Maternal and Child Health Nursing
Exam 3
1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The
client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic
dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions.
Which of the following is the most important aspect of nursing intervention at this time?
A. Timing and recording length of contractions.
B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.
2. A client who hallucinates is not in touch with reality. It is important for the nurse to:
A. Isolate the client from other patients.
B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship.
3. The nurse is caring to a child client who has had a tonsillectomy. The child complains
of having dryness of the throat. Which of the following would the nurse give to the
child?
A. Cola with ice
B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old
client. The nurse caring to the client provides instructions that the nasal spray must be
used exactly as directed to prevent the development of:
A. Increased nasal congestion.
B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be
assigned to care for the client must institute appropriate precautions. The nurse should:
A. Place the client in a private room.
B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
D. Don a surgical mask with a face shield when entering the room.
6. Which of the following is the most frequent cause of noncompliance to the medical
treatment of open-angle glaucoma?
A. The frequent nausea and vomiting accompanying use of miotic drug.
B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation due to miotic effects of
pilocarpine.
D. The painful and insidious progression of this type of glaucoma.
7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse
enters in a client’s room and notes that the client’s tube has become disconnected from
the Pleurovac. What would be the initial nursing action?
A. Apply pressure directly over the incision site.
B. Clamp the chest tube near the incision site.
C. Clamp the chest tube closer to the drainage system.
D. Reconnect the chest tube to the Pleurovac.
8. Which of the following complications during a breech birth the nurse needs to be
alarmed?
A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed with severe depression. Which of the
following nursing approach is important in depression?
A. Protect the client against harm to others.
B. Provide the client with motor outlets for aggressive, hostile feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with elimination, nourishment, and sleep.
10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is
suspecting that the baby may have hypothyroidism when mother states that her baby
does not:
A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.
11. The physician calls the nursing unit to leave an order. The senior nurse had
conversation with the other staff. The newly hired nurse answers the phone so that the
senior nurses may continue their conversation. The new nurse does not knowthe
physician or the client to whom the order pertains. The nurse should:
A. Ask the physician to call back after the nurse has read the hospital policy
manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff nurses to take the
telephone order.
12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida
in transition complicated by hypertension. A new pregnant woman in active labor is
admitted in the same unit. The nurse manager assigned the same nurse to the second
client. The nurse feels that the client with hypertension requires one-to-one care. What
would be the initial actionof the nurse?
A. Accept the new assignment and complete an incident report describing a
shortage of nursing staff.
B. Report the incident to the nursing supervisor and request to be floated.
C. Report the nursing assessment of the client in transitional labor to the nurse
manager and discuss misgivings about the new assignment.
D. Accept the new assignment and provide the best care.
13. A newborn infant with Down syndrome is to be discharged today. The nurse is
preparing to give the discharge teaching regarding the proper care at home. The nurse
would anticipate that the mother is probably at the:
A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.
14. The emergency department has shortage of staff. The nurse manager informs the
staff nurse in the critical care unit that she has to float to the emergency department.
What should the staff nurse expect under these conditions?
A. The float staff nurse will be informed of the situation before the shift begins.
B. The staff nurse will be able to negotiate the assignments in the emergency
department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the nurses.
15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The
client is receiving digoxin. Which of the following questions will be asked by the nurse
to the parents of the child in order to assess the client’s risk for digoxin toxicity?
A. “Has he been exposed to any childhood communicable diseases in the past
2-3 weeks?”
B. “Has he been taking diuretics at home?”
C. “Do any of his brothers and sisters have history of cardiac problems?”
D. “Has he been going to school regularly?”
16. The nurse noticed that the signed consent form has an error. The form states,
“Amputation of the right leg” instead of the left leg that is to be amputated. The nurse
has administered already the preoperative medications. What should the nurse do?
A. Call the physician to reschedule the surgery.
B. Call the nearest relative to come in to sign a new form.
C. Cross out the error and initial the form.
D. Have the client sign another form.
17. The nurse in the nursing care unit checks the fluctuation in the water-seal
compartment of a closed chest drainage system. The fluctuation has stopped, the nurse
would:
A. Vigorously strip the tube to dislodge a clot.
B. Raise the apparatus above the chest to move fluid.
C. Increase wall suction above 20 cm H2O pressure.
D. Ask the client to cough and take a deep breath.
18. The pediatric nurse in the neonatal unit was informed that the baby that is brought
to the mother in the hospital room is wrong. The nurse determines that two babies were
placed in the wrong cribs. The most appropriate nursing action would be to:
A. Determine who is responsible for the mistake and terminate his or her
employment.
B. Record the event in an incident/variance report and notify the nursing
supervisor.
C. Reassure both mothers, report to the charge nurse, and do not record.
D. Record detailed notes of the event on the mother’s medical record.
19. Before the administration of digoxin, the nurse completes an assessment to a toddler
client for signs and symptoms of digoxin toxicity. Which of the following is the earliest
and most significant sign of digoxin toxicity?
A. Tinnitus
B. Nausea and vomiting
C. Vision problem
D. Slowing in the heart rate
20. Which of the following treatment modality is appropriate for a client with paranoid
tendency?
A. Activity therapy.
B. Individual therapy.
C. Group therapy.
D. Family therapy.
21. The client with rheumatoid arthritis is for discharge. In preparing the client for
discharge on prednisone therapy, the nurse should advise the client to:
A. Wear sunglasses if exposed to bright light for an extended period of time.
B. Take oral preparations of prednisone before meals.
C. Have periodic complete blood counts while on the medication.
D. Never stop or change the amount of the medication without medical advice.
22. A pregnant client tells the nurse that she is worried about having urinary frequency.
What will be the most appropriate nursing response?
A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. If
you have frequency associated with fever, pain on voiding, or blood in the
urine, call your doctor/nurse-midwife.
B. “Placental progesterone causes irritability of the bladder sphincter. Your
symptoms will go away after the baby comes.”
C. “Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids
to 1L/daily.”
D. “Frequency is due to bladder irritation from concentrate urine and is normal
in pregnancy. Increase your daily fluid intake to 3L.”
23. Which of the following will help the nurse determine that the expression of hostility
is useful?
A. Expression of anger dissipates the energy.
B. Energy from anger is used to accomplish what needs to be done.
C. Expression intimidates others.
D. Degree of hostility is less than the provocation.
24. The nurse is providing an orientation regarding case management to the nursing
students. Which characteristics should the nurse include in the discussion in
understanding case management?
A. Main objective is a written plan that combines discipline-specific processes
used to measure outcomes of care.
B. Main purpose is to identify expected client, family and staff performance
against the timeline for clients with the same diagnosis.
C. Main focus is comprehensive coordination of client care, avoid unnecessary
duplication of services, improve resource utilization and decrease cost.
D. Primary goal is to understand why predicted outcomes have not been met
and the correction of identified problems.
25. The physician orders a dose of IV phenytoin to a child client. In preparing in the
administration of the drug, which nursing action is not correct?
A. Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.
B. Check the phenytoin solution to be sure it is clear or light yellow in color,
never cloudy.
C. Plan to give phenytoin over 30-60 minutes, using an in-line filter.
D. Flush the IV tubing with normal saline before starting phenytoin.
26. The pregnant woman visits the clinic for check –up. Which assessment findings will
help the nurse determine that the client is in 8-week gestation?
A. Leopold maneuvers.
B. Fundal height.
C. Positive radioimmunoassay test (RIA test).
D. Auscultation of fetal heart tones.
27. Which of the following nursing intervention is essential for the client who had
pneumonectomy?
A. Medicate for pain only when needed.
B. Connect the chest tube to water-seal drainage.
C. Notify the physician if the chest drainage exceeds 100mL/hr.
D. Encourage deep breathing and coughing.
28. The nurse is providing a health teaching to a group of parents regarding Chlamydia
trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis is not only
an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause:
A. Discoloration of baby and adult teeth.
B. Pneumonia in the newborn.
C. Snuffles and rhagades in the newborn.
D. Central hearing defects in infancy.
29. The nurse is assigned to care to a 17-year-old male client with a history of substance
abuse. The client asks the nurse, “Have you ever tried or used drugs?” The most correct
response of the nurse would be:
A. “Yes, once I tried grass.”
B. “No, I don’t think so.”
C. “Why do you want to know that?”
D. “How will my answer help you?”
30. Which of the following describes a health care team with the principles of
participative leadership?
A. Each member of the team can independently make decisions regarding the
client’s care without necessarily consulting the other members.
B. The physician makes most of the decisions regarding the client’s care.
C. The team uses the expertise of its members to influence the decisions
regarding the client’s care.
D. Nurses decide nursing care; physicians decide medical and other treatment
for the client.
31. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn
baby. Which hormone, normally secreted during the postpartum period, influences both
the milk ejection reflex and uterine involution?
A. Oxytocin.
B. Estrogen.
C. Progesterone.
D. Relaxin.
32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse
is responsible for the overall planning, giving and evaluating care during the entire shift.
After the shift, same responsibility will be endorsed to the next nurse in charge. This
describes nursing care delivered via the:
A. Primary nursing method.
B. Case method.
C. Functional method.
D. Team method.
33. The ambulance team calls the emergency department that they are going to bring a
client who sustained burns in a house fire. While waiting for the ambulance, the nurse
will anticipate emergency care to include assessment for:
A. Gas exchange impairment.
B. Hypoglycemia.
C. Hyperthermia.
D. Fluid volume excess.
34. Most couples are using “natural” family planning methods. Most accidental
pregnancies in couples preferred to use this method have been related to unprotected
intercourse before ovulation. Which of the following factor explains why pregnancy
may be achieved by unprotected intercourse during the preovulatory period?
A. Ovum viability.
B. Tubal motility.
C. Spermatozoal viability.
D. Secretory endometrium.
35. An older adult client wakes up at 2 o’clock in the morning and comes to the nurse’s
station saying, “I am having difficulty in sleeping.” What is the best nursing response
to the client?
A. “I’ll give you a sleeping pill to help you get more sleep now.”
B. “Perhaps you’d like to sit here at the nurse’s station for a while.”
C. “Would you like me to show you where the bathroom is?”
D. “What woke you up?”
36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active
labor, her membranes ruptured spontaneously 2 hours ago. While auscultating for the
point of maximum intensity of fetal heart tones before applying an external fetal
monitor, the nurse counts 100 beats per minute. The immediate nursing action is to:
A. Start oxygen by mask to reduce fetal distress.
B. Examine the woman for signs of a prolapsed cord.
C. Turn the woman on her left side to increase placental perfusion.
D. Take the woman’s radial pulse while still auscultating the FHR.
37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter
medications like:
A. Antihistamines.
B. NSAIDs.
C. Antacids.
D. Salicylates.
38. A male client is brought to the emergency department due to motor vehicle accident.
While monitoring the client, the nurse suspects increasing intracranial pressure when:
A. Client is oriented when aroused from sleep, and goes back to sleep
immediately.
B. Blood pressure is decreased from 160/90 to 110/70.
C. Client refuses dinner because of anorexia.
D. Pulse is increased from 88-96 with occasional skipped beat.
39. The nurse is conducting a lecture to a class of nursing students about advance
directives to preoperative clients. Which of the following statement by the nurse js
correct?
A. “The spouse, but not the rest of the family, may override the advance
directive.”
B. “An advance directive is required for a “do not resuscitate” order.”
C. “A durable power of attorney, a form of advance directive, may only be held
by a blood relative.”
D. “The advance directive may be enforced even in the face of opposition by
the spouse.”
40. A client diagnosed with schizophrenia is shouting and banging on the door leading
to the outside, saying, “I need to go to an appointment.” What is the appropriate nursing
intervention?
A. Tell the client that he cannot bang on the door.
B. Ignore this behavior.
C. Escort the client going back into the room.
D. Ask the client to move away from the door.
41. Which of the following action is an accurate tracheal suctioning technique?
A. 25 seconds of continuous suction during catheter insertion.
B. 20 seconds of continuous suction during catheter insertion.
C. 10 seconds of intermittent suction during catheter withdrawal.
D. 15 seconds of intermittent suction during catheter withdrawal.
42. The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that the
most important thing that must be ready at the bedside is:
A. Suture set.
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.
43. A mother is in the third stage of labor. Which of the following signs will help the
nurse determine the signs of placental separation?
A. The uterus becomes globular.
B. The umbilical cord is shortened.
C. The fundus appears at the introitus.
D. Mucoid discharge is increased.
44. After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse
report to the physician?
A. 3+ peripheral pulses.
B. Change in level of consciousness and headache.
C. Occasional dysrhythmias.
D. Heart rate of 100/bpm.
45. A client who undergone left nephrectomy has a large flank incision. Which of the
following nursing action will facilitate deep breathing and coughing?
A.
B.
C.
D.
Push fluid administration to loosen respiratory secretions.
Have the client lie on the unaffected side.
Maintain the client in high Fowler’s position.
Coordinate breathing and coughing exercise with administration of
analgesics.
46. The community nurse is teaching the group of mothers about the cervical mucus
method of natural family planning. Which characteristics are typical of the cervical
mucus during the “fertile” period of the menstrual cycle?
A. Absence of ferning.
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy.
D. Yellow and sticky.
47. A client with ruptured appendix had surgery an hour ago and is transferred to the
nursing care unit. The nurse placed the client in a semi-Fowler’s position primarily to:
A. Facilitate movement and reduce complications from immobility.
B. Fully aerate the lungs.
C. Splint the wound.
D. Promote drainage and prevent subdiaphragmatic abscesses.
48. Which of the following will best describe a management function?
A. Writing a letter to the editor of a nursing journal.
B. Negotiating labor contracts.
C. Directing and evaluating nursing staff members.
D. Explaining medication side effects to a client.
49. The parents of an infant client ask the nurse to teach them how to administer
Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:
A.
B.
C.
D.
In the middle of the lower conjunctival sac of the infant’s eye.
Directly onto the infant’s sclera.
In the outer canthus of the infant’s eye.
In the inner canthus of the infant’s eye.
50. The nurse is assessing on the client who is admitted due to vehicle accident. Which
of the following findings will help the nurse that there is internal bleeding?
A. Frank blood on the clothing.
B. Thirst and restlessness.
C. Abdominal pain.
D. Confusion and altered of consciousness.
51. The nurse is completing an assessment to a newborn baby boy. The nurse observes
that the skin of the newborn is dry and flaking and there are several areas of an apparent
macular rash. The nurse charts this as:
A. Icterus neonatorum
B. Multiple hemangiomas
C. Erythema toxicum
D. Milia
52. The client is brought to the emergency department because of serious vehicle
accident. After an hour, the client has been declared brain dead. The nurse who has been
with the client must now talk to the family about organ donation. Which of the following
consideration is necessary?
A. Include as many family members as possible.
B. Take the family to the chapel.
C. Discuss life support systems.
D. Clarify the family’s understanding of brain death.
53. The nurse is teaching exercises that are good for pregnant women increasing tone
and fitness and decreasing lower backache. Which of the following should the nurse
exclude in the exercise program?
A. Stand with legs apart and touch hands to floor three times per day.
B. Ten minutes of walking per day with an emphasis on good posture.
C. Ten minutes of swimming or leg kicking in pool per day.
D. Pelvic rock exercise and squats three times a day.
54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The
nurse taking care of the client knows that the primary treatment goal is to:
A. Provide distraction.
B. Support but limit the behavior.
C. Prohibit the behavior.
D. Point out the behavior.
55. After ileostomy, the nurse expects that the drainage appliance will be applied to the
stoma:
A. When the client is able to begin self-care procedures.
B. 24 hours later, when the swelling subsided.
C. In the operating room after the ileostomy procedure.
D. After the ileostomy begins to function.
56. A female client who has a 28-day menstrual cycle asks the community health nurse
when she get pregnant during her cycle. What will be the best nursing response?
A. It is impossible to determine the fertile period reliably. So it is best to assume
that a woman is always fertile.
B. In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for
about 24 hours and the sperm live for about 72 hours. The fertile period
would be approximately between day 11 and day 15.
C. In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for
about 72 hours and the sperm live for about 24 hours. The fertile period
would be approximately between day 13 and 17.
D. In a 28-day cycle, ovulation occurs 8 days before the next period or at about
day 20. The fertile period is between day 20 and the beginning of the next
period.
57. Which of the following statement describes the role of a nurse as a client advocate?
A nurse may override clients’ wishes for their own good.
A nurse has the moral obligation to prevent harm and do well for clients.
A nurse helps clients gain greater independence and self-determination.
A nurse measures the risk and benefits of various health situations while
factoring in cost.
58. A community health nurse is providing a health teaching to a woman infected with
herpes simplex 2. Which of the following health teaching must the nurse include to
reduce the chances of transmission of herpes simplex 2?
A.
B.
C.
D.
A. “Abstain from intercourse until lesions heal.”
B. “Therapy is curative.”
C. “Penicillin is the drug of choice for treatment.”
D. “The organism is associated with later development of hydatidiform mole.
59. The nurse in the psychiatric ward informed the male client that he will be attending
the 9:00 AM group therapy sessions. The client tells the nurse that he must wash his
hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which concept
does the nursing staff need to keep in mind in planning nursing intervention for this
client?
A. Depression underlines ritualistic behavior.
B. Fear and tensions are often expressed in disguised form through symbolic
processes.
C. Ritualistic behavior makes others uncomfortable.
D. Unmet needs are discharged through ritualistic behavior.
60. The nurse assesses the health condition of the female client. The client tells the
nurse that she discovered a lump in the breast last year and hesitated to seek medical
advice. The nurse understands that, women who tend to delay seeking medical advice
after discovering the disease are displaying what common defense mechanism?
A. Intellectualization.
B. Suppression.
C. Repression.
D. Denial.
61. Which of the following situations cannot be delegated by the registered nurse to the
nursing assistant?
A. A postoperative client who is stable needs to ambulate.
B. Client in soft restraint who is very agitated and crying.
C. A confused elderly woman who needs assistance with eating.
D. Routine temperature check that must be done for a client at end of shift.
62. In the admission care unit, which of the following client would the nurse give
immediate attention?
A. A client who is 3 days postoperative with left calf pain.
B. A client who is postoperative hip pinning who is complaining of pain.
C. New admitted client with chest pain.
D. A client with diabetes who has a glucoscan reading of 180.
63. A couple seeks medical advice in the community health care unit. A couple has been
unable to conceive; the man is being evaluated for possible problems. The physician
ordered semen analysis. Which of the following instructions is correct regarding
collection of a sperm specimen?
A. Collect a specimen at the clinic, place in iced container, and give to
laboratory personnel immediately.
B. Collect specimen after 48-72 hours of abstinence and bring to clinic within
2 hours.
C. Collect specimen in the morning after 24 hours of abstinence and bring to
clinic immediately.
D. Collect specimen at night, refrigerate, and bring to clinic the next morning.
64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation
with sign of preterm labor. The nurse expects that the drug will:
A. Treat infection.
B. Suppress labor contraction.
C. Stimulate the production of surfactant.
D. Reduce the risk of hypertension.
65. A tracheostomy cuff is to be deflated, which of the following nursing intervention
should be implemented before starting the procedures?
A. Suction the trachea and mouth.
B. Have the obdurator available.
C. Encourage deep breathing and coughing.
D. Do a pulse oximetry reading.
66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This
means that:
A. Gloves are worn when handling the client’s tissue, excretions, and linen.
B. Both client and attending nurse must wear masks at all times.
C. Nurse and visitors must wear masks until chemotherapy is begun. Client is
instructed in cough and tissue techniques.
D. Full isolation; that is, caps and gowns are required during the period of
contagion.
67. A client with lung cancer is admitted in the nursing care unit. The husband wants to
know the condition of his wife. How should the nurse respond to the husband?
A. Find out what information he already has.
B. Suggest that he discuss it with his wife.
C. Refer him to the doctor.
D. Refer him to the nurse in charge.
68. A hospitalized client cannot find his handkerchief and accuses other cient in the
room and the nurse of stealing them. Which is the most therapeutic approach to this
client?
A. Divert the client’s attention.
B. Listen without reinforcing the client’s belief.
C. Inject humor to defuse the intensity.
D. Logically point out that the client is jumping to conclusions.
69. After a cystectomy and formation of an ileal conduit, the nurse provides instruction
regarding prevention of leakage of the pouch and backflow of the urine. The nurse is
correct to include in the instruction to empty the urine pouch:
A. Every 3-4 hours.
B. Every hour.
C. Twice a day.
D. Once before bedtime.
70. Which telephone call from a student’s mother should the school nurse take care of
at once?
A. A telephone call notifying the school nurse that the child’ pediatrician has
informed the mother that the child will need cardiac repair surgery within
the next few weeks.
B. A telephone call notifying the school nurse that the child’s pediatrician has
informed the mother that the child has head lice.
C. A telephone call notifying the school nurse that a child has a temperature of
102ºF and a rash covering the trunk and upper extremities of the body.
D. A telephone call notifying the school nurse that a child underwent an
emergency appendectomy during the previous night.
71. Which of the following signs and symptoms that require immediate attention and
may indicate most serious complications during pregnancy?
A. Severe abdominal pain or fluid discharge from the vagina.
B. Excessive saliva, “bumps around the areolae, and increased vaginal mucus.
C. Fatigue, nausea, and urinary frequency at any time during pregnancy.
D. Ankle edema, enlarging varicosities, and heartburn.
72. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn
becomes slightly cyanotic. What is the initial nursing action?
A. Elevate his head to promote gravity drainage of secretions.
B. Wrap him in another blanket, to reduce heat loss.
C. Stimulate him to cry,, to increase oxygenation.
D. Aspirate his mouth and nose with bulb syringe.
73. The nurse is formulating a plan of care to a client with a somatoform disorder. The
nurse needs to have knowledge of which psychodynamic principle?
A. The symptoms of a somatoform disorder are an attempt to adjust to painful
life situations or to cope with conflicting sexual, aggressive, or dependent
feelings.
B. The major fundamental mechanism is regression.
C. The client’s symptoms are imaginary and the suffering is faked.
D. An extensive, prolonged study of the symptoms will be reassuring to the
client, who seeks sympathy, attention and love.
74. An infant is brought to the health care clinic for three immunizations at the same
time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B
immunizations should:
A. Be drawn in the same syringe and given in one injection.
B. Be mixed and inject in the same sites.
C. Not be mixed and the nurse must give three injections in three sites.
D. Be mixed and the nurse must give the injection in three sites.
75. A female client with cancer has radium implants. The nurse wants to maintain the
implants in the correct position. The nurse should position the client:
A. Flat in bed.
B. On the side only.
C. With the foot of the bed elevated.
D. With the head elevated 45-degrees (semi-Fowler’s).
76. The nurse wants to know if the mother of a toddler understands the instructions
regarding the administration of syrup of ipecac. Which of the following statement will
help the nurse to know that the mother needs additional teaching?
A. “I’ll give the medicine if my child gets into some toilet bowl cleaner.”
B. “I’ll give the medicine if my child gets into some aspirin.”
C. “I’ll give the medicine if my child gets into some plant bulbs.”
D. “I’ll give the medicine if my child gets into some vitamin pills.”
77. To assess if the cranial nerve VII of the client was damaged, which changes would
not be expected?
A. Drooling and drooping of the mouth.
B. Inability to open eyelids on operative side.
C. Sagging of the face on the operative side.
D. Inability to close eyelid on operative side.
78. The community health nurse makes a home visit to a family. During the visit, the
nurse observes that the mother is beating her child. What is the priority nursing
intervention in this situation?
Assess the child’s injuries.
Report the incident to protective agencies.
Refer the family to appropriate support group.
Assist the family to identify stressors and use of other coping mechanisms
to prevent further incidents.
79. The nurse in the neonatal care unit is supervising the actions of a certified nursing
assistant in giving care to the newborns. The nursing assistant mistakenly gives a
formula feeding to a newborn that is on water feeding only. The nurse is responsible for
the mistake of the nursing assistant:
A.
B.
C.
D.
A. Always, as a representative of the institution.
B. Always, because nurses who supervise less-trained individuals are
responsible for their mistakes.
C. If the nurse failed to determine whether the nursing assistant was competent
to take care of the client.
D. Only if the nurse agreed that the newborn could be fed formula.
80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day
is encouraged to the client. the primary reason for this is to:
A. Reduce the size of existing stones.
B. Prevent crystalline irritation to the ureter.
C. Reduce the size of existing stones
D. Increase the hydrostatic pressure in the urinary tract.
81. The nurse is counseling a couple in their mid 30’s who have been unable to conceive
for about 6 months. They are concerned that one or both of them may be infertile. What
is the best advice the nurse could give to the couple?
A. “it is no unusual to take 6-12 months to get pregnant, especially when the
partners are in their mid-30s. Eat well, exercise, and avoid stress.”
B. “Start planning adoption. Many couples get pregnant when they are trying
to adopt.”
C. “Consult a fertility specialist and start testing before you get any older.”
D. “Have sex as often as you can, especially around the time of ovulation, to
increase your chances of pregnancy.”
82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for
Creatinine clearance is to be done. The client tells the nurse, “I can’t remember what
this test is for.” The best response by the nurse is:
A. “It provides a way to see if you are passing any protein in your urine.”
B. “It tells how well the kidneys filter wastes from the blood.”
C. “It tells if your renal insufficiency has affected your heart.”
D. “The test measures the number of particles the kidney filters.”
83. The nurse observes the female client in the psychiatric ward that she is having a
hard time sleeping at night. The nurse asks the client about it and the client says, “I
can’t sleep at night because of fear of dying.” What is the best initial nursing response?
A.
B.
C.
D.
“It must be frightening for you to feel that way. Tell me more about it.”
“Don’t worry, you won’t die. You are just here for some test.”
“Why are you afraid of dying?”
“Try to sleep. You need the rest before tomorrow’s test.”
84. In the hospital lobby, the registered nurse overhears a two staff members discussing
about the health condition of her client. What would be the appropriate action for the
registered nurse to take?
A. Join in the conversation, giving her input about the case.
B. Ignore them, because they have the right to discuss anything they want to.
C. Tell them it is not appropriate to discuss such things.
D. Report this incident to the nursing supervisor.
85. The client has had a right-sided cerebrovascular accident. In transferring the client
from the wheelchair to bed, in what position should a client be placed to facilitate safe
transfer?
A. Weakened (L) side of the cient next to bed.
B. Weakened (R) side of the client next to bed.
C. Weakened (L) side of the client away from bed.
D. Weakened (R) side of the cient away from bed.
86. The child client has undergone hip surgery and is in a spica cast. Which of the
following toy should be avoided to be in the child’s bed?
A. A toy gun.
B. A stuffed animal.
C. A ball.
D. Legos.
87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM)
must be given to a client after birth fo the fetus. The nurse is correct to explain that
oxytocin:
A. Minimizes discomfort from “afterpains.”
B. Suppresses lactation.
C. Promotes lactation.
D. Maintains uterine tone.
88. The nurse in the nursing care unit is aware that one of the medical staff displays
unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This
behavior has been reported to the nurse manager several times, but no changes
observed. The nurse should:
A. Continue to report observations of unusual behavior until the problem is
resolved.
B. Consider that the obligation to protect the patient from harm has been met
by the prior reports and do nothing further.
C. Discuss the situation with friends who are also nurses to get ideas .
D. Approach the partner of this medical staff member with these concerns.
89. The physician ordered tetracycline PO qid to a child client who weights 20kg. The
recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single
dose that can be safely administered to this child?
A. 1 g
B. 500 mg
C. 250 mg
D. 125 mg
90. The nurse is completing an obstetric history of a woman in labor. Which event in
the obstetric history will help the nurse suspects dysfunctional labor in the current
pregnancy?
A. Total time of ruptured membranes was 24 hours with the second birth.
B. First labor lasting 24 hours.
C. Uterine fibroid noted at time of cesarean delivery.
D. Second birth by cesarean for face presentation.
91. The nurse is planning to talk to the client with an antisocial personality disorder.
What would be the most therapeutic approach?
A. Provide external controls.
B. Reinforce the client’s self-concept.
C. Give the client opportunities to test reality.
D. Gratify the client’s inner needs.
92. The nurse is teaching a group of women about fertility awareness, the nurse should
emphasize that basal body temperature:
A.
B.
C.
D.
Can be done with a mercury thermometer but no a digital one.
The average temperature taken each morning.
Should be recorded each morning before any activity.
Has a lower degree of accuracy in predicting ovulation than the cervical
mucus test.
93. The nursing applicant has given the chance to ask questions during a job interview
at a local hospital. What should be the most important question to ask that can increase
chances of securing a job offer?
A. Begin with questions about client care assignments, advancement
opportunities, and continuing education.
B. Decline to ask questions, because that is the responsibility of the interviewer.
C. Ask as many questions about the facility as possible.
D. Clarify information regarding salary, benefits, and working hours first,
because this will help in deciding whether or not to take the job.
94. The nurse advised the pregnant woman that smoking and alcohol should be avoided
during pregnancy. The nurse takes into account that the developing fetus is most
vulnerable to environment teratogens that cause malformation during:
A. The entire pregnancy.
B. The third trimester.
C. The first trimester.
D. The second trimester.
95. A male client tells the nurse that there is a big bug in his bed. The most therapeutic
nursing response would be:
A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed, but you seem afraid.”
D. “You must be seeing things.”
96. A pregnant client in late pregnancy is complaining of groin pain that seems worse
on the right side. Which of the following is the most likely cause of it?
A. Beginning of labor.
B. Bladder infection.
C. Constipation.
D. Tension on the round ligament.
97. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct
in imparting the idea that the Good Samaritan law protects the nurse from a suit for
malpractice when:
A. The nurse stops to render emergency aid and leaves before the ambulance
arrives.
B. The nurse acts in an emergency at his or her place of employment.
C. The nurse refuses to stop for an emergency outside of the scope of
employment.
D. The nurse is grossly negligent at the scene of an emergency.
98. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan
of care for this client, which nursing care is least likely to be done?
A.
B.
C.
D.
Deep-tendon reflexes once per shift.
Vital signs and FHR and rhythm q4h while awake.
Absolute bed rest.
Daily weight.
99. While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on
assessing the condition of the client. The nurse notes that the newborn’s respiration is
72 breaths per minute. What would be the initial nursing action?
A. Burp the newborn.
B. Stop the feeding.
C. Continue the feeding.
D. Notify the physician.
100. A client who undergone appendectomy 3 days ago is scheduled for discharge
today. The nurse notes that the client is restless, picking at bedclothes and saying, “I am
late on my appointment,” and calling the nurse by the wrong name. The nurse suspects:
A.
B.
C.
D.
Panic reaction.
Medication overdose.
Toxic reaction to an antibiotic.
Delirium tremens.
Answers and Rationales
1. A. The oxytocic effect of Pitocin increases the intensity and durations of
contractions; prolonged contractions will jeopardize the safetyof the fetus
and necessitate discontinuing the drug.
2. B. It is of paramount importance to prevent the client from hurting himself
or herself or others.
3. B. After tonsillectomy, clear, cool liquids should be given. Citrus,
carbonated, and hot or cold liquids should be avoided because they may
irritate the throat. Red liquids should be avoided because they give the
appearance of blood if the child vomits. Milk and milk products including
pudding are avoided because they coat the throat, cause the child to clear the
throat, and increase the risk of bleeding.
4. A. Phenylephrine, with frequent and continued use, can cause rebound
congestion of mucous membranes.
5. B. The N 95 respirator is a high-particulate filtration mask that meets the
CDC performance criteria for a tuberculosis respirator.
6. C. The most frequent cause of noncompliance to the treatment of chronic, or
open-angle glaucoma is the miotic effects of pilocarpine. Pupillary
constriction impedes normal accommodation, making night driving difficult
and hazardous, reducing the client’s ability to read for extended periods and
making participation in games with fast-moving objects impossible.
7. B. This stops the sucking of air through the tube and prevents the entry of
contaminants. In addition, clamping near the chest wall provides for some
stability and may prevent the clamp from pulling on the chest tube.
8. D. Because umbilical cord’s insertion site is born before the fetal head, the
cord may be compressed by the after-coming head in a breech birth.
9. B. It is important to externalize the anger away from self.
10. D. Development normally proceeds cephalocaudally; so the first major
developmental milestone that the infant achieves is the ability to hold the
head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s
muscle tone would be poor and the infant would not be able to achieve this
milestone.
11. D. Get a senior nurse who know s the policies, the client, and the doctor.
Generally speaking, a nurse should not accept telephone orders. However, if
it is necessary to take one, follow the hospital’s policy regarding telephone
orders. Failure to followhospital policy could be considered negligence. In
this case, the nurse was new and did not know the hospital’s policy
concerning telephone orders. The nurse was also unfamiliar with the doctor
and the client. Therefore the nurse should not take the order unless a) no one
else is available and b) it is an emergency situation.
12. C. The nurse is obligated to inform the nurse manager about changes in the
condition of the client, which may change the decision made by the nurse
manager.
13. A. Perinatal risk factors for the development of Down syndrome include
advanced maternal age, especially with the first pregnancy.
14. B. Assignments should be based on scope of practice and expertise.
15. B. The child who is concurrently taking digoxin and diuretics is at increased
risk for digoxin toxicity due to the loss of potassium. The child and parents
should be taught what foods are high in potassium, and the child should be
encouraged to eat a high-potassium diet. In addition, the child’s serum
potassium level should be carefully monitored.
16. A. The responsible for an accurate informed consent is the physician. An
exception to this answer would be a life-threatening emergency, but there
are no data to support another response.
17. D. Asking the client to cough and take a deep breath will help determine if
the chest tube is kinked or if the lungs has reexpanded.
18. B. Every event that exposes a client to harm should be recorded in an incident
report, as well as reported to the appropriate supervisors in order to resolve
the current problems and permit the institution to prevent the problem from
happening again.
19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler,
any heart rate that falls below the norm of about 100-120 bpm would indicate
Bradycardia and would necessitate holding the medication and notifying the
physician.
20. B. This option is least threatening.
21. D. In preparing the client for discharge that is receiving prednisone, the nurse
should caution the client to (a) take oral preparations after meals; (b)
remember that routine checks of vital signs, weight, and lab studies are
critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF
MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication
in a light-resistant container.
22. A. Progesterone also reduces smooth muscle motility in the urinary tract and
predisposes the pregnant woman to urinary tract infections. Women should
contact their doctors if they exhibit signs of infection. Kegel exercise will
help strengthen the perineal muscles; limiting fluids at bedtime reduces the
possibility of being awakened by the necessity of voiding.
23. B. This is the proper use of anger.
24. C. There are several models of case management, but the commonality is
comprehensive coordination of care to better predict needs of high-risk
clients, decrease exacerbations and continually monitor progress overtime.
25. A. Phenytoin should be infused or injected into larger veins to avoid the
discoloration know as purple glove syndrome; infusing into a smaller vein is
not appropriate.
26. C. Serum radioimmunoassay (RIA) is accurate within 7days of conception.
This test is specific for HCG, and accuracy is not compromised by confusion
with LH.
27. D. Surgery and anesthesia can increase mucus production. Deep breathing
and coughing are essential to prevent atelectasis and pneumonia in the
client’s only remaining lung.
28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough,
eosinophilia) and conjunctivitis from Chlamydia.
29. D. The client may perceive this as avoidance, but it is more important to
redirect back to the client, especially in light of the manipulative behavior of
drug abusers and adolescents.
30. C. It describes a democratic process in which all members have input in the
client’s care.
31. A. Contraction of the milk ducts and let-down reflex occur under the
stimulation of oxytocin released by the posterior pituitary gland.
32. B. In case management, the nurse assumes total responsibility for meeting
the needs of the client during the entire time on duty.
33. A. Smoke inhalation affects gas exchange.
34. C. Sperm deposited during intercourse may remain viable for about 3 days.
If ovulation occurs during this period, conception may result.
35. B. This option shows acceptance (key concept) of this age-typical sleep
pattern (that of waking in the early morning).
36. D. Taking the mother’s pulse while listening to the FHR will differentiate
between the maternal and fetal heart rates and rule out fetal Bradycardia.
37. A. Antihistamines cause pupil dilation and should be avoided with glaucoma.
38. A. This suggests that the level of consciousness is decreasing.
39. D. An advance directive is a form of informed consent, and only a competent
adult or the holder of a durable power of attorney has the right to consent or
refuse treatment. If the spouse does not hold the power of attorney, the
decisions of the holder, even if opposed by the spouse, are enforced.
40. C. Gentle but firm guidance and nonverbal direction is needed to intervene
when a client with schizophrenic symptoms is being disruptive.
41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter is
being withdrawn.
42. D. The priority for this client is being able to establish an airway.
43. A. Signs of placental separation include a change in the shape of the uterus
from ovoid to globular.
44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic
enzyme that lyses thrombi and emboli. Bleeding is an adverse effect.
Monitor clotting times and signs of any gastrointestinal or internal bleeding.
45. D. Because flank incision in nephrectomy is directly below the diaphragm,
deep breathing is painful. Additionally, there is a greater incisional pull each
time the person moves than there is with abdominal surgery. Incisional pain
following nephrectomy generally requires analgesics administration every
3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and
deep-breathing exercises should be planned to maximize the analgesic
effects.
46. B. Under high estrogen levels, during the period surrounding ovulation, the
cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating
sperm passage.
47. D. After surgery for a ruptured appendix, the client should be placed in a
semi-Fowler’s position to promote drainage and to prevent possible
complications.
48. C. Directing and evaluation of staff is a major responsibility of a nursing
manager.
49. A. The recommended procedure for administering eyedrops to any client
calls for the drops to be placed in the middle of the lower conjunctival sac.
50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal
bleeding is difficult to recognized and evaluate because it is not apparent.
51. C. Erythema toxicum is the normal, nonpathological macular newborn rash.
52. D. The family needs to understand what brain death is before talking about
organ donation. They need time to accept the death of their family member.
An environment conducive to discussing an emotional issue is needed.
53. A. Bending from the waist in pregnancy tends to make backache worse.
54. B. Support and limit setting decrease anxiety and provide external control.
55. C. The stoma drainage bag is applied in the operating room. Drainage from
the ileostomy contains secretions that are rich in digestive enzymes and
highly irritating to the skin. Protection of the skin from the effects of these
enzymes is begun at once. Skin exposed to these enzymes even for a short
time becomes reddened, painful and excoriated.
56. B. It is the most accurate statement of physiological facts for a 28-day
menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span
of 72 hours. Fertilization could occur from sperm deposited before
ovulation.
57. C. An advocate role encourage freedom of choice, includes speaking out for
the client, and supports the client’s best interests.
58. A. Abstinence will eliminate any unnecessary pain during intercourse and
will reduce the possibility of transmitting infection to one’s sexual partner.
59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic
behavioral defense of hand washing decreases anxiety by avoiding group
therapy.
60. D. Denial is a very strong defense mechanism used to allay the emotional
effects of discovering a potential threat. Although denial has been found to
be an effective mechanism for survival in some instances, such as during
natural disasters, it may in greater pathology in a woman with potential
breast carcinoma.
61. B. The registered nurse cannot delegate the responsibility for assessment and
evaluation of clients. The status of the client in restraint requires further
assessment to determine if there are additional causes for the behavior.
62. C. The client with chest pain may be having a myocardial infarction, and
immediate assessment and intervention is a priority.
63. B. Is correct because semen analysis requires that a freshly masturbated
specimen be obtained after a rest (abstinence) period of 48-72 hours.
64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce
surfactant.
65. A. Secretions may have pooled above the tracheostomy cuff. If these are not
suctioned before deflation, the secretions may be aspirated.
66. C. Proper handling of sputum is essential to allay droplet transference of
bacilli in the air. Clients need to be taught to cover their nose and mouth with
tissues when sneezing or coughing. Chemotherapy generally renders the
client noninfectious within days to a few weeks, usually before cultures for
tubercle bacilli are negative. Until chemical isolation is established, many
institutions require the client to wear a mask when visitors are in the room
or when the nurse is in attendance. Client should be in a well-ventilated
room, without air recirculation, to prevent air contamination.
67. A. It is best to establish baseline information first.
68. B. Listening is probably the most effective response of the four choices.
69. A. Urine flow is continuous. The pouch has an outlet valve for easy drainage
every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if
the adhesive is loose).
70. C. A high fever accompanied by a body rash could indicate that the child has
a communicable disease and would have exposed other students to the
infection. The school nurse would want to investigate this telephone call
immediately so that plans could be instituted to control the spread of such
infection.
71. A. Severe abdominal pain may indicate complications of pregnancy such as
abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the
vagina may indicate premature rupture of the membrane.
72. D. Gentle aspiration of mucus helps maintain a patent airway, required for
effective gas exchange.
73. A. Somatoform disorders provide a way of coping with conflicts.
74. C. Immunization should never be mixed together in a syringe, thus
necessitating three separate injections in three sites. Note: some
manufacturers make a premixed combination of immunization that is safe
and effective.
75. A. Clients with radioactive implants should be positioned flat in bed to
prevent dislodgement of the vaginal packing. The client may roll to the side
for meals but the upper body should not be raised more than 20 degrees.
76. A. Syrup of ipecac is not administered when the ingested substances is
corrosive in nature. Toilet bowl cleaners, as a collective whole, are highly
corrosive substances. If the ingested substance “burned” the esophagus
going down, it will “burn” the esophagus coming back up when the child
begins to vomit after administration of syrup of ipecac.
77. B. Inability to open eyelids on operative side is seen with cranial nerve III
damage.
78. A. Assessment of physical injuries (like bruises, lacerations, bleeding and
fractures) is the first priority.
79. C. The nurse who is supervising others has a legal obligation to determine
that they are competent to perform the assignment, as well as legal obligation
to provide adequate supervision.
80. D. Increasing hydrostatic pressure in the urinary tract will facilitate passage
of the calculi.
81. A. Infertility is not diagnosed until atleast 12months of unprotected
intercourse has failed to produce a pregnancy. Older couples will experience
a longer time to get pregnant.
82. B. Determining how well the kidneys filter wastes states the purpose of a
Creatinine clearance test.
83. A. Acknowledging a feeling tone is the most therapeutic response and
provides a broad opening for the client to elaborate feelings.
84. C. The behavior should be stopped. The first is to remind the staff that
confidentiality maybe violated.
85. C. With a right-sided cerebrovascular accident the client would have leftsided hemiplegia or weakness. The client’s good side should be closest to
the bed to facilitate the transfer.
86. D. Legos are small plastic building blocks that could easily slip under the
child’s cast and lead to a break in skin integrity and even infection. Pencils,
backscratchers, and marbles are some other narrow or small items that could
easily slip under the child’s cast and lead to a break in skin integrity and
infection.
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.
88. B. The submission of reports about incidents that expose clients to harm does
not remove the obligation to report ongoing behavior as long as the risk to
the client continues.
89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child
weighs 20kg and the maximum dose is 50mg/kg, this would indicate a total
daily dose of 1000mg of tetracycline. In this case, the child is being given
this medication four times a day. Therefore the maximum single dose that
can be given is 250mg (1000 mg of tetracycline divided by four doses.)
90. C. An abnormality in the uterine muscle could reduce the effectiveness of
uterine contractions and lengthen the duration of subsequent labors.
91. A. Personality disorders stem from a weak superego, implying a lack of
adequate controls.
92. C. The basal body temperature is the lowest body temperature of a healthy
person that is taken immediately after waking and before getting out of bed.
The BBT usually varies from 36.2 ºC to 36.3ºC during menses and for about
5-7 days afterward. About the time of ovulation, a slight drop in temperature
may be seen, after ovulation in concert with the increasing progesterone
levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This elevation
remains until 2-3 days before menstruation, or if pregnancy has occurred.
93. A. This choice implies concern for client care and self-improvement.
94. C. The first trimester is the period of organogenesis, that is, cell
differentiation into the various organs, tissues, and structures.
95. C. This response does not contradict the client’s perception, is honest, and
shows empathy.
96. D. Tension on round ligament occurs because of the erect human posture and
pressure exerted by the growing fetus.
97. D. The Good Samaritan Law does not impose a duty to stop at the scene of
an emergency outside of the scope of employment, therefore nurses who do
not stop are not liable for suit.
98. C. Although reducing environment stimuli and activity is necessary for a
woman with mild preeclampsia, she will most probably have bathroom
privileges.
99. B. A normal respiratory rate for a newborn is 30-40 breaths per minute.
100. D. The behavior described is likely to be symptoms of delirium tremens,
or alcohol withdrawal (often unsuspected on a surgical unit.)