfrom the gown, holding the inside of the gownand keeping the edges off the floor; turn andfold the gown inside out; discard it in acontaminated linen container; then wash herhands again.12. B. According to the Centers for Disease Control(CDC), blood-to-blood contact occurs mostcommonly when a health care worker attemptsto cap a used needle. Therefore, used needlesshould never be recapped; instead they shouldbe inserted in a specially designed punctureresistant, labeled container. Wearing gloves isnot always necessary when administering an I.M.injection. Enteric precautions prevent thetransfer of pathogens via feces.13. A. Nurses and other health care professionalspreviously believed that massaging a reddenedarea with lotion would promote venous returnand reduce edema to the area. However,research has shown that massage only increasesthe likelihood of cellular ischemia and necrosisto the area.14. B. Before a blood transfusion is performed, theblood of the donor and recipient must bechecked for compatibility. This is done by bloodtyping (a test that determines a person’s bloodtype) and cross-matching (a procedure thatdetermines the compatibility of the donor’s andrecipient’s blood after the blood types has beenmatched). If the blood specimens areincompatible, hemolysis and antigen-antibodyreactions will occur.
  • 15915. A. Platelets are disk-shaped cells that areessential for blood coagulation. A platelet countdetermines the number of thrombocytes inblood available for promoting hemostasis andassisting with blood coagulation after injury. Italso is used to evaluate the patient’s potentialfor bleeding; however, this is not its primarypurpose. The normal count ranges from 150,000to 350,000/mm3. A count of 100,000/mm3 orless indicates a potential for bleeding; count ofless than 20,000/mm3 is associated withspontaneous bleeding.16. D. Leukocytosis is any transient increase in thenumber of white blood cells (leukocytes) in theblood. Normal WBC counts range from 5,000 to100,000/mm3. Thus, a count of 25,000/mm3indicates leukocytosis.17. A. Fatigue, muscle cramping, and muscleweaknesses are symptoms of hypokalemia (aninadequate potassium level), which is a potentialside effect of diuretic therapy. The physicianusually orders supplemental potassium toprevent hypokalemia in patients receivingdiuretics. Anorexia is another symptom ofhypokalemia. Dysphagia means difficultyswallowing.18. A. Pregnancy or suspected pregnancy is the onlycontraindication for a chest X-ray. However, if achest X-ray is necessary, the patient can wear alead apron to protect the pelvic region fromradiation. Jewelry, metallic objects, and buttonswould interfere with the X-ray and thus shouldnot be worn above the waist. A signed consent isnot required because a chest X-ray is not aninvasive examination. Eating, drinking andmedications are allowed because the X-ray is ofthe chest, not the abdominal region.19. A. Obtaining a sputum specimen early in thismorning ensures an adequate supply of bacteriafor culturing and decreases the risk ofcontamination from food or medication.20. A. Initial sensitivity to penicillin is commonlymanifested by a skin rash, even in individualswho have not been allergic to it previously.Because of the danger of anaphylactic shock, henurse should withhold the drug and notify thephysician, who may choose to substituteanother drug. Administering an antihistamine isa dependent nursing intervention that requires awritten physician’s order. Although applyingcorn starch to the rash may relieve discomfort, itis not the nurse’s top priority in such apotentially life-threatening situation.21. D. The Z-track method is an I.M. injectiontechnique in which the patient’s skin is pulled insuch a way that the needle track is sealed offafter the injection. This procedure sealsmedication deep into the muscle, therebyminimizing skin staining and irritation. Rubbingthe injection site is contraindicated because itmay cause the medication to extravasate intothe skin.22. D. The vastus lateralis, a long, thick muscle thatextends the full length of the thigh, is viewed bymany clinicians as the site of choice for I.M.injections because it has relatively few majornerves and blood vessels. The middle third of themuscle is recommended as the injection site.The patient can be in a supine or sitting positionfor an injection into this site.23. A. The mid-deltoid injection site canaccommodate only 1 ml or less of medicationbecause of its size and location (on the deltoidmuscle of the arm, close to the brachial arteryand radial nerve).24. D. A 25G, 5/8” needle is the recommended sizefor insulin injection because insulin isadministered by the subcutaneous route. An18G, 1 ½” needle is usually used for I.M.injections in children, typically in the vastuslateralis. A 22G, 1 ½” needle is usually used foradult I.M. injections, which are typicallyadministered in the vastus lateralis orventrogluteal site.25. D. Because an intradermal injection does notpenetrate deeply into the skin, a small-bore 25Gneedle is recommended. This type of injection isused primarily to administer antigens toevaluate reactions for allergy or sensitivitystudies. A 20G needle is usually used for I.M.injections of oil- based medications; a 22Gneedle for I.M. injections; and a 25G needle, forI.M. injections; and a 25G needle, forsubcutaneous insulin injections.26. A. Parenteral penicillin can be administered I.M.or added to a solution and given I.V. It cannot beadministered subcutaneously or intradermally.27. D. gr 10 x 60mg/gr 1 = 600 mg28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute29. A. Hemoglobinuria, the abnormal presence ofhemoglobin in the urine, indicates a hemolyticreaction (incompatibility of the donor’s andrecipient’s blood). In this reaction, antibodies inthe recipient’s plasma combine rapidly withdonor RBC’s; the cells are hemolyzed in eithercirculatory or reticuloendothelial system.
  • 160Hemolysis occurs more rapidly in ABOincompatibilities than in Rh incompatibilities.Chest pain and urticarial may be symptoms ofimpending anaphylaxis. Distended neck veins arean indication of hypervolemia.30. C. In real failure, the kidney loses their ability toeffectively eliminate wastes and fluids. Becauseof this, limiting the patient’s intake of oral andI.V. fluids may be necessary. Fever, chronicobstructive pulmonary disease, and dehydrationare conditions for which fluids should beencouraged.31. D. Phlebitis, the inflammation of a vein, can becaused by chemical irritants (I.V. solutions ormedications), mechanical irritants (the needle orcatheter used during venipuncture orcannulation), or a localized allergic reaction tothe needle or catheter. Signs and symptoms ofphlebitis include pain or discomfort, edema andheat at the I.V. insertion site, and a red streakgoing up the arm or leg from the I.V. insertionsite.32. D. Return demonstration provides the mostcertain evidence for evaluating the effectivenessof patient teaching.33. D. Capsules, enteric-coated tablets, and mostextended duration or sustained release productsshould not be dissolved for use in a gastrostomytube. They are pharmaceutically manufacturedin these forms for valid reasons, and alteringthem destroys their purpose. The nurse shouldseek an alternate physician’s order when anordered medication is inappropriate for deliveryby tube.34. D. A drug-allergy is an adverse reaction resultingfrom an immunologic response following aprevious sensitizing exposure to the drug. Thereaction can range from a rash or hives toanaphylactic shock. Tolerance to a drug meansthat the patient experiences a decreasingphysiologic response to repeated administrationof the drug in the same dosage. Idiosyncrasy isan individual’s unique hypersensitivity to a drug,food, or other substance; it appears to begenetically determined. Synergism, is a druginteraction in which the sum of the drug’scombined effects is greater than that of theirseparate effects.35. D. A hemoglobin and hematocrit count would beordered by the physician if bleeding weresuspected. The other answers are appropriatenursing interventions for a patient who hasundergone femoral arteriography.36. A. Coughing, a protective response that clearsthe respiratory tract of irritants, usually isinvoluntary; however it can be voluntary, aswhen a patient is taught to perform coughingexercises. An antitussive drug inhibits coughing.Splinting the abdomen supports the abdominalmuscles when a patient coughs.37. C. In an infected patient, shivering results fromthe body’s attempt to increase heat productionand the production of neutrophils andphagocytotic action through increased skeletalmuscle tension and contractions. Initialvasoconstriction may cause skin to feel cold tothe touch. Applying additional bed clothes helpsto equalize the body temperature and stop thechills. Attempts to cool the body result in furthershivering, increased metabloism, and thusincreased heat production.38. D. A clinical nurse specialist must havecompleted a master’s degree in a clinicalspecialty and be a registered professional nurse.The National League of Nursing accreditseducational programs in nursing and provides atesting service to evaluate student nursingcompetence but it does not certify nurses. TheAmerican Nurses Association identifiesrequirements for certification and offersexaminations for certification in many areas ofnursing, such as medical surgical nursing. Thesecertification (credentialing) demonstrates thatthe nurse has the knowledge and the ability toprovide high quality nursing care in the area ofher certification. A graduate of an associatedegree program is not a clinical nurse specialist:however, she is prepared to provide bed sidenursing with a high degree of knowledge andskill. She must successfully complete thelicensing examination to become a registeredprofessional nurse.39. D. Microorganisms usually do not grow in anacidic environment.40. D. Bile colors the stool brown. Any inflammationor obstruction that impairs bile flow will affectthe stool pigment, yielding light, clay-coloredstool. Upper GI bleeding results in black or tarrystool. Constipation is characterized by small,hard masses. Many medications and foods willdiscolor stool – for example, drugs containingiron turn stool black.; beets turn stool red.41. D. In the evaluation step of the nursing process,the nurse must decide whether the patient hasachieved the expected outcome that wasidentified in the planning phase.
  • 16142. A. The main sources of vitamin A are yellow andgreen vegetables (such as carrots, sweetpotatoes, squash, spinach, collard greens,broccoli, and cabbage) and yellow fruits (such asapricots, and cantaloupe). Animal sourcesinclude liver, kidneys, cream, butter, and eggyolks.43. D. Maintaing the drainage tubing and collectionbag level with the patient’s bladder could resultin reflux of urine into the kidney. Irrigating thebladder with Neosporin and clamping thecatheter for 1 hour every 4 hours must beprescribed by a physician.44. D. The ELISA test of venous blood is used toassess blood and potential blood donors tohuman immunodeficiency virus (HIV). A positiveELISA test combined with various signs andsymptoms helps to diagnose acquiredimmunodeficiency syndrome (AIDS)45. D. Tachypnea (an abnormally rapid rate ofbreathing) would indicate that the patient wasstill hypoxic (deficient in oxygen).The partialpressures of arterial oxygen and carbon dioxidelisted are within the normal range. Eupnea refersto normal respiration.46. D. Studies have shown that showering with anantiseptic soap before surgery is the mosteffective method of removing microorganismsfrom the skin. Shaving the site of the intendedsurgery might cause breaks in the skin, therebyincreasing the risk of infection; however, ifindicated, shaving, should be done immediatelybefore surgery, not the day before. A topicalantiseptic would not remove microorganismsand would be beneficial only after propercleaning and rinsing. Tub bathing might transferorganisms to another body site rather than rinsethem away.47. C. The leg muscles are the strongest muscles inthe body and should bear the greatest stresswhen lifting. Muscles of the abdomen, back, andupper arms may be easily injured.48. C. The factors, known as Virchow’s triad,collectively predispose a patient tothromboplebitis; impaired venous return to theheart, blood hypercoagulability, and injury to ablood vessel wall. Increased partialthromboplastin time indicates a prolongedbleeding time during fibrin clot formation,commonly the result of anticoagulant (heparin)therapy. Arterial blood disorders (such as pulsusparadoxus) and lung diseases (such as COPD) donot necessarily impede venous return of injurevessel walls.49. A. Because of restricted respiratory movement, arecumbent, immobilize patient is at particularrisk for respiratory acidosis from poor gasexchange; atelectasis from reduced surfactantand accumulated mucus in the bronchioles, andhypostatic pneumonia from bacterial growthcaused by stasis of mucus secretions.50. B. The immobilized patient commonly suffersfrom urine retention caused by decreasedmuscle tone in the perineum. This leads tobladder distention and urine stagnation, whichprovide an excellent medium for bacterialgrowth leading to infection. Immobility alsoresults in more alkaline urine with excessiveamounts of calcium, sodium and phosphate, agradual decrease in urine production, and anincreased specific gravity.
  • 162PRACTICE TEST II Maternal and Child Health1. For the client who is using oral contraceptives,the nurse informs the client about the need totake the pill at the same time each day toaccomplish which of the following?a. Decrease the incidence of nauseab. Maintain hormonal levelsc. Reduce side effectsd. Prevent drug interactions2. When teaching a client about contraception.Which of the following would the nurse includeas the most effective method for preventingsexually transmitted infections?a. Spermicidesb. Diaphragmc. Condomsd. Vasectomy3. When preparing a woman who is 2 dayspostpartum for discharge, recommendations forwhich of the following contraceptive methodswould be avoided?a. Diaphragmb. Female condomc. Oral contraceptivesd. Rhythm method4. For which of the following clients would thenurse expect that an intrauterine device wouldnot be recommended?a. Woman over age 35b. Nulliparous womanc. Promiscuous young adultd. Postpartum client5. A client in her third trimester tells the nurse,“I’m constipated all the time!” Which of thefollowing should the nurse recommend?a. Daily enemasb. Laxativesc. Increased fiber intaked. Decreased fluid intake6. Which of the following would the nurse use asthe basis for the teaching plan when caring for apregnant teenager concerned about gaining toomuch weight during pregnancy?a. 10 pounds per trimesterb. 1 pound per week for 40 weeksc. ½ pound per week for 40 weeksd. A total gain of 25 to 30 pounds7. The client tells the nurse that her last menstrualperiod started on January 14 and ended onJanuary 20. Using Nagele’s rule, the nursedetermines her EDD to be which of thefollowing?a. September 27b. October 21c. November 7d. December 278. When taking an obstetrical history on a pregnantclient who states, “I had a son born at 38 weeksgestation, a daughter born at 30 weeks gestationand I lost a baby at about 8 weeks,” the nurseshould record her obstetrical history as which ofthe following?a. G2 T2 P0 A0 L2b. G3 T1 P1 A0 L2c. G3 T2 P0 A0 L2d. G4 T1 P1 A1 L29. When preparing to listen to the fetal heart rateat 12 weeks’ gestation, the nurse would usewhich of the following?a. Stethoscope placed midline at theumbilicusb. Doppler placed midline at thesuprapubic regionc. Fetoscope placed midway between theumbilicus and the xiphoid processd. External electronic fetal monitor placedat the umbilicus10. When developing a plan of care for a clientnewly diagnosed with gestational diabetes,which of the following instructions would be thepriority?a. Dietary intakeb. Medicationc. Exercised. Glucose monitoring11. A client at 24 weeks gestation has gained 6pounds in 4 weeks. Which of the following wouldbe the priority when assessing the client?a. Glucosuriab. Depressionc. Hand/face edemad. Dietary intake12. A client 12 weeks’ pregnant come to theemergency department with abdominal
  • 163cramping and moderate vaginal bleeding.Speculum examination reveals 2 to 3 cmscervical dilation. The nurse would documentthese findings as which of the following?a. Threatened abortionb. Imminent abortionc. Complete abortiond. Missed abortion13. Which of the following would be the prioritynursing diagnosis for a client with an ectopicpregnancy?a. Risk for infectionb. Painc. Knowledge Deficitd. Anticipatory Grieving14. Before assessing the postpartum client’s uterusfor firmness and position in relation to theumbilicus and midline, which of the followingshould the nurse do first?a. Assess the vital signsb. Administer analgesiac. Ambulate her in the halld. Assist her to urinate15. Which of the following should the nurse dowhen a primipara who is lactating tells the nursethat she has sore nipples?a. Tell her to breast feed more frequentlyb. Administer a narcotic before breastfeedingc. Encourage her to wear a nursingbrassiered. Use soap and water to clean the nipples16. The nurse assesses the vital signs of a client, 4hours’ postpartum that are as follows: BP 90/60;temperature 100.4ºF; pulse 100 weak, thready;R 20 per minute. Which of the following shouldthe nurse do first?a. Report the temperature to the physicianb. Recheck the blood pressure withanother cuffc. Assess the uterus for firmness andpositiond. Determine the amount of lochia17. The nurse assesses the postpartum vaginaldischarge (lochia) on four clients. Which of thefollowing assessments would warrantnotification of the physician?a. A dark red discharge on a 2-daypostpartum clientb. A pink to brownish discharge on a clientwho is 5 days postpartumc. Almost colorless to creamy discharge ona client 2 weeks after deliveryd. A bright red discharge 5 days afterdelivery18. A postpartum client has a temperature of101.4ºF, with a uterus that is tender whenpalpated, remains unusually large, and notdescending as normally expected. Which of thefollowing should the nurse assess next?a. Lochiab. Breastsc. Incisiond. Urine19. Which of the following is the priority focus ofnursing practice with the current earlypostpartum discharge?a. Promoting comfort and restoration ofhealthb. Exploring the emotional status of thefamilyc. Facilitating safe and effective self-andnewborn cared. Teaching about the importance of familyplanning20. Which of the following actions would be leasteffective in maintaining a neutral thermalenvironment for the newborn?a. Placing infant under radiant warmerafter bathingb. Covering the scale with a warmedblanket prior to weighingc. Placing crib close to nursery window forfamily viewingd. Covering the infant’s head with a knitstockinette21. A newborn who has an asymmetrical Mororeflex response should be further assessed forwhich of the following?a. Talipes equinovarusb. Fractured claviclec. Congenital hypothyroidismd. Increased intracranial pressure
  • 16422. During the first 4 hours after a malecircumcision, assessing for which of thefollowing is the priority?a. Infectionb. Hemorrhagec. Discomfortd. Dehydration23. The mother asks the nurse. “What’s wrong withmy son’s breasts? Why are they so enlarged?”Whish of the following would be the bestresponse by the nurse?a. “The breast tissue is inflamed from thetrauma experienced with birth”b. “A decrease in material hormonespresent before birth causesenlargement,”c. “You should discuss this with yourdoctor. It could be a malignancy”d. “The tissue has hypertrophied while thebaby was in the uterus”24. Immediately after birth the nurse notes thefollowing on a male newborn: respirations 78;apical hearth rate 160 BPM, nostril flaring; mildintercostal retractions; and grunting at the endof expiration. Which of the following should thenurse do?a. Call the assessment data to thephysician’s attentionb. Start oxygen per nasal cannula at 2L/min.c. Suction the infant’s mouth and naresd. Recognize this as normal first period ofreactivity25. The nurse hears a mother telling a friend on thetelephone about umbilical cord care. Which ofthe following statements by the motherindicates effective teaching?a. “Daily soap and water cleansing is best”b. ‘Alcohol helps it dry and kills germs”c. “An antibiotic ointment applied dailyprevents infection”d. “He can have a tub bath each day”26. A newborn weighing 3000 grams and feedingevery 4 hours needs 120 calories/kg of bodyweight every 24 hours for proper growth anddevelopment. How many ounces of 20 cal/ozformula should this newborn receive at eachfeeding to meet nutritional needs?a. 2 ouncesb. 3 ouncesc. 4 ouncesd. 6 ounces27. The postterm neonate with meconium-stainedamniotic fluid needs care designed to especiallymonitor for which of the following?a. Respiratory problemsb. Gastrointestinal problemsc. Integumentary problemsd. Elimination problems28. When measuring a client’s fundal height, whichof the following techniques denotes the correctmethod of measurement used by the nurse?a. From the xiphoid process to theumbilicusb. From the symphysis pubis to the xiphoidprocessc. From the symphysis pubis to the fundusd. From the fundus to the umbilicus29. A client with severe preeclampsia is admittedwith of BP 160/110, proteinuria, and severepitting edema. Which of the following would bemost important to include in the client’s plan ofcare?a. Daily weightsb. Seizure precautionsc. Right lateral positioningd. Stress reduction30. A postpartum primipara asks the nurse, “Whencan we have sexual intercourse again?” Which ofthe following would be the nurse’s bestresponse?a. “Anytime you both want to.”b. “As soon as choose a contraceptivemethod.”c. “When the discharge has stopped andthe incision is healed.”d. “After your 6 weeks examination.”31. When preparing to administer the vitamin Kinjection to a neonate, the nurse would selectwhich of the following sites as appropriate forthe injection?a. Deltoid muscleb. Anterior femoris musclec. Vastus lateralis muscled. Gluteus maximus muscle
  • 16532. When performing a pelvic examination, thenurse observes a red swollen area on the rightside of the vaginal orifice. The nurse woulddocument this as enlargement of which of thefollowing?a. Clitorisb. Parotid glandc. Skene’s glandd. Bartholin’s gland33. To differentiate as a female, the hormonalstimulation of the embryo that must occurinvolves which of the following?a. Increase in maternal estrogen secretionb. Decrease in maternal androgensecretionc. Secretion of androgen by the fetal gonadd. Secretion of estrogen by the fetal gonad34. A client at 8 weeks’ gestation calls complainingof slight nausea in the morning hours. Which ofthe following client interventions should thenurse question?a. Taking 1 teaspoon of bicarbonate ofsoda in an 8-ounce glass of waterb. Eating a few low-sodium crackers beforegetting out of bedc. Avoiding the intake of liquids in themorning hoursd. Eating six small meals a day instead ofthee large meals35. The nurse documents positive ballottement inthe client’s prenatal record. The nurseunderstands that this indicates which of thefollowing?a. Palpable contractions on the abdomenb. Passive movement of the unengagedfetusc. Fetal kicking felt by the clientd. Enlargement and softening of the uterus36. During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The nurse documentsthis as which of the following?a. Braxton-Hicks signb. Chadwick’s signc. Goodell’s signd. McDonald’s sign37. During a prenatal class, the nurse explains therationale for breathing techniques duringpreparation for labor based on theunderstanding that breathing techniques aremost important in achieving which of thefollowing?a. Eliminate pain and give the expectantparents something to dob. Reduce the risk of fetal distress byincreasing uteroplacental perfusionc. Facilitate relaxation, possibly reducingthe perception of paind. Eliminate pain so that less analgesia andanesthesia are needed38. After 4 hours of active labor, the nurse notesthat the contractions of a primigravida client arenot strong enough to dilate the cervix. Which ofthe following would the nurse anticipate doing?a. Obtaining an order to begin IV oxytocininfusionb. Administering a light sedative to allowthe patient to rest for several hourc. Preparing for a cesarean section forfailure to progressd. Increasing the encouragement to thepatient when pushing begins39. A multigravida at 38 weeks’ gestation isadmitted with painless, bright red bleeding andmild contractions every 7 to 10 minutes. Whichof the following assessments should be avoided?a. Maternal vital signb. Fetal heart ratec. Contraction monitoringd. Cervical dilation40. Which of the following would be the nurse’smost appropriate response to a client who askswhy she must have a cesarean delivery if she hasa complete placenta previa?a. “You will have to ask your physicianwhen he returns.”b. “You need a cesarean to preventhemorrhage.”c. “The placenta is covering most of yourcervix.”d. “The placenta is covering the opening ofthe uterus and blocking your baby.”41. The nurse understands that the fetal head is inwhich of the following positions with a facepresentation?a. Completely flexedb. Completely extendedc. Partially extended
  • 166d. Partially flexed42. With a fetus in the left-anterior breechpresentation, the nurse would expect the fetalheart rate would be most audible in which of thefollowing areas?a. Above the maternal umbilicus and to theright of midlineb. In the lower-left maternal abdominalquadrantc. In the lower-right maternal abdominalquadrantd. Above the maternal umbilicus and to theleft of midline43. The amniotic fluid of a client has a greenish tint.The nurse interprets this to be the result ofwhich of the following?a. Lanugob. Hydramnioc. Meconiumd. Vernix44. A patient is in labor and has just been told shehas a breech presentation. The nurse should beparticularly alert for which of the following?a. Quickeningb. Ophthalmia neonatorumc. Picad. Prolapsed umbilical cord45. When describing dizygotic twins to a couple, onwhich of the following would the nurse base theexplanation?a. Two ova fertilized by separate spermb. Sharing of a common placentac. Each ova with the same genotyped. Sharing of a common chorion46. Which of the following refers to the single cellthat reproduces itself after conception?a. Chromosomeb. Blastocystc. Zygoted. Trophoblast47. In the late 1950s, consumers and health careprofessionals began challenging the routine useof analgesics and anesthetics during childbirth.Which of the following was an outgrowth of thisconcept?a. Labor, delivery, recovery, postpartum(LDRP)b. Nurse-midwiferyc. Clinical nurse specialistd. Prepared childbirth48. A client has a midpelvic contracture from aprevious pelvic injury due to a motor vehicleaccident as a teenager. The nurse is aware thatthis could prevent a fetus from passing throughor around which structure during childbirth?a. Symphysis pubisb. Sacral promontoryc. Ischial spinesd. Pubic arch49. When teaching a group of adolescents aboutvariations in the length of the menstrual cycle,the nurse understands that the underlyingmechanism is due to variations in which of thefollowing phases?a. Menstrual phaseb. Proliferative phasec. Secretory phased. Ischemic phase50. When teaching a group of adolescents aboutmale hormone production, which of thefollowing would the nurse include as beingproduced by the Leydig cells?a. Follicle-stimulating hormoneb. Testosteronec. Leuteinizing hormoned. Gonadotropin releasing hormone
  • 167ANSWERS AND RATIONALE – MATERNAL ANDCHILD HEALTH1. B. Regular timely ingestion of oral contraceptivesis necessary to maintain hormonal levels of thedrugs to suppress the action of thehypothalamus and anterior pituitary leading toinappropriate secretion of FSH and LH.Therefore, follicles do not mature, ovulation isinhibited, and pregnancy is prevented. Theestrogen content of the oral site contraceptivemay cause the nausea, regardless of when thepill is taken. Side effects and drug interactionsmay occur with oral contraceptives regardless ofthe time the pill is taken.2. C. Condoms, when used correctly andconsistently, are the most effectivecontraceptive method or barrier againstbacterial and viral sexually transmittedinfections. Although spermicides kill sperm, theydo not provide reliable protection against thespread of sexually transmitted infections,especially intracellular organisms such as HIV.Insertion and removal of the diaphragm alongwith the use of the spermicides may causevaginal irritations, which could place the client atrisk for infection transmission. Male sterilizationeliminates spermatozoa from the ejaculate, butit does not eliminate bacterial and/or viralmicroorganisms that can cause sexuallytransmitted infections.3. A. The diaphragm must be fitted individually toensure effectiveness. Because of the changes tothe reproductive structures during pregnancyand following delivery, the diaphragm must berefitted, usually at the 6 weeks’ examinationfollowing childbirth or after a weight loss of 15lbs or more. In addition, for maximumeffectiveness, spermicidal jelly should be placedin the dome and around the rim. However,spermicidal jelly should not be inserted into thevagina until involution is completed atapproximately 6 weeks. Use of a female condomprotects the reproductive system from theintroduction of semen or spermicides into thevagina and may be used after childbirth. Oralcontraceptives may be started within the firstpostpartum week to ensure suppression ofovulation. For the couple who has determinedthe female’s fertile period, using the rhythmmethod, avoidance of intercourse during thisperiod, is safe and effective.4. C. An IUD may increase the risk of pelvicinflammatory disease, especially in women withmore than one sexual partner, because of theincreased risk of sexually transmitted infections.An UID should not be used if the woman has anactive or chronic pelvic infection, postpartuminfection, endometrial hyperplasia or carcinoma,or uterine abnormalities. Age is not a factor indetermining the risks associated with IUD use.Most IUD users are over the age of 30. Althoughthere is a slightly higher risk for infertility inwomen who have never been pregnant, the IUDis an acceptable option as long as the risk-benefit ratio is discussed. IUDs may be insertedimmediately after delivery, but this is notrecommended because of the increased risk andrate of expulsion at this time.5. C. During the third trimester, the enlarginguterus places pressure on the intestines. Thiscoupled with the effect of hormones on smoothmuscle relaxation causes decreased intestinalmotility (peristalsis). Increasing fiber in the dietwill help fecal matter pass more quickly throughthe intestinal tract, thus decreasing the amountof water that is absorbed. As a result, stool issofter and easier to pass. Enemas couldprecipitate preterm labor and/or electrolyte lossand should be avoided. Laxatives may causepreterm labor by stimulating peristalsis and mayinterfere with the absorption of nutrients. Usefor more than 1 week can also lead to laxativedependency. Liquid in the diet helps provide asemisolid, soft consistency to the stool. Eight toten glasses of fluid per day are essential tomaintain hydration and promote stoolevacuation.6. D. To ensure adequate fetal growth anddevelopment during the 40 weeks of apregnancy, a total weight gain 25 to 30 pounds isrecommended: 1.5 pounds in the first 10 weeks;9 pounds by 30 weeks; and 27.5 pounds by 40weeks. The pregnant woman should gain lessweight in the first and second trimester than inthe third. During the first trimester, the clientshould only gain 1.5 pounds in the first 10weeks, not 1 pound per week. A weight gain of ½pound per week would be 20 pounds for thetotal pregnancy, less than the recommendedamount.7. B. To calculate the EDD by Nagele’s rule, add 7days to the first day of the last menstrual periodand count back 3 months, changing the yearappropriately. To obtain a date of September 27,
  • 1687 days have been added to the last day of theLMP (rather than the first day of the LMP), plus 4months (instead of 3 months) were countedback. To obtain the date of November 7, 7 dayshave been subtracted (instead of added) fromthe first day of LMP plus November indicatescounting back 2 months (instead of 3 months)from January. To obtain the date of December27, 7 days were added to the last day of the LMP(rather than the first day of the LMP) andDecember indicates counting back only 1 month(instead of 3 months) from January.8. D. The client has been pregnant four times,including current pregnancy (G). Birth at 38weeks’ gestation is considered full term (T),while birth form 20 weeks to 38 weeks isconsidered preterm (P). A spontaneous abortionoccurred at 8 weeks (A). She has two livingchildren (L).9. B. At 12 weeks gestation, the uterus rises out ofthe pelvis and is palpable above the symphysispubis. The Doppler intensifies the sound of thefetal pulse rate so it is audible. The uterus hasmerely risen out of the pelvis into the abdominalcavity and is not at the level of the umbilicus.The fetal heart rate at this age is not audiblewith a stethoscope. The uterus at 12 weeks isjust above the symphysis pubis in the abdominalcavity, not midway between the umbilicus andthe xiphoid process. At 12 weeks the FHR wouldbe difficult to auscultate with a fetoscope.Although the external electronic fetal monitorwould project the FHR, the uterus has not risento the umbilicus at 12 weeks.10. A. Although all of the choices are important inthe management of diabetes, diet therapy is themainstay of the treatment plan and shouldalways be the priority. Women diagnosed withgestational diabetes generally need only diettherapy without medication to control theirblood sugar levels. Exercise, is important for allpregnant women and especially for diabeticwomen, because it burns up glucose, thusdecreasing blood sugar. However, dietary intake,not exercise, is the priority. All pregnant womenwith diabetes should have periodic monitoringof serum glucose. However, those withgestational diabetes generally do not need dailyglucose monitoring. The standard of carerecommends a fasting and 2- hour postprandialblood sugar level every 2 weeks.11. C. After 20 weeks’ gestation, when there is arapid weight gain, preeclampsia should besuspected, which may be caused by fluidretention manifested by edema, especially of thehands and face. The three classic signs ofpreeclampsia are hypertension, edema, andproteinuria. Although urine is checked forglucose at each clinic visit, this is not the priority.Depression may cause either anorexia orexcessive food intake, leading to excessiveweight gain or loss. This is not, however, thepriority consideration at this time. Weight gainthought to be caused by excessive food intakewould require a 24-hour diet recall. However,excessive intake would not be the primaryconsideration for this client at this time.12. B. Cramping and vaginal bleeding coupled withcervical dilation signifies that termination of thepregnancy is inevitable and cannot beprevented. Thus, the nurse would document animminent abortion. In a threatened abortion,cramping and vaginal bleeding are present, butthere is no cervical dilation. The symptoms maysubside or progress to abortion. In a completeabortion all the products of conception areexpelled. A missed abortion is early fetalintrauterine death without expulsion of theproducts of conception.13. B. For the client with an ectopic pregnancy,lower abdominal pain, usually unilateral, is theprimary symptom. Thus, pain is the priority.Although the potential for infection is alwayspresent, the risk is low in ectopic pregnancybecause pathogenic microorganisms have notbeen introduced from external sources. Theclient may have a limited knowledge of thepathology and treatment of the condition andwill most likely experience grieving, but this isnot the priority at this time.14. D. Before uterine assessment is performed, it isessential that the woman empty her bladder. Afull bladder will interfere with the accuracy ofthe assessment by elevating the uterus anddisplacing to the side of the midline. Vital signassessment is not necessary unless anabnormality in uterine assessment is identified.Uterine assessment should not cause acute painthat requires administration of analgesia.Ambulating the client is an essential componentof postpartum care, but is not necessary prior toassessment of the uterus.15. A. Feeding more frequently, about every 2hours, will decrease the infant’s frantic, vigoroussucking from hunger and will decrease breastengorgement, soften the breast, and promote
  • 169ease of correct latching-on for feeding. Narcoticsadministered prior to breast feeding are passedthrough the breast milk to the infant, causingexcessive sleepiness. Nipple soreness is notsevere enough to warrant narcotic analgesia. Allpostpartum clients, especially lactating mothers,should wear a supportive brassiere with widecotton straps. This does not, however, preventor reduce nipple soreness. Soaps are drying tothe skin of the nipples and should not be usedon the breasts of lactating mothers. Dry nippleskin predisposes to cracks and fissures, whichcan become sore and painful.16. D. A weak, thready pulse elevated to 100 BPMmay indicate impending hemorrhagic shock. Anincreased pulse is a compensatory mechanism ofthe body in response to decreased fluid volume.Thus, the nurse should check the amount oflochia present. Temperatures up to 100.48F inthe first 24 hours after birth are related to thedehydrating effects of labor and are considerednormal. Although rechecking the blood pressuremay be a correct choice of action, it is not thefirst action that should be implemented in lightof the other data. The data indicate a potentialimpending hemorrhage. Assessing the uterus forfirmness and position in relation to the umbilicusand midline is important, but the nurse shouldcheck the extent of vaginal bleeding first. Then itwould be appropriate to check the uterus, whichmay be a possible cause of the hemorrhage.17. D. Any bright red vaginal discharge would beconsidered abnormal, but especially 5 days afterdelivery, when the lochia is typically pink tobrownish. Lochia rubra, a dark red discharge, ispresent for 2 to 3 days after delivery. Bright redvaginal bleeding at this time suggests latepostpartum hemorrhage, which occurs after thefirst 24 hours following delivery and is generallycaused by retained placental fragments orbleeding disorders. Lochia rubra is the normaldark red discharge occurring in the first 2 to 3days after delivery, containing epithelial cells,erythrocyes, leukocytes and decidua. Lochiaserosa is a pink to brownish serosanguineousdischarge occurring from 3 to 10 days afterdelivery that contains decidua, erythrocytes,leukocytes, cervical mucus, and microorganisms.Lochia alba is an almost colorless to yellowishdischarge occurring from 10 days to 3 weeksafter delivery and containing leukocytes,decidua, epithelial cells, fat, cervical mucus,cholesterol crystals, and bacteria.18. A. The data suggests an infection of theendometrial lining of the uterus. The lochia maybe decreased or copious, dark brown inappearance, and foul smelling, providing furtherevidence of a possible infection. All the client’sdata indicate a uterine problem, not a breastproblem. Typically, transient fever, usually101ºF, may be present with breastengorgement. Symptoms of mastitis includeinfluenza-like manifestations. Localized infectionof an episiotomy or C-section incision rarelycauses systemic symptoms, and uterineinvolution would not be affected. The client datado not include dysuria, frequency, or urgency,symptoms of urinary tract infections, whichwould necessitate assessing the client’s urine.19. C. Because of early postpartum discharge andlimited time for teaching, the nurse’s priority isto facilitate the safe and effective care of theclient and newborn. Although promotingcomfort and restoration of health, exploring thefamily’s emotional status, and teaching aboutfamily planning are important inpostpartum/newborn nursing care, they are notthe priority focus in the limited time presentedby early post-partum discharge.20. C. Heat loss by radiation occurs when theinfant’s crib is placed too near cold walls orwindows. Thus placing the newborn’s crib closeto the viewing window would be least effective.Body heat is lost through evaporation duringbathing. Placing the infant under the radiantwarmer after bathing will assist the infant to berewarmed. Covering the scale with a warmedblanket prior to weighing prevents heat lossthrough conduction. A knit cap prevents heatloss from the head a large head, a large bodysurface area of the newborn’s body.21. B. A fractured clavicle would prevent the normalMoro response of symmetrical sequentialextension and abduction of the arms followed byflexion and adduction. In talipes equinovarus(clubfoot) the foot is turned medially, and inplantar flexion, with the heel elevated. The feetare not involved with the Moro reflex.Hypothyroiddism has no effect on the primitivereflexes. Absence of the Moror reflex is the mostsignificant single indicator of central nervoussystem status, but it is not a sign of increasedintracranial pressure.22. B. Hemorrhage is a potential risk following anysurgical procedure. Although the infant has beengiven vitamin K to facilitate clotting, the
  • 170prophylactic dose is often not sufficient toprevent bleeding. Although infection is apossibility, signs will not appear within 4 hoursafter the surgical procedure. The primarydiscomfort of circumcision occurs during thesurgical procedure, not afterward. Althoughfeedings are withheld prior to the circumcision,the chances of dehydration are minimal.23. B. The presence of excessive estrogen andprogesterone in the maternal- fetal bloodfollowed by prompt withdrawal at birthprecipitates breast engorgement, which willspontaneously resolve in 4 to 5 days after birth.The trauma of the birth process does not causeinflammation of the newborn’s breast tissue.Newborns do not have breast malignancy. Thisreply by the nurse would cause the mother tohave undue anxiety. Breast tissue does nothypertrophy in the fetus or newborns.24. D. The first 15 minutes to 1 hour after birth isthe first period of reactivity involving respiratoryand circulatory adaptation to extrauterine life.The data given reflect the normal changes duringthis time period. The infant’s assessment datareflect normal adaptation. Thus, the physiciandoes not need to be notified and oxygen is notneeded. The data do not indicate the presenceof choking, gagging or coughing, which are signsof excessive secretions. Suctioning is notnecessary.25. B. Application of 70% isopropyl alcohol to thecord minimizes microorganisms (germicidal) andpromotes drying. The cord should be kept dryuntil it falls off and the stump has healed.Antibiotic ointment should only be used to treatan infection, not as a prophylaxis. Infants shouldnot be submerged in a tub of water until thecord falls off and the stump has completelyhealed.26. B. To determine the amount of formula needed,do the following mathematical calculation. 3 kg x120 cal/kg per day = 360 calories/day feeding q 4hours = 6 feedings per day = 60 calories perfeeding: 60 calories per feeding; 60 calories perfeeding with formula 20 cal/oz = 3 ounces perfeeding. Based on the calculation. 2, 4 or 6ounces are incorrect.27. A. Intrauterine anoxia may cause relaxation ofthe anal sphincter and emptying of meconiuminto the amniotic fluid. At birth some of themeconium fluid may be aspirated, causingmechanical obstruction or chemicalpneumonitis. The infant is not at increased riskfor gastrointestinal problems. Even though theskin is stained with meconium, it is noninfectious(sterile) and nonirritating. The posttermmeconium- stained infant is not at additional riskfor bowel or urinary problems.28. C. The nurse should use a nonelastic, flexible,paper measuring tape, placing the zero point onthe superior border of the symphysis pubis andstretching the tape across the abdomen at themidline to the top of the fundus. The xiphoid andumbilicus are not appropriate landmarks to usewhen measuring the height of the fundus(McDonald’s measurement).29. B. Women hospitalized with severepreeclampsia need decreased CNS stimulation toprevent a seizure. Seizure precautions provideenvironmental safety should a seizure occur.Because of edema, daily weight is important butnot the priority. Preclampsia causes vasospasmand therefore can reduce utero-placentalperfusion. The client should be placed on her leftside to maximize blood flow, reduce bloodpressure, and promote diuresis. Interventions toreduce stress and anxiety are very important tofacilitate coping and a sense of control, butseizure precautions are the priority.30. C. Cessation of the lochial discharge signifieshealing of the endometrium. Risk of hemorrhageand infection are minimal 3 weeks after anormal vaginal delivery. Telling the clientanytime is inappropriate because this responsedoes not provide the client with the specificinformation she is requesting. Choice of acontraceptive method is important, but not thespecific criteria for safe resumption of sexualactivity. Culturally, the 6- weeks’ examinationhas been used as the time frame for resumingsexual activity, but it may be resumed earlier.31. C. The middle third of the vastus lateralis is thepreferred injection site for vitamin Kadministration because it is free of blood vesselsand nerves and is large enough to absorb themedication. The deltoid muscle of a newborn isnot large enough for a newborn IM injection.Injections into this muscle in a small child mightcause damage to the radial nerve. The anteriorfemoris muscle is the next safest muscle to usein a newborn but is not the safest. Because ofthe proximity of the sciatic nerve, the gluteusmaximus muscle should not be until the childhas been walking 2 years.32. D. Bartholin’s glands are the glands on eitherside of the vaginal orifice. The clitoris is female
  • 171erectile tissue found in the perineal area abovethe urethra. The parotid glands are open into themouth. Skene’s glands open into the posteriorwall of the female urinary meatus.33. D. The fetal gonad must secrete estrogen for theembryo to differentiate as a female. An increasein maternal estrogen secretion does not affectdifferentiation of the embryo, and maternalestrogen secretion occurs in every pregnancy.Maternal androgen secretion remains the sameas before pregnancy and does not affectdifferentiation. Secretion of androgen by thefetal gonad would produce a male fetus.34. A. Using bicarbonate would increase the amountof sodium ingested, which can causecomplications. Eating low-sodium crackerswould be appropriate. Since liquids can increasenausea avoiding them in the morning hourswhen nausea is usually the strongest isappropriate. Eating six small meals a day wouldkeep the stomach full, which often decreasenausea.35. B. Ballottement indicates passive movement ofthe unengaged fetus. Ballottement is not acontraction. Fetal kicking felt by the clientrepresents quickening. Enlargement andsoftening of the uterus is known as Piskacek’ssign.36. B. Chadwick’s sign refers to the purple-blue tingeof the cervix. Braxton Hicks contractions arepainless contractions beginning around the 4thmonth. Goodell’s sign indicates softening of thecervix. Flexibility of the uterus against the cervixis known as McDonald’s sign.37. C. Breathing techniques can raise the painthreshold and reduce the perception of pain.They also promote relaxation. Breathingtechniques do not eliminate pain, but they canreduce it. Positioning, not breathing, increasesuteroplacental perfusion.38. A. The client’s labor is hypotonic. The nurseshould call the physical and obtain an order foran infusion of oxytocin, which will assist theuterus to contact more forcefully in an attemptto dilate the cervix. Administering light sedativewould be done for hypertonic uterinecontractions. Preparing for cesarean section isunnecessary at this time. Oxytocin wouldincrease the uterine contractions and hopefullyprogress labor before a cesarean would benecessary. It is too early to anticipate clientpushing with contractions.39. D. The signs indicate placenta previa and vaginalexam to determine cervical dilation would notbe done because it could cause hemorrhage.Assessing maternal vital signs can helpdetermine maternal physiologic status. Fetalheart rate is important to assess fetal well-beingand should be done. Monitoring the contractionswill help evaluate the progress of labor.40. D. A complete placenta previa occurs when theplacenta covers the opening of the uterus, thusblocking the passageway for the baby. Thisresponse explains what a complete previa is andthe reason the baby cannot come out except bycesarean delivery. Telling the client to ask thephysician is a poor response and would increasethe patient’s anxiety. Although a cesarean wouldhelp to prevent hemorrhage, the statement doesnot explain why the hemorrhage could occur.With a complete previa, the placenta is coveringthe entire cervix, not just most of it.41. B. With a face presentation, the head iscompletely extended. With a vertexpresentation, the head is completely or partiallyflexed. With a brow (forehead) presentation, thehead would be partially extended.42. D. With this presentation, the fetal upper torsoand back face the left upper maternal abdominalwall. The fetal heart rate would be most audibleabove the maternal umbilicus and to the left ofthe middle. The other positions would beincorrect.43. C. The greenish tint is due to the presence ofmeconium. Lanugo is the soft, downy hair on theshoulders and back of the fetus. Hydramniosrepresents excessive amniotic fluid. Vernix is thewhite, cheesy substance covering the fetus.44. D. In a breech position, because of the spacebetween the presenting part and the cervix,prolapse of the umbilical cord is common.Quickening is the woman’s first perception offetal movement. Ophthalmia neonatorumusually results from maternal gonorrhea and isconjunctivitis. Pica refers to the oral intake ofnonfood substances.45. A. Dizygotic (fraternal) twins involve two ovafertilized by separate sperm. Monozygotic(identical) twins involve a common placenta,same genotype, and common chorion.46. C. The zygote is the single cell that reproducesitself after conception. The chromosome is thematerial that makes up the cell and is gainedfrom each parent. Blastocyst and trophoblast arelater terms for the embryo after zygote.
  • 17247. D. Prepared childbirth was the direct result ofthe 1950’s challenging of the routine use ofanalgesic and anesthetics during childbirth. TheLDRP was a much later concept and was not adirect result of the challenging of routine use ofanalgesics and anesthetics during childbirth.Roles for nurse midwives and clinical nursespecialists did not develop from this challenge.48. C. The ischial spines are located in the mid-pelvicregion and could be narrowed due to theprevious pelvic injury. The symphysis pubis,sacral promontory, and pubic arch are not partof the mid-pelvis.49. B. Variations in the length of the menstrual cycleare due to variations in the proliferative phase.The menstrual, secretory and ischemic phasesdo not contribute to this variation.50. B. Testosterone is produced by the Leyding cellsin the seminiferous tubules. Follicle-stimulatinghormone and leuteinzing hormone are releasedby the anterior pituitary gland. Thehypothalamus is responsible for releasinggonadotropin-releasing hormone.
  • 173MEDICAL SURGICAL NURSING1. Marco who was diagnosed with brain tumor wasscheduled for craniotomy. In preventing thedevelopment of cerebral edema after surgery,the nurse should expect the use of:a. Diureticsb. Antihypertensivec. Steroidsd. Anticonvulsants2. Halfway through the administration of blood,the female client complains of lumbar pain. Afterstopping the infusion Nurse Hazel should:a. Increase the flow of normal salineb. Assess the pain furtherc. Notify the blood bankd. Obtain vital signs.3. Nurse Maureen knows that the positivediagnosis for HIV infection is made based onwhich of the following:a. A history of high risk sexual behaviors.b. Positive ELISA and western blot testsc. Identification of an associatedopportunistic infectiond. Evidence of extreme weight loss andhigh fever4. Nurse Maureen is aware that a client who hasbeen diagnosed with chronic renal failurerecognizes an adequate amount of high-biologic-value protein when the food the client selectedfrom the menu was:a. Raw carrotsb. Apple juicec. Whole wheat breadd. Cottage cheese5. Kenneth who has diagnosed with uremicsyndrome has the potential to developcomplications. Which among the followingcomplications should the nurse anticipates:a. Flapping hand tremorsb. An elevated hematocrit levelc. Hypotensiond. Hypokalemia6. A client is admitted to the hospital with benignprostatic hyperplasia, the nurse most relevantassessment would be:a. Flank pain radiating in the groinb. Distention of the lower abdomenc. Perineal edemad. Urethral discharge7. A client has undergone with penile implant.After 24 hrs of surgery, the client’s scrotum wasedematous and painful. The nurse should:a. Assist the client with sitz bathb. Apply war soaks in the scrotumc. Elevate the scrotum using a soft supportd. Prepare for a possible incision anddrainage.8. Nurse hazel receives emergency laboratoryresults for a client with chest pain andimmediately informs the physician. An increasedmyoglobin level suggests which of the following?a. Liver diseaseb. Myocardial damagec. Hypertensiond. Cancer9. Nurse Maureen would expect the client withmitral stenosis would demonstrate symptomsassociated with congestion in the:a. Right atriumb. Superior vena cavac. Aortad. Pulmonary10. A client has been diagnosed with hypertension.The nurse priority nursing diagnosis would be:a. Ineffective health maintenanceb. Impaired skin integrityc. Deficient fluid volumed. Pain11. Nurse Hazel teaches the client with angina aboutcommon expected side effects of nitroglycerinincluding:a. high blood pressureb. stomach crampsc. headached. shortness of breath12. The following are lipid abnormalities. Which ofthe following is a risk factor for the developmentof atherosclerosis and PVD?a. High levels of low density lipid (LDL)cholesterolb. High levels of high density lipid (HDL)cholesterolc. Low concentration triglyceridesd. Low levels of LDL cholesterol.
  • 17413. Which of the following represents a significantrisk immediately after surgery for repair of aorticaneurysm?a. Potential wound infectionb. Potential ineffective copingc. Potential electrolyte balanced. Potential alteration in renal perfusion14. Nurse Josie should instruct the client to eatwhich of the following foods to obtain the bestsupply of Vitamin B12?a. dairy productsb. vegetablesc. Grainsd. Broccoli15. Karen has been diagnosed with aplastic anemia.The nurse monitors for changes in which of thefollowing physiologic functions?a. Bowel functionb. Peripheral sensationc. Bleeding tendenciesd. Intake and out put16. Lydia is scheduled for elective splenectomy.Before the clients goes to surgery, the nurse incharge final assessment would be:a. signed consentb. vital signsc. name bandd. empty bladder17. What is the peak age range in acquiring acutelymphocytic leukemia (ALL)?a. 4 to 12 years.b. 20 to 30 yearsc. 40 to 50 yearsd. 60 60 70 years18. Marie with acute lymphocytic leukemia suffersfrom nausea and headache. These clinicalmanifestations may indicate all of the followingexcepta. effects of radiationb. chemotherapy side effectsc. meningeal irritationd. gastric distension19. A client has been diagnosed with DisseminatedIntravascular Coagulation (DIC). Which of thefollowing is contraindicated with the client?a. Administering Heparinb. Administering Coumadinc. Treating the underlying caused. Replacing depleted blood products20. Which of the following findings is the bestindication that fluid replacement for the clientwith hypovolemic shock is adequate?a. Urine output greater than 30ml/hrb. Respiratory rate of 21 breaths/minutec. Diastolic blood pressure greater than 90mmhgd. Systolic blood pressure greater than 110mmhg21. Which of the following signs and symptomswould Nurse Maureen include in teaching planas an early manifestation of laryngeal cancer?a. Stomatitisb. Airway obstructionc. Hoarsenessd. Dysphagia22. Karina a client with myasthenia gravis is toreceive immunosuppressive therapy. The nurseunderstands that this therapy is effectivebecause it:a. Promotes the removal of antibodies thatimpair the transmission of impulsesb. Stimulates the production ofacetylcholine at the neuromuscularjunction.c. Decreases the production ofautoantibodies that attack theacetylcholine receptors.d. Inhibits the breakdown of acetylcholineat the neuromuscular junction.23. A female client is receiving IV Mannitol. Anassessment specific to safe administration of thesaid drug is:a. Vital signs q4hb. Weighing dailyc. Urine output hourlyd. Level of consciousness q4h24. Patricia a 20 year old college student withdiabetes mellitus requests additionalinformation about the advantages of using a penlike insulin delivery devices. The nurse explainsthat the advantages of these devices oversyringes include:a. Accurate dose deliveryb. Shorter injection time
  • 175c. Lower cost with reusable insulincartridgesd. Use of smaller gauge needle.25. A male client’s left tibia is fractures in anautomobile accident, and a cast is applied. Toassess for damage to major blood vessels fromthe fracture tibia, the nurse in charge shouldmonitor the client for:a. Swelling of the left thighb. Increased skin temperature of the footc. Prolonged reperfusion of the toes afterblanchingd. Increased blood pressure26. After a long leg cast is removed, the male clientshould:a. Cleanse the leg by scrubbing with a briskmotionb. Put leg through full range of motiontwice dailyc. Report any discomfort or stiffness to thephysiciand. Elevate the leg when sitting for longperiods of time.27. While performing a physical assessment of amale client with gout of the great toe,NurseVivian should assess for additional tophi(urate deposits) on the:a. Buttocksb. Earsc. Faced. Abdomen28. Nurse Katrina would recognize that thedemonstration of crutch walking with tripod gaitwas understood when the client places weighton the:a. Palms of the hands and axillary regionsb. Palms of the handc. Axillary regionsd. Feet, which are set apart29. Mang Jose with rheumatoid arthritis states, “theonly time I am without pain is when I lie in bedperfectly still”. During the convalescent stage,the nurse in charge with Mang Jose shouldencourage:a. Active joint flexion and extensionb. Continued immobility until pain subsidesc. Range of motion exercises twice dailyd. Flexion exercises three times daily30. A male client has undergone spinal surgery, thenurse should:a. Observe the client’s bowel movementand voiding patternsb. Log-roll the client to prone positionc. Assess the client’s feet for sensation andcirculationd. Encourage client to drink plenty of fluids31. Marina with acute renal failure moves into thediuretic phase after one week of therapy. Duringthis phase the client must be assessed for signsof developing:a. Hypovolemiab. renal failurec. metabolic acidosisd. hyperkalemia32. Nurse Judith obtains a specimen of clear nasaldrainage from a client with a head injury. Whichof the following tests differentiates mucus fromcerebrospinal fluid (CSF)?a. Proteinb. Specific gravityc. Glucosed. Microorganism33. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asksthe nurse, “What caused me to have a seizure?Which of the following would the nurse includein the primary cause of tonic-clonic seizures inadults more the 20 years?a. Electrolyte imbalanceb. Head traumac. Epilepsyd. Congenital defect34. What is the priority nursing assessment in thefirst 24 hours after admission of the client withthrombotic CVA?a. Pupil size and papillary responseb. cholesterol levelc. Echocardiogramd. Bowel sounds35. Nurse Linda is preparing a client with multiplesclerosis for discharge from the hospital tohome. Which of the following instruction is mostappropriate?
  • 176a. “Practice using the mechanical aids thatyou will need when future disabilitiesarise”.b. “Follow good health habits to changethe course of the disease”.c. “Keep active, use stress reductionstrategies, and avoid fatigue.d. “You will need to accept the necessityfor a quiet and inactive lifestyle”.36. The nurse is aware the early indicator of hypoxiain the unconscious client is:a. Cyanosisb. Increased respirationsc. Hypertensiond. Restlessness37. A client is experiencing spinal shock. NurseMyrna should expect the function of the bladderto be which of the following?a. Normalb. Atonicc. Spasticd. Uncontrolled38. Which of the following stage the carcinogen isirreversible?a. Progression stageb. Initiation stagec. Regression staged. Promotion stage39. Among the following components thorough painassessment, which is the most significant?a. Effectb. Causec. Causing factorsd. Intensity40. A 65 year old female is experiencing flare up ofpruritus. Which of the client’s action couldaggravate the cause of flare ups?a. Sleeping in cool and humidifiedenvironmentb. Daily baths with fragrant soapc. Using clothes made from 100% cottond. Increasing fluid intake41. Atropine sulfate (Atropine) is contraindicated inall but one of the following client?a. A client with high bloodb. A client with bowel obstructionc. A client with glaucomad. A client with U.T.I42. Among the following clients, which among themis high risk for potential hazards from thesurgical experience?a. 67-year-old clientb. 49-year-old clientc. 33-year-old clientd. 15-year-old client43. Nurse Jon assesses vital signs on a clientundergone epidural anesthesia.44. Which of the following would the nurse assessnext?a. Headacheb. Bladder distensionc. Dizzinessd. Ability to move legs45. Nurse Katrina should anticipate that all of thefollowing drugs may be used in the attempt tocontrol the symptoms of Menieres diseaseexcept:a. Antiemeticsb. Diureticsc. Antihistaminesd. Glucocorticoids46. Which of the following complications associatedwith tracheostomy tube?a. Increased cardiac outputb. Acute respiratory distress syndrome(ARDS)c. Increased blood pressured. Damage to laryngeal nerves47. Nurse Faith should recognize that fluid shift in aclient with burn injury results from increase inthe:a. Total volume of circulating whole bloodb. Total volume of intravascular plasmac. Permeability of capillary wallsd. Permeability of kidney tubules48. An 83-year-old woman has several ecchymoticareas on her right arm. The bruises are probablycaused by:a. increased capillary fragility andpermeabilityb. increased blood supply to the skinc. self-inflicted injuryd. elder abuse
  • 17749. Nurse Anna is aware that early adaptation ofclient with renal carcinoma is:a. Nausea and vomitingb. flank painc. weight gaind. intermittent hematuria50. A male client with tuberculosis asks Nurse Brianhow long the chemotherapy must be continued.Nurse Brian’s accurate reply would be:a. 1 to 3 weeksb. 6 to 12 monthsc. 3 to 5 monthsd. 3 years and more51. A client has undergone laryngectomy. Theimmediate nursing priority would be:a. Keep trachea free of secretionsb. Monitor for signs of infectionc. Provide emotional supportd. Promote means of communication
  • 178ANSWERS AND RATIONALE – MEDICAL SURGICALNURSING1. C. Glucocorticoids (steroids) are used for theiranti-inflammatory action, which decreases thedevelopment of edema.2. A. The blood must be stopped at once, and thennormal saline should be infused to keep the linepatent and maintain blood volume.3. B. These tests confirm the presence of HIVantibodies that occur in response to thepresence of the human immunodeficiency virus(HIV).4. D. One cup of cottage cheese containsapproximately 225 calories, 27g of protein, 9g offat, 30mg cholesterol, and 6g of carbohydrate.Proteins of high biologic value (HBV) containoptimal levels of amino acids essential for life.5. A. Elevation of uremic waste products causesirritation of the nerves, resulting in flappinghand tremors.6. B. This indicates that the bladder is distendedwith urine, therefore palpable.7. C. Elevation increases lymphatic drainage,reducing edema and pain.8. B. Detection of myoglobin is a diagnostic tool todetermine whether myocardial damage hasoccurred.9. D. When mitral stenosis is present, the leftatrium has difficulty emptying its contents intothe left ventricle because there is no valve toprevent back ward flow into the pulmonary vein,the pulmonary circulation is under pressure.10. A. Managing hypertension is the priority for theclient with hypertension. Clients withhypertension frequently do not experience pain,deficient volume, or impaired skin integrity. It isthe asymptomatic nature of hypertension thatmakes it so difficult to treat.11. C. Because of its widespread vasodilating effects,nitroglycerin often produces side effects such asheadache, hypotension and dizziness.12. A. An increased in LDL cholesterol concentrationhas been documented at risk factor for thedevelopment of atherosclerosis. LDL cholesterolis not broken down into the liver but isdeposited into the wall of the blood vessels.13. D. There is a potential alteration in renalperfusion manifested by decreased urine output.The altered renal perfusion may be related torenal artery embolism, prolonged hypotension,or prolonged aortic cross-clamping during thesurgery.14. A. Good source of vitamin B12 are dairyproducts and meats.15. C. Aplastic anemia decreases the bone marrowproduction of RBC’s, white blood cells, andplatelets. The client is at risk for bruising andbleeding tendencies.16. B. An elective procedure is scheduled in advanceso that all preparations can be completed aheadof time. The vital signs are the final check thatmust be completed before the client leaves theroom so that continuity of care and assessmentis provided for.17. A. The peak incidence of Acute LymphocyticLeukemia (ALL) is 4 years of age. It is uncommonafter 15 years of age.18. D. Acute Lymphocytic Leukemia (ALL) does notcause gastric distention. It does invade thecentral nervous system, and clients experienceheadaches and vomiting from meningealirritation.19. B. Disseminated Intravascular Coagulation (DIC)has not been found to respond to oralanticoagulants such as Coumadin.20. A. Urine output provides the most sensitiveindication of the client’s response to therapy forhypovolemic shock. Urine output should beconsistently greater than 30 to 35 mL/hr.21. C. Early warning signs of laryngeal cancer canvary depending on tumor location. Hoarsenesslasting 2 weeks should be evaluated because it isone of the most common warning signs.22. C. Steroids decrease the body’s immuneresponse thus decreasing the production ofantibodies that attack the acetylcholinereceptors at the neuromuscular junction23. C. The osmotic diuretic mannitol iscontraindicated in the presence of inadequaterenal function or heart failure because itincreases the intravascular volume that must befiltered and excreted by the kidney.24. A. These devices are more accurate becausethey are easily to used and have improvedadherence in insulin regimens by young peoplebecause the medication can be administereddiscreetly.25. C. Damage to blood vessels may decrease thecirculatory perfusion of the toes, this wouldindicate the lack of blood supply to theextremity.26. D. Elevation will help control the edema thatusually occurs.27. B. Uric acid has a low solubility, it tends toprecipitate and form deposits at various sites
  • 179where blood flow is least active, includingcartilaginous tissue such as the ears.28. B. The palms should bear the client’s weight toavoid damage to the nerves in the axilla.29. A. Active exercises, alternating extension,flexion, abduction, and adduction, mobilizeexudates in the joints relieves stiffness and pain.30. C. Alteration in sensation and circulationindicates damage to the spinal cord, if theseoccurs notify physician immediately.31. A. In the diuretic phase fluid retained during theoliguric phase is excreted and may reach 3 to 5liters daily, hypovolemia may occur and fluidsshould be replaced.32. C. The constituents of CSF are similar to those ofblood plasma. An examination for glucosecontent is done to determine whether a bodyfluid is a mucus or a CSF. A CSF normally containsglucose.33. B. Trauma is one of the primary causes of braindamage and seizure activity in adults. Othercommon causes of seizure activity in adultsinclude neoplasms, withdrawal from drugs andalcohol, and vascular disease.34. A. It is crucial to monitor the pupil size andpapillary response to indicate changes aroundthe cranial nerves.35. C. The nurse most positive approach is toencourage the client with multiple sclerosis tostay active, use stress reduction techniques andavoid fatigue because it is important to supportthe immune system while remaining active.36. D. Restlessness is an early indicator of hypoxia.The nurse should suspect hypoxia in unconsciousclient who suddenly becomes restless.37. B. In spinal shock, the bladder becomescompletely atonic and will continue to fill unlessthe client is catheterized.38. A. Progression stage is the change of tumor fromthe preneoplastic state or low degree ofmalignancy to a fast growing tumor that cannotbe reversed.39. D. Intensity is the major indicative of severity ofpain and it is important for the evaluation of thetreatment.40. B. The use of fragrant soap is very drying to skinhence causing the pruritus.41. C. Atropine sulfate is contraindicated withglaucoma patients because it increasesintraocular pressure.42. A. A 67 year old client is greater risk because theolder adult client is more likely to have a less-effective immune system.43. B. The last area to return sensation is in theperineal area, and the nurse in charge shouldmonitor the client for distended bladder.44. D. Glucocorticoids play no significant role indisease treatment.45. D. Tracheostomy tube has several potentialcomplications including bleeding, infection andlaryngeal nerve damage.46. C. In burn, the capillaries and small vesselsdilate, and cell damage cause the release of ahistamine-like substance. The substance causesthe capillary walls to become more permeableand significant quantities of fluid are lost.47. A. Aging process involves increased capillaryfragility and permeability. Older adults have adecreased amount of subcutaneous fat andcause an increased incidence of bruise likelesions caused by collection of extravascularblood in loosely structured dermis.48. D. Intermittent pain is the classic sign of renalcarcinoma. It is primarily due to capillary erosionby the cancerous growth.49. B. Tubercle bacillus is a drug resistant organismand takes a long time to be eradicated. Usually acombination of three drugs is used for minimumof 6 months and at least six months beyondculture conversion.50. A. Patent airway is the most priority; thereforeremoval of secretions is necessary
  • 180PSYCHIATRIC NURSING1. Marco approached Nurse Trish asking for adviceon how to deal with his alcohol addiction. NurseTrish should tell the client that the only effectivetreatment for alcoholism is:a. Psychotherapyb. Alcoholics anonymous (A.A.)c. Total abstinenced. Aversion Therapy2. Nurse Hazel is caring for a male client whoexperience false sensory perceptions with nobasis in reality. This perception is known as:a. Hallucinationsb. Delusionsc. Loose associationsd. Neologisms3. Nurse Monet is caring for a female client whohas suicidal tendency. When accompanying theclient to the restroom, Nurse Monet should…a. Give her privacyb. Allow her to urinatec. Open the window and allow her to getsome fresh aird. Observe her4. Nurse Maureen is developing a plan of care for afemale client with anorexia nervosa. Whichaction should the nurse include in the plan?a. Provide privacy during mealsb. Set-up a strict eating plan for the clientc. Encourage client to exercise to reduceanxietyd. Restrict visits with the family5. A client is experiencing anxiety attack. The mostappropriate nursing intervention should include?a. Turning on the televisionb. Leaving the client alonec. Staying with the client and speaking inshort sentencesd. Ask the client to play with other clients6. A female client is admitted with a diagnosis ofdelusions of GRANDEUR. This diagnosis reflects abelief that one is:a. Being Killedb. Highly famous and importantc. Responsible for evil worldd. Connected to client unrelated to oneself7. A 20 year old client was diagnosed withdependent personality disorder. Which behavioris not likely to be evidence of ineffectiveindividual coping?a. Recurrent self-destructive behaviorb. Avoiding relationshipc. Showing interest in solitary activitiesd. Inability to make choices and decisionwithout advise8. A male client is diagnosed with schizotypalpersonality disorder. Which signs would thisclient exhibit during social situation?a. Paranoid thoughtsb. Emotional affectc. Independence needd. Aggressive behavior9. Nurse Claire is caring for a client diagnosed withbulimia. The most appropriate initial goal for aclient diagnosed with bulimia is?a. Encourage to avoid foodsb. Identify anxiety causing situationsc. Eat only three meals a dayd. Avoid shopping plenty of groceries10. Nurse Tony was caring for a 41 year old femaleclient. Which behavior by the client indicatesadult cognitive development?a. Generates new levels of awarenessb. Assumes responsibility for her actionsc. Has maximum ability to solve problemsand learn new skillsd. Her perception are based on reality11. A neuromuscular blocking agent is administeredto a client before ECT therapy. The Nurse shouldcarefully observe the client for?a. Respiratory difficultiesb. Nausea and vomitingc. Dizzinessd. Seizures12. A 75 year old client is admitted to the hospitalwith the diagnosis of dementia of theAlzheimer’s type and depression. The symptomthat is unrelated to depression would be?a. Apathetic response to the environmentb. “I don’t know” answer to questionsc. Shallow of labile effectd. Neglect of personal hygiene
  • 18113. Nurse Trish is working in a mental health facility;the nurse priority nursing intervention for anewly admitted client with bulimia nervosawould be to?a. Teach client to measure I & Ob. Involve client in planning daily mealc. Observe client during mealsd. Monitor client continuously14. Nurse Patricia is aware that the major healthcomplication associated with intractableanorexia nervosa would be?a. Cardiac dysrhythmias resulting tocardiac arrestb. Glucose intolerance resulting inprotracted hypoglycemiac. Endocrine imbalance causing coldamenorrhead. Decreased metabolism causing coldintolerance15. Nurse Anna can minimize agitation in adisturbed client by?a. Increasing stimulationb. limiting unnecessary interactionc. increasing appropriate sensoryperceptiond. ensuring constant client and staffcontact16. A 39 year old mother with obsessive-compulsivedisorder has become immobilized by herelaborate hand washing and walking rituals.Nurse Trish recognizes that the basis of O.C.disorder is often:a. Problems with being too conscientiousb. Problems with anger and remorsec. Feelings of guilt and inadequacyd. Feeling of unworthiness andhopelessness17. Mario is complaining to other clients about notbeing allowed by staff to keep food in his room.Which of the following interventions would bemost appropriate?a. Allowing a snack to be kept in his roomb. Reprimanding the clientc. Ignoring the clients behaviord. Setting limits on the behavior18. Conney with borderline personality disorder whois to be discharge soon threatens to “dosomething” to herself if discharged. Which of thefollowing actions by the nurse would be mostimportant?a. Ask a family member to stay with theclient at home temporarilyb. Discuss the meaning of the client’sstatement with herc. Request an immediate extension for theclientd. Ignore the clients statement because it’sa sign of manipulation19. Joey a client with antisocial personality disorderbelches loudly. A staff member asks Joey, “Doyou know why people find you repulsive?” thisstatement most likely would elicit which of thefollowing client reaction?a. Depensivenessb. Embarrassmentc. Shamed. Remorsefulness20. Which of the following approaches would bemost appropriate to use with a client sufferingfrom narcissistic personality disorder whendiscrepancies exist between what the clientstates and what actually exist?a. Rationalizationb. Supportive confrontationc. Limit settingd. Consistency21. Cely is experiencing alcohol withdrawal exhibitstremors, diaphoresis and hyperactivity. Bloodpressure is 190/87 mmhg and pulse is 92 bpm.Which of the medications would the nurseexpect to administer?a. Naloxone (Narcan)b. Benzlropine (Cogentin)c. Lorazepam (Ativan)d. Haloperidol (Haldol)22. Which of the following foods would the nurseTrish eliminate from the diet of a client inalcohol withdrawal?a. Milkb. Orange Juicec. Sodad. Regular Coffee23. Which of the following would Nurse Hazelexpect to assess for a client who is exhibitinglate signs of heroin withdrawal?a. Yawning & diaphoresis
  • 182b. Restlessness & Irritabilityc. Constipation & steatorrhead. Vomiting and Diarrhea24. To establish open and trusting relationship witha female client who has been hospitalized withsevere anxiety, the nurse in charge should?a. Encourage the staff to have frequentinteraction with the clientb. Share an activity with the clientc. Give client feedback about behaviord. Respect client’s need for personal space25. Nurse Monette recognizes that the focus ofenvironmental (MILIEU) therapy is to:a. Manipulate the environment to bringabout positive changes in behaviorb. Allow the client’s freedom to determinewhether or not they will be involved inactivitiesc. Role play life events to meet individualneedsd. Use natural remedies rather than drugsto control behavior26. Nurse Trish would expect a child with a diagnosisof reactive attachment disorder to:a. Have more positive relation with thefather than the motherb. Cling to mother & cry on separationc. Be able to develop only superficialrelation with the othersd. Have been physically abuse27. When teaching parents about childhooddepression Nurse Trina should say?a. It may appear acting out behaviorb. Does not respond to conventionaltreatmentc. Is short in duration & resolves easilyd. Looks almost identical to adultdepression28. Nurse Perry is aware that language developmentin autistic child resembles:a. Scanning speechb. Speech lagc. Shutteringd. Echolalia29. A 60 year old female client who lives alone tellsthe nurse at the community health center “Ireally don’t need anyone to talk to”. The TV ismy best friend. The nurse recognizes that theclient is using the defense mechanism known as?a. Displacementb. Projectionc. Sublimationd. Denial30. When working with a male client sufferingphobia about black cats, Nurse Trish shouldanticipate that a problem for this client wouldbe?a. Anxiety when discussing phobiab. Anger toward the feared objectc. Denying that the phobia existd. Distortion of reality when completingdaily routines31. Linda is pacing the floor and appears extremelyanxious. The duty nurse approaches in anattempt to alleviate Linda’s anxiety. The mosttherapeutic question by the nurse would be?a. Would you like to watch TV?b. Would you like me to talk with you?c. Are you feeling upset now?d. Ignore the client32. Nurse Penny is aware that the symptoms thatdistinguish post-traumatic stress disorder fromother anxiety disorder would be:a. Avoidance of situation & certainactivities that resemble the stressb. Depression and a blunted affect whendiscussing the traumatic situationc. Lack of interest in family & othersd. Re-experiencing the trauma in dreams orflashback33. Nurse Benjie is communicating with a male clientwith substance-induced persisting dementia; theclient cannot remember facts and fills in thegaps with imaginary information. Nurse Benjie isaware that this is typical of?a. Flight of ideasb. Associative loosenessc. Confabulationd. Concretism34. Nurse Joey is aware that the signs & symptomsthat would be most specific for diagnosisanorexia are?a. Excessive weight loss, amenorrhea &abdominal distensionb. Slow pulse, 10% weight loss & alopecia
  • 183c. Compulsive behavior, excessive fears &nausead. Excessive activity, memory lapses & anincreased pulse35. A characteristic that would suggest to NurseAnne that an adolescent may have bulimiawould be:a. Frequent regurgitation & re-swallowingof foodb. Previous history of gastritisc. Badly stained teethd. Positive body image36. Nurse Monette is aware that extremelydepressed clients seem to do best in settingswhere they have:a. Multiple stimulib. Routine Activitiesc. Minimal decision makingd. Varied Activities37. To further assess a client’s suicidal potential.Nurse Katrina should be especially alert to theclient expression of:a. Frustration & fear of deathb. Anger & resentmentc. Anxiety & lonelinessd. Helplessness & hopelessness38. A nursing care plan for a male client with bipolarI disorder should include:a. Providing a structured environmentb. Designing activities that will require theclient to maintain contact with realityc. Engaging the client in conversing aboutcurrent affairsd. Touching the client provide assurance39. When planning care for a female client usingritualistic behavior, Nurse Gina must recognizethat the ritual:a. Helps the client focus on the inability todeal with realityb. Helps the client control the anxietyc. Is under the client’s conscious controld. Is used by the client primarily forsecondary gains40. A 32 year old male graduate student, who hasbecome increasingly withdrawn and neglectfulof his work and personal hygiene, is brought tothe psychiatric hospital by his parents. Afterdetailed assessment, a diagnosis ofschizophrenia is made. It is unlikely that theclient will demonstrate:a. Low self esteemb. Concrete thinkingc. Effective self-boundariesd. Weak ego41. A 23 year old client has been admitted with adiagnosis of schizophrenia says to the nurse“Yes, its march, March is little woman”. That’sliteral you know”. These statement illustrate:a. Neologismsb. Echolaliac. Flight of ideasd. Loosening of association42. A long term goal for a paranoid male client whohas unjustifiably accused his wife of having manyextramarital affairs would be to help the clientdevelop:a. Insight into his behaviorb. Better self-controlc. Feeling of self-worthd. Faith in his wife43. A male client who is experiencing disorderedthinking about food being poisoned is admittedto the mental health unit. The nurse uses whichcommunication technique to encourage theclient to eat dinner?a. Focusing on self-disclosure of own foodpreferenceb. Using open ended question and silencec. Offering opinion about the need to eatd. Verbalizing reasons that the client maynot choose to eat44. Nurse Nina is assigned to care for a clientdiagnosed with Catatonic Stupor. When NurseNina enters the client’s room, the client is foundlying on the bed with a body pulled into a fetalposition. Nurse Nina should?a. Ask the client direct questions toencourage talkingb. Rake the client into the dayroom to bewith other clientsc. Sit beside the client in silence andoccasionally ask open-ended questiond. Leave the client alone and continue withproviding care to the other clients
  • 18445. Nurse Tina is caring for a client with delirium andstates that “look at the spiders on the wall”.What should the nurse respond to the client?a. “You’re having hallucination, there areno spiders in this room at all”b. “I can see the spiders on the wall, butthey are not going to hurt you”c. “Would you like me to kill the spiders”d. “I know you are frightened, but I do notsee spiders on the wall”46. Nurse Jonel is providing information to acommunity group about violence in the family.Which statement by a group member wouldindicate a need to provide additionalinformation?a. “Abuse occurs more in low-incomefamilies”b. “Abuser Are often jealous or self-centered”c. “Abuser use fear and intimidation”d. “Abuser usually have poor self-esteem”47. During electroconvulsive therapy (ECT) the clientreceives oxygen by mask via positive pressureventilation. The nurse assisting with thisprocedure knows that positive pressureventilation is necessary because?a. Anesthesia is administered during theprocedureb. Decrease oxygen to the brain increasesconfusion and disorientationc. Grand mal seizure activity depressesrespirationsd. Muscle relaxations given to preventinjury during seizure activity depressrespirations.48. When planning the discharge of a client withchronic anxiety, Nurse Chris evaluatesachievement of the discharge maintenancegoals. Which goal would be most appropriatelyhaving been included in the plan of carerequiring evaluation?a. The client eliminates all anxiety fromdaily situationsb. The client ignores feelings of anxietyc. The client identifies anxiety producingsituationsd. The client maintains contact with a crisiscounselor49. Nurse Tina is caring for a client with depressionwho has not responded to antidepressantmedication. The nurse anticipates that whattreatment procedure may be prescribed.a. Neuroleptic medicationb. Short term seclusionc. Psychosurgeryd. Electroconvulsive therapy50. Mario is admitted to the emergency room withdrug-included anxiety related to over ingestionof prescribed antipsychotic medication. Themost important piece of information the nursein charge should obtain initially is the:a. Length of time on the med.b. Name of the ingested medication & theamount ingestedc. Reason for the suicide attemptd. Name of the nearest relative & theirphone number
  • 185ANSWERS AND RATIONALE – PSYCHIATRICNURSING1. Answer: CRationale: Total abstinence is the only effectivetreatment for alcoholism2. Answer: ARationale: Hallucinations are visual, auditory,gustatory, tactile or olfactory perceptions thathave no basis in reality.3. Answer: DRationale: The Nurse has a responsibility toobserve continuously the acutely suicidal client.The Nurse should watch for clues, such ascommunicating suicidal thoughts, and messages;hoarding medications and talking about death.4. Answer: BRationale: Establishing a consistent eating planand monitoring client’s weight are important tothis disorder.5. Answer: CRationale: Appropriate nursing interventions foran anxiety attack include using short sentences,staying with the client, decreasing stimuli,remaining calm and medicating as needed.6. Answer:BRationale: Delusion of grandeur is a false beliefthat one is highly famous and important.7. Answer: DRationale: Individual with dependent personalitydisorder typically shows indecisivenesssubmissiveness and clinging behavior so thatothers will make decisions with them.8. Answer: ARationale: Clients with schizotypal personalitydisorder experience excessive social anxiety thatcan lead to paranoid thoughts9. Answer: BRationale: Bulimia disorder generally is amaladaptive coping response to stress andunderlying issues. The client should identifyanxiety causing situation that stimulate thebulimic behavior and then learn new ways ofcoping with the anxiety.10. Answer: ARationale: An adult age 31 to 45 generates newlevel of awareness.11. Answer: ARationale: Neuromuscular Blocker, such asSUCCINYLCHOLINE (Anectine) producesrespiratory depression because it inhibitscontractions of respiratory muscles.12. Answer: CRationale: With depression, there is little or noemotional involvement therefore little alterationin affect.13. Answer: DRationale: These clients often hide food or forcevomiting; therefore they must be carefullymonitored.14. Answer: ARationale: These clients have severely depletedlevels of sodium and potassium because of theirstarvation diet and energy expenditure, theseelectrolytes are necessary for cardiacfunctioning.15. Answer: BRationale: Limiting unnecessary interaction willdecrease stimulation and agitation.16. Answer: CRationale: Ritualistic behavior seen in thisdisorder is aimed at controlling guilt andinadequacy by maintaining an absolute setpattern of behavior.17. Answer: DRationale: The nurse needs to set limits in theclient’s manipulative behavior to help the clientcontrol dysfunctional behavior. A consistentapproach by the staff is necessary to decreasemanipulation.18. Answer: BRationale: Any suicidal statement must beassessed by the nurse. The nurse should discussthe client’s statement with her to determine itsmeaning in terms of suicide.19. Answer: ARationale: When the staff member ask the clientif he wonders why others find him repulsive, theclient is likely to feel defensive because thequestion is belittling. The natural tendency is tocounterattack the threat to self-image.20. Answer: BRationale: The nurse would specifically usesupportive confrontation with the client to pointout discrepancies between what the client statesand what actually exists to increaseresponsibility for self.21. Answer: CRationale: The nurse would most likelyadminister benzodiazepine, such as lorazepan(ativan) to the client who is experiencingsymptom: The client’s experiences symptoms ofwithdrawal because of the reboundphenomenon when the sedation of the CNSfrom alcohol begins to decrease.22. Answer: D
  • 186Rationale: Regular coffee contains caffeinewhich acts as psychomotor stimulants and leadsto feelings of anxiety and agitation. Servingcoffee top the client may add to tremors orwakefulness.23. Answer: DRationale: Vomiting and diarrhea are usually thelate signs of heroin withdrawal, along withmuscle spasm, fever, nausea, repetitive,abdominal cramps and backache.24. Answer: DRationale: Moving to a client’s personal spaceincreases the feeling of threat, which increasesanxiety.25. Answer: ARationale: Environmental (MILIEU) therapy aimsat having everything in the client’s surroundingarea toward helping the client.26. Answer: CRationale: Children who have experiencedattachment difficulties with primary caregiverare not able to trust others and therefore relatesuperficially27. Answer: ARationale: Children have difficulty verballyexpressing their feelings, acting out behavior,such as temper tantrums, may indicateunderlying depression.28. Answer: DRationale: The autistic child repeats sounds orwords spoken by others.29. Answer: DRationale: The client statement is an example ofthe use of denial, a defense that blocks problemby unconscious refusing to admit they exist30. Answer: ARationale: Discussion of the feared objecttriggers an emotional response to the object.31. Answer: BRationale: The nurse presence may provide theclient with support & feeling of control.32. Answer: DRationale: Experiencing the actual trauma indreams or flashback is the major symptom thatdistinguishes post-traumatic stress disorder fromother anxiety disorder.33. Answer: CRationale: Confabulation or the filling in ofmemory gaps with imaginary facts is a defensemechanism used by people experiencingmemory deficits.34. Answer: ARationale: These are the major signs of anorexianervosa. Weight loss is excessive (15% ofexpected weight)35. Answer: CRationale: Dental enamel erosion occurs fromrepeated self-induced vomiting.36. Answer: BRationale: Depression usually is both emotional& physical. A simple daily routine is the best,least stressful and least anxiety producing.37. Answer: DRationale: The expression of these feeling mayindicate that this client is unable to continue thestruggle of life.38. Answer: ARationale: Structure tends to decrease agitationand anxiety and to increase the client’s feeling ofsecurity.39. Answer: BRationale: The rituals used by a client withobsessive compulsive disorder help control theanxiety level by maintaining a set pattern ofaction.40. Answer: CRationale: A person with this disorder would nothave adequate self-boundaries41. Answer: DRationale: Loose associations are thoughts thatare presented without the logical connectionsusually necessary for the listening to interpretthe message.42. Answer: CRationale: Helping the client to develop feelingof self-worth would reduce the client’s need touse pathologic defenses.43. Answer: BRationale: Open ended questions and silence arestrategies used to encourage clients to discusstheir problem in descriptive manner.44. Answer: CRationale: Clients who are withdrawn may beimmobile and mute, and require consistent,repeated interventions. Communication withwithdrawn clients requires much patience fromthe nurse. The nurse facilitates communicationwith the client by sitting in silence, asking open-ended question and pausing to provideopportunities for the client to respond.45. Answer: DRationale: When hallucination is present, thenurse should reinforce reality with the client.46. Answer: A
  • 187Rationale: Personal characteristics of abuserinclude low self-esteem, immaturity,dependence, insecurity and jealousy.47. Answer: DRationale: A short acting skeletal muscle relaxantsuch as succinylcholine (Anectine) isadministered during this procedure to preventinjuries during seizure.48. Answer: CRationale: Recognizing situations that produceanxiety allows the client to prepare to cope withanxiety or avoid specific stimulus.49. Answer: DRationale: Electroconvulsive therapy is aneffective treatment for depression that has notresponded to medication50. Answer: BRationale: In an emergency, lives saving facts areobtained first. The name and the amount ofmedication ingested are of outmost important intreating this potentially life threateningsituation.
  • 188FOUNDATION OF PROFESSIONAL NURSINGPRACTICESituation 1 - Mr. Ibarra is assigned to the triage area andwhile on duty, he assesses the condition of Mrs. Simonwho came in with asthma. She has difficulty breathingand her respiratory rate is 40 per minute. Mr. Ibarra isasked to inject the client epinephrine 0.3mgsubcutaneously1. The indication for epinephrine injection for MrsSimon is to:a. Reduce anaphylaxisb. Relieve hypersensitivity to allergenc. Relieve respirator distress due to bronchial spasmd. Restore client’s cardiac rhythm2. When preparing the epinephrine injection from anampule, the nurse initially:a. Taps the ampule at the top to allow fluid to flow tothe base of the ampuleb. Checks expiration date of the medication ampulec. Removes needle cap of syringe and pulls plunger toexpel aird. Breaks the neck of the ampule with a gauze wrappedaround it3. Mrs. Simon is obese. When administering asubcutaneous injection to an obese patient, it is bestfor the nurse to:a Inject needle at a 15 degree angle over the stretchedskin of the clientb. Pinch skin at the Injection site and use airlocktechniquec. Pull skin of patient down to administer the drug in a Ztrackd. Spread skin or pinch at the injection site and injectneedle at a 45-90 degree angle4. When preparing for a subcutaneous injection, theproper size of syringe and needle would be:a. Syringe 3-5ml and needle gauge 21 to 23b. Tuberculin syringe 1 mi with needle gauge 26 or 27c. Syringe 2ml and needle gauge 22d. Syringe 1-3ml and needle gauge 25 to 275. The rationale for giving medications through thesubcutaneous route is;a. There are many alternative sites for subcutaneousinjectionb. Absorption time of the medicine is slowerc. There are less pain receptors in this aread. The medication can be injected while the client is inany positionSituation 2 - The use of massage and meditation to helpdecrease stress and pain have been stronglyrecommended based on documented testimonials.6. Martha wants to do a study on, this topic. "Effects ofmassage and meditation on stress and pain." The typeof research that best suits this topic is:a. applied researchb. qualitative researchc. basic researchd. quantitative research7. The type of research design that does not manipulateindependent variable is:a. experimental designb. quasi-experimental designc. non-experimental designd. quantitative design8. This research topic has the potential to contribute tonursing because it seeks to:a. include new modalities of careb. resolve a clinical problemc. clarify an ambiguous modality of cared. enhance client care9. Martha does review of related literature for thepurpose of:a. determine statistical treatment of data researchb. gathering data about what is already known orunknownc. to identify if problem can be replicatedd. answering the research question10. Client’s rights should be protected when doingresearch using human subjects. Martha identifies theserights as follows EXCEPT:a. right of self-determinationb. right to compensationc. right of privacyd. right not to be harmed
  • 189Situation 3 - Richard has a nursing diagnosis ofineffective airway clearance related to excessivesecretions and is at risk for infection because of retainedsecretions. Part of Nurse Marios nursing care plan is toloosen and remove excessive secretions in the airway,11. Mario listens to Richards bilateral sounds and findsthat congestion is in the upper lobes of the lungs. Theappropriate position to drain the anterior and posteriorapical segments of the lungs when Mario doespercussion would be:a. Client lying on his back then flat on his abdomen onTrendelenburg positionb. Client seated upright in bed or on a chair then leaningforward in sitting position then flat on his back and onhis abdomenc. Client lying flat on his back and then flat on hisabdomend. Client lying on his right then left side onTrendelenburg position12. When documenting outcome of Richards treatmentMario should include the following in his recordingEXCEPT:a. Color, amount and consistent of sputumb. Character of breath sounds and respirator/rate beforeand after procedurec. Amount of fluid intake of client before and after theprocedured. Significant changes in vital signs13. When assessing Richard for chest percussion orchest vibration and postural drainage Mario wouldfocus on the following EXCEPT:a. Amount of food and fluid taken during the last mealbefore treatmentb. Respiratory rate, breath sounds and location ofcongestionc. Teaching the clients relatives to perform theprocedured. Doctors order regarding position restriction andclients tolerance for lying flat14. Mario prepares Richard for postural drainage andpercussion. Which of the flowing is a specialconsideration when doing the procedure?a. Respiratory rate of 16 to 20 per minuteb. Client can tolerate sitting and lying positionc. Client has no signs of infectiond. Time of fast food and fluid intake of the client15. The purpose of chest percussion and vibration is toloosen secretions in the lungs. The difference betweenthe procedure is;a. Percussion uses only one hand white vibration usesboth handsb. Percussion delivers cushioned blows to the chest withcupped palms while gently shakes secretion loose on theexhalation cyclec. In both percussion and vibration the hands are on topof each other and hand action is in tune with clientsbreath rhythmd. Percussion slaps the chest to loosen secretions whilevibration shakes the secretions along with the inhalationof airSituation 4 - A 61 year old man, Mr. Regalado, isadmitted to the private ward for observation; aftercomplaints of severe chest pain. You are assigned to takecare of the client.16. When doing an initial assessment, the best way foryou to identify the client’s priority problem is to:a. Interview the client for chief complaints and othersymptomsb. Talk to the relatives to gather data about history ofillnessc. Do auscultation to check for chest congestiond. Do a physical examination white asking the clientrelevant questions17. Upon establishing Mr. Regalados nursing needs,the next nursing approach would be to:a. introduce the client to the ward staff to put the clientand family at easeb. Give client and relatives a brief tour of the physical setup the unitc. Take his vital signs for a baseline assessmentd. Establish priority needs and implement appropriateinterventions18. Mr. Regalado says he has "trouble going to sleep".In order to plan your nursing intervention you will.a. Observe his sleeping patterns in the next few daysb. Ask him what he means by this statementc. Check his physical environment to decrease noise leveld. Take his blood pressure before sleeping and upon
  • 190waking up19. Mr. Regalados lower extremities are swollen andshiny. He has pitting pedal edema. When taking care ofMr. Regalado, which of the following interventionwould be the most appropriate immediate nursingapproach.a. Moisturize lower extremities to prevent skin irritationb. Measure fluid intake and output to decrease edemac. Elevate lower extremities for postural drainaged. Provide the client a list of food low in sodium20. Mr. Regalado will be discharged from your unitwithin the hour. Nursing actions when preparing aclient for discharge include all EXCEPT:a. Making a final physical assessment before clientleaves the hospitalb. Giving instructions about his medication regimenc. Walking the client to the hospital exit to ensure hissafetyd. Proper recording of pertinent dataSituation 5 - Nancy, mother of 2 young kids. 36 years old,had a mammogram and was told that she has breastcysts and that she may need surgery. This causes heranxiety as shown by increase in her pulse and respiratoryrate, sweating and feelings of tension.21. Considering her level of anxiety, the nurse can bestassist Nancy by:a. Giving her activities to divert her attentionb. Giving detailed explanations about the treatments shewill undergoc. Preparing her and her family in case surgery is notsuccessfuld. Giving her clear but brief information at the level ofher understanding22. Nancy blames God for her situation. She is easilyprovoked to tears and wants to be left alone, refusingto eat or talk to her family. A religious person before,she now refuses to pray or go to church stating thatGod has abandoned her. The nurse understands thatNancy is grieving for her self and is in the stage of:a. bargainingb. denialc. angerd. acceptance23. The nurse visits Nancy and prods her to eat herfood. Nancy replies "whats the use? My time is runningout. The nurses best response would be:a. "The doctor ordered full diet for you so that you willbe strong for surgery."b. "I understand how you fee! but you have 1o try foryour childrens sake."c. "Have you told your, doctor how you feel? Are youchanging your mind) about surgery?"d. "You sound like you are giving up."24. The nurse feels sad about Nancys illness and tellsher head nurse during the end of shift endorsementthat "its unfair for Nancy to have cancer when she isstill so young and with two kinds. The best response ofthe head nurse would be:a. Advise the nurse to "be strong and learn to control herfeelings"b. Assign the nurse to another client to avoid sympathyfor the clientc. Reassure the nurse that the client has hope if she goesthrough all statements prescribed for herc. Ask the other nurses what they feel about the patientto find out if they share the same feelings25. Realizing that she feels angry about Nancyscondition, the nurse Seams that being self-aware is aconscious process that she should do in any situationlike this because:a. This is a necessary part of the nurse -clientrelationship processb. The nurse is a role model for the client and should bestrongC. How the nurse thinks and feels affect her actionstowards her client and her workd. The nurse has to be therapeutic at all times andshould not be affectedSituation 6 – Mrs. Seva, 32 years old, asks you aboutpossible problems regarding her elimination now thatshe is in the menopausal stage.26. Instruction on health promotion regarding urinaryelimination is important. Which would you include?a. Hold urine, as long as she can before emptying thebladder to strengthen her sphincters musclesb. If burning sensation is experienced while voiding,drink pineapple-juicec. After urination, wipe from anal area up towards the
  • 191pubisd. Jell client to empty the bladder at each voiding27. Mrs. Seva also tells the nurse that she is oftenconstipated. Because she is aging, what physicalchanges predispose her to constipation?a. inhibition of the parasympathetic reflexb. weakness of sphincter muscles of the anusc. loss of tone of the smooth muscles of the colord. decreased ability to absorb fluids in the lowerintestines28. The nurse understands that one of these factorscontributes to constipation:a. excessive exerciseb. high fiber dietc. no regular tine for defecation dailyd. prolonged use of laxatives29. Mrs. Seva talks about rear of being incontinent dueto a prior experience of dribbling urine when laughingor sneezing and when she has a full bladder. Your mostappropriate .instruction would be to:a. tell client to drink less fluids to avoid accidentsb. instruct client to start wearing thin adult diapersc. ask the client to bring change of underwear "just incase"d. teach client pelvic exercise to strengthen perinealmuscles30. Mrs. Seva asked for instructions for skin care for hermother who has urinary incontinence and is almostalways in bed. Your instruction would focus onprevention of skin irritation and breakdown bya. Using thick diapers to absorb urine wellb. Drying the skin with baby powder to prevent or maskthe smell of ammoniac. Thorough washing, rising and during of skin area thatget wet with urined. Making sure that linen are smooth and dry at all timesSituation 7 - Using Maslows need theory, Airway,Breathing and Circulation are the physiological needsvital to life. The nurses knowledge and ability to identifyand immediately intervene to meet these needs isimportant to save lives.31. Which of these clients has a problem with thetransport of oxygen from the lungs to the tissues:a. Carol with a tumor in the brainb. Theresa with anemiac. Sonny Boy with a fracture in the femurd. Brigette with diarrhea32. You noted from the lab exams in the chart of Mr.Santos that he has reduced oxygen in the blood.This condition is called:a. Cyanosisb. Hypoxiac. Hypoxemiad. Anemia33. You will nasopharyngeal suctioning Mr. Abad. Yourguide for the length of insertion of the tubing for anadult would be:a. tip of the nose to the base of the .neckb. the distance from the tip of the nose to the middle ofthe cheekc. the distance from the tip of the nose to the tip of theear lobed. eight to ten inches34. While doing nasopharyngeal suctioning on .Mr.Abad, the nurse can avoid trauma to the area by:a. Apply suction for at least 20-30 seconds each time toensure that all secretions are removedb. Using gloves to prevent introduction of pathogens tothe respiratory systemc. Applying no suction while inserting the catheterd. Rotating catheter as it is inserted with gentle suction35. Myrna has difficulty breathing when on her backand must sit upright in bed to breath, effectively andcomfortably. The nurse documents this condition as:a. Apneab. Orthopneac. Dyspnead. TachypneaSituation 8 - You are assigned to screen forhypertension: Your task is to take blood pressurereadings and you are informed about avoiding thecommon mistakes in BP taking that lead to false orinaccurate blood pressure readings.36. When taking blood pressure reading the cuff shouldbe:
  • 192a. deflated fully then immediately start second readingfor same clientb deflated quickly after inflating up to 180 mmHgc. large enough to wrap around upper arm of the adultclient 1 cm above brachial arteryd. inflated to 30 mmHg above the estimated systolic BPbased on palpation of radial or bronchial artery37. Chronic Obstructive Pulmonary Disease (COPD) inone of the leading causes of death worldwide and is apreventable disease. The primary cause of COPD is:a. tobacco hackb. bronchitisc. asthmad. cigarette smoking38. In your health education class for clients withdiabetes you teach, them the areas, for control .Diabetes which include all EXCEPT:a. regular physical activityb. thorough knowledge of foot carec. prevention nutritiond. proper nutrition39. You teach your clients the difference between, TypeI (IDDM) and Type II (NDDM) Diabetes. Which of thefollowing is true?a. both types diabetes mellitus clients are all prone todeveloping ketosisb. Type II (NIDDM) is more common and is alsopreventable compared to Type I (IDDM) diabetes whichis genetic in etiologyc. Type I (IDDM) is characterized by fastinghyperglycemiad. Type II (IDDM) is characterized by abnormal immuneresponse40. Lifestyle-related diseases in general share areascommon risk factors. These are the following excepta. physical activityb. smokingc. geneticsd. nutritionSituation 9 - Nurse Rivera witnesses a vehicular accidentnear the hospital where she works. She decides to getinvolved and help the victims of the accident.41. Her priority nursing action would be to:a. Assess damage to propertyb. Assist in the police investigation since she is a witnessc. Report the incident immediately to the local policeauthoritiesd. Assess the extent of injuries incurred by the victims, ofthe accident42. Priority attention should be given to which of theseclients?a. Linda who shows severe anxiety due to trauma of theaccidentb. Ryan who has chest injury, is pate and with difficultyof breathingc. Noel who has lacerations on the arms with mild-bleedingc. Andy whose left ankle swelled and has some abrasions43. In the emergency room, Nurse Rivera is assigned toattend to the client with .lacerations on the arms, whileassessing the extent of the wound the nurse observesthat the wound is now starting to bleed profusely. Themost immediate nursing action would be to:a. Apply antiseptic to prevent infectionb. Clean the wound vigorously of contaminantsc. Control and. reduce bleeding of the woundd. Bandage the wound and elevate the arm44. The nurse applies pressure dressing on the bleedingsite. This intervention is done to:a. Reduce the need to change dressing frequentlyb. Allow the pus to surface fasterc. Protect the wound from micro organisms in the aird. Promote hemostasis45. After the treatment, the client is sent home andasked to come back for follow-up care. Yourresponsibilities when the client is to be dischargedinclude the following EXCEPT:a. Encouraging the client to go to the, outpatient clinicfor follow up careb. Accurate recording, of treatment done andinstructions given to clientc. Instructing the client to see you after discharge forfurther assistanced. Providing instructions regarding wound careSituation 10 - While working in the clinic, a new client,Geline, 35 years old, arrives for her doctors
  • 193appointment. As the clinic nurse, you are to assist theclient fiil up forms, gather data and make an assessment.46. The nurse purpose of your initial nursing interviewis to:a. Record pertinent information in the client chart forhealth team to readb Assist the client find solutions to her health concernsc. Understand her lifestyle, health needs and possibleproblems to develop a plan of cared. Make nursing diagnoses for identified health problems47. While interviewing Geline, she starts to moan anddoubles up in pain, She tells you that this pain occursabout an hour after taking black coffee withoutbreakfast for a few weeks now. You will record this asfollows:a. Claims to have abdominal pains after intake of coffeeunrelieved by analgesicsb. After drinking coffee, the client experienced severeabdominal painc. Client complained of intermittent abdominal pain anhour after drinking coffeed. Client reported abdominal pain an hour after drinkingblack coffee for three weeks now48. Geline tells you that she drinks black coffeefrequently within the day to "have energy and be wideawake" and she eats nothing for breakfast and eatsstrictly vegetable salads for lunch and dinner to loseweight. She has lost weight during the past two weeks,in planning a healthy balanced diet with Geline, youwill:a. Start her off with a cleansing diet to free her body oftoxins then change to a vegetarian, diet and drink plentyof fluidsb. Plan a high protein, diet; low carbohydrate diet for herconsidering her favorite foodc. Instruct her to attend classes in nutrition to find foodrich in complex carbohydrates to maintain daily highenergy leveld. Discuss with her the importance of eating a variety offood from the major food groups with plenty of fluids49. Geline tells you that she drinks 4-5 cups of blackcoffee and diet cola drinks. She also smokes up to apack of cigarettes daily. She confesses that she is in her2nd month of pregnancy but she does not want tobecome fat that is why she limits her food intake. Youwarn or caution her about which of the following?a. Caffeine products affect the central nervous systemand may cause the mother to have a "nervousbreakdown"b. Malnutrition and its possible effects on growth anddevelopment problems in the unborn fetusc. Caffeine causes a stimulant effect on both the motherand the babyd. Studies show conclusively that caffeine causes mentalretardation50. Your health education plan for Geline stressesproper diet for a pregnant woman and the preventionof non-communicable diseases that are influenced byher lifestyle these include of the following EXCEPT:a. Cardiovascular diseasesb. Cancerc. Diabetes Mellitusd. OsteoporosisSituation 11 - Management of nurse practitioners isdone by qualified nursing leaders who have had clinicalexperience and management experience.51. An example of a management function of a nurse is:a. Teaching patient do breathing and coughing exercisesb. Preparing for a surprise party for a clientc. Performing nursing procedures for clientsd. Directing and evaluating the staff nurses52. Your head nurse in the unit believes that the staffnurses are not capable of decision making so she makesthe decisions for everyone without consulting anybody.This type of leadership is:a. Laissez faire leadershipb. Democratic leadershipc. Autocratic leadershipd. Managerial leadership53. When the head nurse in your ward plots andapproves your work schedules and directs your work,she is demonstrating:a. Responsibilityb. Delegationc. Accountabilityd. Authority54. The following tasks can be safely delegated by anurse to a non-nurse health worker EXCEPT:
  • 194a. Transfer a client from bed to chairb. Change IV infusionsc. Irrigation of a nasogastric tubed. Take vital signs55. You made a mistake in giving the medicine to thewrong client You notify the client’s doctor and write anincident report. You are demonstrating:a. Responsibilityb. Accountabilityc. Authorityd. AutocracySituation 12 – Mr. Dizon, 84 years old, is brought to the.Emergency Room for complaint of hypertension flushedface, severe headache, and nausea. You are doing theinitial assessment of vital signs.56. You are to measure the client’s initial bloodpressure reading by doing all of the following EXCEPT:a. Take the blood pressure reading on both arms forcomparisonb. Listen to and identify the phases of Korotkoff’s soundsc. Pump the cuff up to around 50 mmHg above the pointwhere the pulse is obliteratedd. Observe procedures for infection control57. A pulse oximeter is attached to Mr. Dizon’s fingerto:a. Determine if the client’s hemoglobin level is low and ifhe needs blood transfusionb. Check level of client’s tissue perfusionc. Measure the efficacy of the client’s anti hypertensivemedicationsd. Detect oxygen saturation of arterial blood beforesymptoms of hypoxemia develops58. After a few hours in the Emergency Room, Mr.Dizon is admitted to the ward with an order of hourlymonitoring of blood pressure. The nurse finds that thecuff is too narrow and this will cause the blood pressurereading to be:a. Inconsistentb. low systolic and high diastolic pressurec. higher than what the reading should bed. lower than what the reading should be59. Through the client’s health history, you gather thatMr. Dizon smokes and drinks coffee. When taking theblood pressure of a client who recently smoked ordrank coffee, how long should be the nurse wait beforetaking the client’s blood pressure for accurate reading?a. 15 minutesb. 30 minutesc. 1 hourd. 5 minutes60. While the client has the pulse oximeter on hisfingertip, you notice that the sunlight is shining on .thearea where the oximeter is. Your action will be to:a. Set and turn on the alarm of the oximeterb. Do nothing since there is no identified problemc. Cover the fingertip sensor with a towel or bedsheetd. Change the location of the sensor every four hoursSituation 13 - The nurses understanding of ethico-legalresponsibilities will guide his/her nursing practice.61. The principles that .govern right and properconducts of a person regarding life, biology and thehealth professions is referred to as:a. Moralityb. Religionc. Valuesd. Bioethics62. The purpose of having nurses’ code of ethics is:a. Delineate the scope and areas of nursing practiceb. Identify nursing action recommended for specifichealthcare situationsc. To help the public understand professional conduct,expected of nursesd. To define the roles and functions of the health caregiver, nurses, clients63. The most important nursing responsibility whereethical situations emerge in patient care is to:a. Act only when advised that the action is ethicallysoundb. Not take sides remain neutral and fairc. Assume that ethical questions are the responsibility: ofthe health teamd. Be accountable for his or her own actions64. You inform the patient about his rights whichinclude the following EXCEPT:
  • 195a. Right to expect reasonable continuity of careb. Right to consent to or decline to participate inresearch studies or experimentsc. Right to obtain information about another patientd. Right to expect that the records about his care will betreated as confidential65. The principle states that a person has unconditionalworth and has the capacity to determine his owndestiny.a. Bioethicsb. Justicec. Fidelityd. AutonomySituation 14 – Your director of nursing wants to improvethe quality of health care offered in the hospital. As astaff nurse in that hospital you know that this entailsquality assurance programs.66. The following mechanisms can be utilized as part ofthe quality assessment program of your hospitalEXCEPT:a. Patient satisfaction surveys providedb. Peer review clinical records of care of clientc. RO of the Nursing Intervention Classificationd.67. The nurse of the Standards of Nursing Practice isimportant in the hospital. Which of the followingstatements best describes what it is?a. These are statements that describe the maximum orhighest level of acceptable performance in nursingpractice.b. It refers to the scope of nursing as defined in RepublicAct 9173c. It is a license issued by the Professional RegulationCommission to protect the public from substandardnursing practice.d. The Standards of care includes the various steps of thenursing process and the standards of professionalperformance.68. You are taking care of critically ill client and thedoctor in charge calls to order a DNR (do notresuscitate) for the client. Which of the following is theappropriate action when getting DNR order over thephone?a. Have the registered nurse, family spokesperson, nursesupervisor and doctor signb. Have two nurses validate the phone order, bothnurses sign the order and the doctor should sign hisorder within 24 hours.c. Have the registered nurse, family and doctor sign theorderd. Have 1 nurse take the order and sign it and have thedoctor sign it within 24 hours69. To ensure the client safety before starting bloodtransfusion the following are needed before theprocedure can be done EXCEPT:a. take baseline vital signsb. blood should be warmed to room temperature for 30minutes before blood transfusion is administeredc. have two nurses verify client identification, bloodtype, unit number and expiration date of bloodd. get a consent signed for blood transfusion70. Part of standards of care has to do with the use ofrestraints. Which of the following statements is NOTtrue?a. Doctor’s order for restraints should be signed within24 hoursb. Remove and reapply restraints every two hoursc. Check client’s pulse, blood pressure and circulationevery four hoursd. Offer food and toileting every two hoursSituation 15 – During the NUTRITION EDUCATION classdiscussion a 58 year old man, Mr. Bruno shows increasedinterest.71. Mr. Bruno asks what the "normal" allowable saltintake is. Your best response to Mr. Bruno is:a. 1 tsp of salt/day with iodine and sprinkle of MSGb. 5 gms per day or 1 tsp of table salt/dayc. 1 tbsp of salt/day with some patis and toyod. 1 tsp of salt/day but not patis or toyo72. Your instructions to reduce or limit salt intakeinclude all the following EXCEPT:a. eat natural food with little or no salt addedb. limit use of table salt and use condiments insteadc. use herbs and spicesd. limit intake of preserved or processed food73. Teaching strategies and approaches when givingnutrition education is influenced by age, sex and
  • 196immediate concerns of the group. Your presentationfor a group of young mothers would be best if youfocus on:a. diets limited in salt and fatb. harmful effect on drugs and alcohol intakec. commercial preparation of dishesd. cooking demonstration and meal planning74. Cancer cure is dependent ona. use of alternative methods of healingb. watching out for warning signs of cancerc. proficiency in doing breast self-examinationd. early detection and prompt treatment75. The role of the health worker in health education isto:a. report incidence of non-communicable disease tocommunity health centerb. educate as many people about warning signs of non-communicable diseasesc. focus on smoking cessation projectsd. monitor clients with hypertensionSituation 16 – You are assigned to take care of 10patients during the morning shift. The endorsementincludes the IV infusion and medications for theseclients.76. Mr. Felipe, 36 years old is to be given 2700ml ofD5RL to infuse for 18 hours starting at 8am. At whatrate should the IV fluid be flowing hourly?a. 100 ml/hourb. 210 ml/hourc. 150 ml/hourd. 90 ml/hour77. Mr. Atienza is to receive 150mg/hour of D5W IVinfusion for 12 hours for a total of 1800ml. He is alsolosing gastric fluid which must be replaced every twohours. Between 8am to 10am. Mr. Atienza has lost250ml of gastric fluid. How much fluid should hereceive at 11am?a. 350 ml/hourb. 275 ml/hourc. 400 ml/hourd. 200 ml/hour78. You are to apply a transdermal patch ofnitroglycerin to your client. The following importantguidelines to observe EXCEPT:a. Apply to hairlines clean are of the skin not subject tomuch wrinklingb. Patches may be applied to distal part of theextremities like forearmc. Change application and site regularly to preventirritation of the skind. Wear gloves to avoid any medication of your hand79. You will be applying eye drops to Miss Romualdez.After checking all the necessary information andcleaning the affected eyelid and eyelashes youadminister the ophthalmic drops by instilling the eyedrops.a. directly onto the corneab. pressing on the lacrimal ductc. into the outer third of the lower conjunctival sacd. from the inner canthus going towards the side of theeye80. When applying eye ointment, the followingguidelines apply EXCEPT:a. squeeze about 2 cm of ointment and gently close butnot squeeze eyeb. apply ointment from the inner canthus going outwardof the affected eyec. discard the first bead of the eye ointment beforeapplication because the tube likely to expel more thandesired amount of ointmentd. hold the tube above the conjunctival sac do not let tiptouch the conjuctivaSituation 17 – The staff nurse supervisor request all thestaff nurses to “brainstorm” and learn ways to instructdiabetic clients on self-administration of insulin. Shewants to ensure that there are nurses available daily todo health education classess.81. The plan of the nurse supervisor is an example ofa. in service education processb. efficient management of human resourcesc. increasing human resourcesd. primary prevention82. When Mrs. Guevarra, a nurse, delegates aspects ofthe clients care to the nurse-aide who is an unlicensedstaff, Mrs. Guevarra.
  • 197a. makes the assignment to teach the staff memberb. is assigning the responsibility to the aide but not theaccountability for those tasksc. does not have to supervise or evaluate the aided. most know how to perform task delegated83. Connie, the-new nurse, appears tired and sluggishand lacks the enthusiasms she give six weeks ago whenshe started the job. The nurse supervisor should:a. empathize with the nurse and listen to herb. tell her to take the day offc. discuss how she is adjusting to her new jobd. ask about her family life84. Process of formal negotiations of workingconditions between a group of registered nurses andemployer is:a. grievanceb. arbitrationc. collective bargainingd. strike85. You are attending a certification program oncardiopulmonary resuscitation (CPR) offered andrequired by the hospital employing you. This is;a. professional course towards creditsb. in-service educationc. advance trainingd. continuing educationSituation 18 - There are various developments in healtheducation that the nurse should know about.86. The provision of health information in the ruralareas nationwide through television and radioprograms and video conferencing is referred to as:a. Community health programb. Telehealth programc. Wellness programd. Red cross program87. A nearby community provides blood pressurescreening, height and weight measurement smokingcessation classes and aerobics class services. This typeof program is referred to as:a. outreach programb. hospital extension programc. barangay health centerd. wellness center88. Part of teaching client in health promotion isresponsibility for one’s health. When Danica states sheneed to improve her nutritional status this means:a. Goals and interventions to be followed by client arebased on nurses prioritiesb. Goals and intervention developed by nurse and clientshould be approved by the doctorc. Nurse will decide goals and, interventions needed tomeet client goalsd. Client will decide the goals and interventions requiredto meet her goals89. Nurse Beatrice is providing tertiary prevention toMrs. De Villa. An example of tertiary provestion is:a. Marriage counselingb. Self-examination for breast cancerc. Identifying complication of diabetesd. Poison, control90. Mrs. Ostrea has a schedule for Pap Smear. She has astrong family history of cervical cancer. This is anexample of:a. tertiary preventionb. secondary preventionc. health screeningd. primary preventionSituation: 19 - Ronnie has a vehicular accident where hesustained injury to his left ankle. In the EmergencyRoom, you notice how anxious he looks.91. You establish rapport with him and to reduce hisanxiety you initiallya. Take him to the radiology, section for X-ray of affectedextremityb. Identify yourself and state your purpose in being withthe clientc. Talk to the physician for an order of Valiumd. Do inspection and palpation to check extent of hisinjuries92. While doing your assessment, Ronnie asks you "Do Ihave a fracture? I dont want to have a cast.” The mostappropriate nursing response would be:a. "You have to have an X-ray first to know if you have afracture."
  • 198b. "Why do you; sound so scared? It is just a cast and itsnot painful"c. "You seem to be concerned about being in a cast."d. "Based on my assessment, there doesn’t seem to be afracture."
  • 199ANSWER KEY - FOUNDATION OF PROFESSIONALNURSING PRACTICE1. C2. B3. D4. D5. B6. B7. C8. D9. B10. B11. B12. C13. C14. D15. A16. A17. C18. B19. A20. C21. D22. C23. D24. D25. C26. D27. C28. D29. D30. C31. B32. C33. C34. C35. B36. D37. D38. B39. B40. C41. D42. B43. D44. D45. C46. C47. D48. D49. B50. D51. D52. C53. D54. B55. B56. C57. D58. C59. B60. C61. D62. C63. D64. C65. D66. D67. A68. D69. D70. C71. B72. B73. D74. D75. B76. C77. -78. B79. B80. C81. C82. B83. C84. C85. B86. B87. A88. D89. C90. B91. B92. C
  • 200COMMUNITY HEALTH NURSING AND CARE OF THEMOTHER AND CHILDSituation 1 - Nurse Minette is an independent NursePractitioner following-up referred clients in theirrespective homes. Here she handles a case ofPOSTPARTIAL MOTHER AND FAMILY focusing on HOMECARE.1. Nurse Minette needs to schedule a first home visit toOB client Leah. When is a first home-care visit typicallymade?a. Within 4 days after dischargeb. Within 24 hours after dischargec. Within 1 hour after discharged. Within 1 week of discharge2. Leah is developing constipation from being on bedrest. What measures would you suggest she take tohelp prevent this?a. Eat more frequent small meals instead of three largeone dailyb. Walk for at least half an hour daily to stimulateperistalsisc. Drink more milk, increased calcium intake preventsconstipationd. Drink eight full glasses of fluid such as water daily3. If you were Minette, which of the following actions,would alert you that a new mother is entering apostpartial at taking-hold phase?a. She urges the baby to stay awake so that she canbreast-feed him in herb. She tells you she was in a lot of pain all during laborc. She says that she has not selected a name fir the babyas yetd. She sleeps as if exhausted from the effort of labor4. At 6-week postpartum visit what should thispostpartial mothers fundic height be?a. Inverted and palpable at the cervixb. Six fingerbreadths below the umbilicusc. No longer palpable on her abdomend. One centimeter above the symphysis pubis5. This postpartal mother wants to loose the weight shegained in pregnancy, so she is reluctant to increase hercalorin intake for breast-feeding. By how much should alactating mother increase her caloric intake during thefirst 6 months after birth?a. 350 kcal/dayb. 5CO kcal/dayc. 200 kcal/dayd. 1,000 kcal/daySituation 2 - As the CPES is applicable for all professionalnurse, the professional growth and development ofNurses with specialties shall be addressed by a SpecialtyCertification Council.The following questions apply to these special groups ofnurses.6. Which of the following serves as the legal basis andstatute authority for the Board of nursing topromulgate measures to effect the creation of aSpecialty Certification Council and promulgateprofessional development programs for this group ofnurse-professionals?a. R.A. 7610b. R.A. 223c. R.A. 9173d. R.A. 71647. By force of law, therefore, the PRC-Board of Nursingreleased Resolution No. 14 Series of the entitled:"Adoption of a Nursing Specialty Certification Programand Creation of Nursing Specialty Certification Council."This rule-making power is called:a. Quasi-Judicial Powerb. Regulatory Powerc. Quasi/Legislative Powerd. Executive/Promulgation Power8. Under the PRC-Board of Nursing Resolutionpromulgating the adoption of a Nursing Specialty-Certification Program and Council, which two (2) of thefollowing serves as the strongest for its enforcement?(a) Advances made in science aid technology haveprovided the climate for specialization in almost allaspects of human endeavor and(b) As necessary consequence, there has emerged a newconcept known as globalization which seeks to removebarriers in trade, .industry and services imposed by thenational laws of countries all over the world; and(c) Awareness of this development should impel thenursing sector to prepare our people in the servicessector to meet .the above challenges; and
  • 201(d) Current trends of specialization in nursing practicerecognized by; the International Council of Nurses (ICN)of which the Philippines is a member for the benefit ofthe Filipino in terms of deepening and refining nursingpractice and enhancing the quality of nursing care.a. b & c are strong justificationb. a & b are strong justificationc. a & c are strong justificationd. a & d are strong justification9. Which of the following is NOT a correct statement asregards Specialty Certification?a. The Board of Nursing intended to create the NursingSpecialty Certification Program as a means ofperpetuating the creation of an elite force of FilipinoNurse Professionalsb. The Board of Nursing shall oversee the administrationof the NSCP through the various Nursing SpecialtyBoards which will eventually, be createdc. The Board of Nursing at the time exercised theirpowers under R.A. 7164 in order to adopt the creation ofthe Nursing Specialty Certification /council and Programd. The Board of Nursing consulted nursing leaders ofnational nursing associations and other concernednursing groups which later decided to ask a special groupof nurses of .the program for nursing specialtycertification10. The NSCC was created for the purpose ofimplementing the Nursing Specialty policy under thedirect supervision and stewardship of the Board ofNursing. Who shall comprise the NSCC?a. A Chairperson who is the current President of the APOa member from .the Academe, and the last membercoming from the Regulatory Boardb. The Chairperson and members of the RegulatoryBoard ipso facto acts as the CPE Councilc. A Chairperson, chosen from among the RegulatoryBoard Members, a Vice Chairperson appointed by theBON at-large; two other members also chosen at-large;and one representing the consumer groupd. A Chairperson who is the President of the Associationfrom the Academe; a member from the RegulatoryBoard, and the last member coming from the APOSituation 3 - Nurse Anna is a new BSEN graduate and hasjust passed her Licensure Examination for Nurses in thePhilippines. She has likewise been hired as a newCommunity Health Nurse in one of the Rural HealthUnits in their City, which of the following conditions maybe acceptable TRUTHS applied to Community HealthNursing Practice.11. Which of the following is the primary focus ofcommunity health nursing practice?a. Cure of illnessesb. Prevention of illnessc. Rehabilitation back to healthd. Promotion of health12. In community health nursing, which of the followingis our unit of service as nurses?a. The Communityb. The Extended Members of every familyc. The individual members of the Barangayd. The Family13. A very important part of the Community HealthNursing Assessment Process includesa. the application of professional judgment in estimatingimportance of facts to family and communityb. evaluation structures arid qualifications of healthcenter teamc. coordination with other sectors in relation to healthconcernsd. carrying out nursing procedures as per plan of action14. In community health nursing it is important to takeinto account the family health with an equallyimportant need to perform ocular inspection of theareas activities which are powerful elements of:a. evaluationb. assessmentc. implementationd. planning15. The initial step in the PLANNING process in order toengage in any nursing project or parties at thecommunity level involves:a. goal-settingb. monitoringc. evaluation of datad. provision of dataSituation 4 - Please continue responding as aprofessional nurse in these other health situationsthrough the following questions.
  • 20216. Transmission of HIV from an infected individual toanother person occurs:a. Most frequency in nurses with needlesticksb. Only if there is a large viral load in the bloodc. Most commonly as a result of sexual contactd. In all infants born to women with HIV infection17. The medical record of a client reveals a condition inwhich the fetus cannot pass through the maternalpelvis. The nurse interprets this as:a. Contracted pelvisb. Maternal disproportionc. Cervical insufficiencyd. Fetopelvic disproportion18. The nurse would anticipate a cesarean birth for aclient who has which infection present at the onset oflabor?a. Herpes simplex virusb. Human papilloma virusc. Hepatitisd. Toxoplasmosia19. After a vaginal examination, the nurse»edetermines that the clients fetus is in an occiputposterior position. The nurse would anticipate that theclient will have:a. A precipitous birthb. Intense back painc. Frequent leg crampsd. Nausea and vomiting20. The rationales for using a prostaglandin gel for aclient prior to the induction of labor is to:a. Soften and efface the cervixb. Numb cervical pain receptorsc. Prevent cervical lacerationsd. Stimulate uterine contractionsSituation 5 - Nurse Lorena is a Family Planning andInfertility Nurse Specialist and currently attends toFAMILY PANNING CLIENTS AND INFERTILE COUPLES. Thefollowing conditions pertain to meeting the nursing ofthis particular population group.21. Dina, 17 years old, asks you how a tubal ligationprevents pregnancy. Which would be the best answer?a. Prostaglandins released from the cut fallopian tubescan kill spermb. Sperm cannot enter the uterus, because the cervicalentrance is blockedc. Sperm can no longer reach the ova, because thefallopian tubes are blockedd. The ovary no longer releases ova, as there is no wherefor them to go22. The Dators are a couple undergoing testing forinfertility. Infertility is said to exist when:a. a woman has no uterusb. a woman has no childrenc. a couple has been trying to conceive for 1 yeard. a couple has wanted a child for 6 months23. Another client names Lilia is diagnosed as havingendometriosis. This condition interferes with thefertility because:a. endometrial implants can block the fallopian tubesb. the uterine cervix becomes inflamed and swollenc. ovaries stop producing adequate estrogend. pressure on the pituitary leads to decreased FSH levels24. Lilia is scheduled to have a hysterosalpingogram.Which of the following, instructions would you give herregarding this procedure?a. She will not be able to conceive for 3 months after theprocedureb. The sonogram of the uterus will reveal any tumorspresentc. Many women experience mild bleeding as an aftereffectd. She may feel some cramping when the dye is inserted25. Lilias cousin on the other hand, knowing nurseLorenas specialization asks what artificial inseminationby donor entails. Which would be your best answer ifyou were Nurse Lorena?a. Donor sperm are introduced vaginally into the uterusor cervixb. Donor sperm are injected intra-abdominally into eachovaryc. Artificial sperm are injected vaginally to test tubalpatencyd. The husbands sperm is administered intravenouslyweeklySituation 6 - There are other important basic knowledge
  • 203in the performance of our task as Community HealthNurse in relation to IMMUNIZATION these include:26. The correct temperature to store vaccines in arefrigerator is:a. between -4 deg C and +8 deg Cb. between 2 deg C and +8 deg Cc. between -8 deg C and 0 deg Cd. between -8 deg C and +8 deg C27. Which of the following vaccines is not done byintramuscular (IM) injection?a. Measles vaccineb. DPTc. Hepa B vaccinesd. DPT28. This vaccine content is derived from RNArecombinants:a. Measlesb. Tetanus toxoidsc. Hepatitis B vaccinesd. DPT29. This is the vaccine needed before a child reachesone (1) year in order for him/her to qualify as a "fullyimmunized child".a. DPTb. Measlesc. Hepatitis Bd. BCG30. Which of the following dose of tetanus toxoid isgiven to the mother to protect her .infant fromneonatal tetanus and likewise provide 10 yearsprotection for the mother?a. Tetanus toxoid 3b. Tetanus toxoid 2c. Tetanus toxoid 1d. Tetanus toxoid 4Situation 7 - Records contain those, comprehensivedescriptions of patients health conditions and needs andat the same serve as evidences of every nursesaccountability in the, care giving process. Nursingrecords normally differ from institution to, institutionnonetheless they follow similar patterns of .meetingneeds for specifics, types of information. The followingpertalos to documentation/records management.31. This special form used when the patient is admittedto the unit. The nurse completes, the information inthis records particularly his/her .basic personal data,current illness, previous health history, health historyof the family, emotional profile, environmental historyas well as physical assessment together with nursingdiagnosis on admission. What do you call this record?a. Nursing Kardexb. Nursing Health History and Assessment Worksheetc. Medicine and Treatment Recordd. Discharge Summary32. These, are sheets/forms which provide an efficientand time saving way to record information that mustbe obtained repeatedly at regular and/or shortintervals, of .time. This does not replace the progressnotes; instead this record of information on vital signs,intake and output, treatment, postoperative care,postpartum care, and diabetic regimen, etc., this isused whenever specific measurements or observationsare needed to-be documented repeatedly. What isthis?a. Nursing Kardexb. Graphic Flow sheetsc. Discharge Summaryd. Medicine and Treatment Record33. These records show all medi