Nursing Board Practice Test Compilation
FOUNDATION OF PROFESSIONAL NURSING PRACTICE 188
Contents
NURSING PRACTICE I: FOUNDATION OF NURSING
PRACTICE .......................................................................... 4
NURSING PRACTICE II ..................................................... 15
NURSING PRACTICE III .................................................... 26
NURSING PRACTICE IV.................................................... 36
NURSING PRACTICE V..................................................... 46
TEST I - Foundation of Professional Nursing Practice .... 56
Answers and Rationale – Foundation of Professional
Nursing Practice ......................................................... 66
TEST II - Community Health Nursing and Care of the
Mother and Child ........................................................... 74
Answers and Rationale – Community Health Nursing
and Care of the Mother and Child ............................. 84
ANSWER KEY - FOUNDATION OF PROFESSIONAL
NURSING PRACTICE.................................................. 199
COMMUNITY HEALTH NURSING AND CARE OF THE
MOTHER AND CHILD .................................................... 200
ANSWER KEY: COMMUNITY HEALTH NURSING AND
CARE OF THE MOTHER AND CHILD .......................... 211
Comprehensive Exam 1................................................ 213
CARE OF CLIENTS WITH PHYSIOLOGIC AND
PSYCHOSOCIAL ALTERATIONS...................................... 222
ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC
AND PSYCHOSOCIAL ALTERATIONS ......................... 234
Nursing Practice Test V ................................................ 235
Nursing Practice Test V ................................................ 245
TEST I - Foundation of Professional Nursing Practice .. 255
TEST III - Care of Clients with Physiologic and
Psychosocial Alterations ................................................ 91
Answers and Rationale – Foundation of Professional
Nursing Practice ....................................................... 265
Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations ................ 102
TEST II - Community Health Nursing and Care of the
Mother and Child ......................................................... 273
TEST IV - Care of Clients with Physiologic and
Psychosocial Alterations .............................................. 111
Answers and Rationale – Community Health Nursing
and Care of the Mother and Child ........................... 283
Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations ................ 122
TEST III - Care of Clients with Physiologic and
Psychosocial Alterations .............................................. 290
TEST V - Care of Clients with Physiologic and Psychosocial
Alterations.................................................................... 133
Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations ................ 301
Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations ................ 144
TEST IV - Care of Clients with Physiologic and
Psychosocial Alterations .............................................. 310
PART III PRACTICE TEST I FOUNDATION OF NURSING . 153
Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations ................ 321
ANSWERS AND RATIONALE – FOUNDATION OF
NURSING .................................................................. 158
PRACTICE TEST II Maternal and Child Health ............... 162
ANSWERS AND RATIONALE – MATERNAL AND CHILD
HEALTH..................................................................... 167
MEDICAL SURGICAL NURSING ..................................... 173
ANSWERS AND RATIONALE – MEDICAL SURGICAL
NURSING .................................................................. 178
PSYCHIATRIC NURSING ................................................ 180
ANSWERS AND RATIONALE – PSYCHIATRIC NURSING
................................................................................. 185
TEST V - Care of Clients with Physiologic and Psychosocial
Alterations.................................................................... 332
Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations ................ 343
PART III ......................................................................... 352
PRACTICE TEST I FOUNDATION OF NURSING .............. 352
ANSWERS AND RATIONALE – FOUNDATION OF
NURSING .................................................................. 357
PRACTICE TEST II Maternal and Child Health ............... 361
ANSWERS AND RATIONALE – MATERNAL AND CHILD
HEALTH..................................................................... 366
MEDICAL SURGICAL NURSING ..................................... 372
MEDICAL SURGICAL NURSING Part 1 ........................... 475
ANSWERS and RATIONALES for MEDICAL SURGICAL
NURSING Part 1 ........................................................ 479
ANSWERS AND RATIONALE – MEDICAL SURGICAL
NURSING .................................................................. 377
MEDICAL SURGICAL NURSING Part 2 ........................... 481
PSYCHIATRIC NURSING ................................................ 379
ANSWERS and RATIONALES for MEDICAL SURGICAL
NURSING Part 2 ........................................................ 489
ANSWERS AND RATIONALE – PSYCHIATRIC NURSING
................................................................................. 384
FUNDAMENTALS OF NURSING PART 1 ........................ 387
FUNDAMENTALS OF NURSING PART 2 ........................ 392
ANSWERS and RATIONALES for FUNDAMENTALS OF
NURSING PART 2 ...................................................... 397
FUNDAMENTALS OF NURSING PART 3 ........................ 401
ANSWERS and RATIONALES for FUNDAMENTALS OF
NURSING PART 3 ...................................................... 405
MATERNITY NURSING Part 1 ........................................ 409
ANSWERS and RATIONALES for MATERNITY NURSING
Part 1 ........................................................................ 418
MEDICAL SURGICAL NURSING Part 2 ....................... 485
MEDICAL SURGICAL NURSING Part 3 ........................... 491
ANSWERS and RATIONALES for MEDICAL SURGICAL
NURSING Part 3 ........................................................ 495
PSYCHIATRIC NURSING Part 1 ...................................... 497
ANSWERS and RATIONALES for PSYCHIATRIC NURSING
Part 1 ........................................................................ 502
PSYCHIATRIC NURSING Part 2 ...................................... 504
ANSWERS and RATIONALES for PSYCHIATRIC NURSING
Part 2 ........................................................................ 509
PSYCHIATRIC NURSING Part 3 ...................................... 512
MATERNITY NURSING Part 2 ........................................ 428
ANSWERS and RATIONALES for PSYCHIATRIC NURSING
Part 3 ........................................................................ 516
Answer for maternity part 2 .................................... 433
PROFESSIONAL ADJUSTMENT ...................................... 519
PEDIATRIC NURSING .................................................... 434
LEADERSHIP and MANAGEMENT ................................. 522
ANSWERS and RATIONALES for PEDIATRIC NURSING
................................................................................. 439
NURSING RESEARCH Part 1 .......................................... 532
COMMUNITY HEALTH NURSING Part 1........................ 444
Nursing Research Suggested Answer Key ................ 546
COMMUNITY HEALTH NURSING Part 2........................ 454
2
NURSING RESEARCH Part 2 .......................................... 542
3
5.
NURSING PRACTICE I: FOUNDATION OF NURSING
PRACTICE
SITUATION: Nursing is a profession. The nurse should
have a background on the theories and foundation of
nursing as it influenced what is nursing today.
1.
2.
3.
4.
4
Nursing is the protection, promotion and
optimization of health and abilities, prevention
of illness and injury, alleviation of suffering
through the diagnosis and treatment of human
response and advocacy in the care of the
individuals, families, communities and the
population. This is the most accepted definition
of nursing as defined by the:
a. PNA
b. ANA
c. Nightingale
d. Henderson
Advancement in Nursing leads to the
development of the Expanded Career Roles.
Which of the following is NOT an expanded
career role for nurses?
a. Nurse practitioner
b. Nurse Researcher
c. Clinical nurse specialist
d. Nurse anaesthesiologist
The Board of Nursing regulated the Nursing
profession in the Philippines and is responsible
for the maintenance of the quality of nursing in
the country. Powers and duties of the board of
nursing are the following, EXCEPT:
a. Issue, suspend, revoke certificates of
registration
b. Issue subpoena duces tecum, ad
testificandum
c. Open and close colleges of nursing
d. Supervise and regulate the practice of
nursing
A nursing student or a beginning staff nurse who
has not yet experienced enough real situations
to make judgments about them is in what stage
of Nursing Expertise?
a. Novice
b. Newbie
c. Advanced Beginner
d. Competent
Benner’s “Proficient” nurse level is different
from the other levels in nursing expertise in the
context of having:
a. the ability to organize and plan activities
b. having attained an advanced level of
education
c. a holistic understanding and perception
of the client
d. intuitive and analytic ability in new
situations
SITUATION: The nurse has been asked to administer an
injection via Z TRACK technique. Questions 6 to 10 refer
to this.
6.
The nurse prepares an IM injection for an adult
client using the Z track technique. 4 ml of
medication is to be administered to the client.
Which of the following site will you choose?
a. Deltoid
b. Rectus femoris
c. Ventrogluteal
d. Vastus lateralis
7.
In infants 1 year old and below, which of the
following is the site of choice for intramuscular
Injection?
a. Deltoid
b. Rectus femoris
c. Ventrogluteal
d. Vastus lateralis
8.
In order to decrease discomfort in Z track
administration, which of the following is
applicable?
a. Pierce the skin quickly and smoothly at
a 90 degree angle
b. Inject the medication steadily at around
10 minutes per millilitre
c. Pull back the plunger and aspirate for 1
minute to make sure that the needle did
not hit a blood vessel
d. Pierce the skin slowly and carefully at a
90 degree angle
9.
After injection using the Z track technique, the
nurse should know that she needs to wait for a
few seconds before withdrawing the needle and
this is to allow the medication to disperse into
the muscle tissue, thus decreasing the client’s
discomfort. How many seconds should the nurse
wait before withdrawing the needle?
a. 2 seconds
5
b. 5 seconds
c. 10 seconds
d. 15 seconds
10.
The rationale in using the Z track technique in an
intramuscular injection is:
a. It decreases the leakage of discolouring
and irritating medication into the
subcutaneous tissues
b. It will allow a faster absorption of the
medication
c. The Z track technique prevent irritation
of the muscle
d. It is much more convenient for the nurse
that the patient smokes and drinks coffee. When
taking the blood pressure of a client who
recently smoked or drank coffee, how long
should the nurse wait before taking the client’s
blood pressure for accurate reading?
a. 15 minutes
b. 30 minutes
c. 1 hour
d. 5 minutes
15.
While the client has pulse oximeter on his
fingertip, you notice that the sunlight is shining
on the area where the oximeter is. Your action
will be to:
a. Set and turn on the alarm of the
oximeter
b. Do nothing since there is no identified
problem
c. Cover the fingertip sensor with a towel
or bedsheet
d. Change the location of the sensor every
four hours
16.
The nurse finds it necessary to recheck the blood
pressure reading. In case of such re assessment,
the nurse should wait for a period of:
a. 15 seconds
b. 1 to 2 minutes
c. 30 minutes
d. 15 minutes
17.
If the arm is said to be elevated when taking the
blood pressure, it will create a:
a. False high reading
b. False low reading
c. True false reading
d. Indeterminate
18.
You are to assessed the temperature of the
client the next morning and found out that he
ate ice cream. How many minutes should you
wait before assessing the client’s oral
temperature?
a. 10 minutes
b. 20 minutes
c. 30 minutes
d. 15 minutes
19.
When auscultating the client’s blood pressure
the nurse hears the following: From 150 mmHg
to 130 mmHg: Silence, Then: a thumping sound
continuing down to 100 mmHg; muffled sound
continuing down to 80 mmHg and then silence.
SITUATION: A Client was rushed to the emergency room
and you are his attending nurse. You are performing a
vital sign assessment.
11.
12.
13.
14.
All of the following are correct methods in
assessment of the blood pressure EXCEPT:
a. Take the blood pressure reading on both
arms for comparison
b. Listen to and identify the phases of
Korotkoff’s sound
c. Pump the cuff to around 50 mmHg
above the point where the pulse is
obliterated
d. Observe procedures for infection control
You attached a pulse oximeter to the client. You
know that the purpose is to:
a. Determine if the client’s hemoglobin
level is low and if he needs blood
transfusion
b. Check level of client’s tissue perfusion
c. Measure the efficacy of the client’s antihypertensive medications
d. Detect oxygen saturation of arterial
blood before symptoms of hypoxemia
develops
After a few hours in the Emergency Room, The
client is admitted to the ward with an order of
hourly monitoring of blood pressure. The nurse
finds that the cuff is too narrow and this will
cause the blood pressure reading to be:
a. inconsistent
b. low systolic and high diastolic
c. higher than what the reading should be
d. lower than what the reading should be
Through the client’s health history, you gather
What is the client’s blood pressure?
a. 130/80
b. 150/100
c. 100/80
d. 150/100
20.
In a client with a previous blood pressure of
130/80 4 hours ago, how long will it take to
release the blood pressure cuff to obtain an
accurate reading?
a. 10-20 seconds
b. 30-45 seconds
c. 1-1.5 minutes
d. 3-3.5 minutes
to lungs. This can be avoided by:
a. Cleaning teeth and mouth with cotton
swabs soaked with mouthwash to avoid
rinsing the buccal cavity
b. swabbing the inside of the cheeks and
lips, tongue and gums with dry cotton
swabs
c. use fingers wrapped with wet cotton
washcloth to rub inside the cheeks,
tongue, lips and ums
d. suctioning as needed while cleaning the
buccal cavity
25.
Situation: Oral care is an important part of hygienic
practices and promoting client comfort.
21.
22.
23.
24.
6
An elderly client, 84 years old, is unconscious.
Assessment of the mouth reveals excessive
dryness and presence of sores. Which of the
following is BEST to use for oral care?
a. lemon glycerine
b. Mineral oil
c. hydrogen peroxide
d. Normal saline solution
When performing oral care to an unconscious
client, which of the following is a special
consideration to prevent aspiration of fluids into
the lungs?
a. Put the client on a sidelying position
with head of bed lowered
b. Keep the client dry by placing towel
under the chin
c. Wash hands and observes appropriate
infection control
d. Clean mouth with oral swabs in a careful
and an orderly progression
The advantages of oral care for a client include
all of the following, EXCEPT:
a. decreases bacteria in the mouth and
teeth
b. reduces need to use commercial
mouthwash which irritate the buccal
mucosa
c. improves client’s appearance and selfconfidence
d. improves appetite and taste of food
A possible problem while providing oral care to
unconscious clients is the risk of fluid aspiration
Your client has difficulty of breathing and is
mouth breathing most of the time. This causes
dryness of the mouth with unpleasant odor. Oral
hygiene is recommended for the client and in
addition, you will keep the mouth moistened by
using:
a. salt solution
b. petroleum jelly
c. water
d. mentholated ointment
Situation – Ensuring safety before, during and after a
diagnostic procedure is an important responsibility of
the nurse.
26.
To help Fernan better tolerate the
bronchoscopy, you should instruct him to
practice which of the following prior to the
procedure?
a. Clenching his fist every 2 minutes
b. Breathing in and out through the nose
with his mouth open
c. Tensing the shoulder muscles while lying
on his back
d. Holding his breath periodically for 30
seconds
27.
Following a bronchoscopy, which of the
following complains to Fernan should be noted
as a possible complication:
a. Nausea and vomiting
b. Shortness of breath and laryngeal
stridor
c. Blood tinged sputum and coughing
d. Sore throat and hoarseness
28.
Immediately after bronchoscopy, you instructed
Fernan to:
a. Exercise the neck muscles
b. Refrain from coughing and talking
7
c. Breathe deeply
d. Clear his throat
29.
Thoracentesis may be performed for cytologic
study of pleural fluid. As a nurse your most
important function during the procedure is to:
a. Keep the sterile equipment from
contamination
b. Assist the physician
c. Open and close the three-way stopcock
d. Observe the patient’s vital signs
30.
Right after thoracentesis, which of the following
is most appropriate intervention?
a. Instruct the patient not to cough or deep
breathe for two hours
b. Observe for symptoms of tightness of
chest or bleeding
c. Place an ice pack to the puncture site
d. Remove the dressing to check for
bleeding
Situation: Knowledge of the acid-base disturbance and
the functions of the electrolytes is necessary to
determine appropriate intervention and nursing actions.
31.
A client with diabetes milletus has a blood
glucose level of 644 mg/dL. The nurse interprets
that this client is at most risk for the
development of which type of acid-base
imbalance?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
32.
In a client in the health care clinic, arterial blood
gas 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 which
acid base disturbance?
a. Respiratory acidosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Metabolic alkalosis
33.
A client has an order for ABG analysis on radial
artery specimens. The nurse ensures that which
of the following has been performed or tested
before the ABG specimens are drawn?
a. Guthrie test
b. Romberg’s test
c. Allen’s test
d. Weber’s test
34.
A nurse is reviewing the arterial blood gas values
of a client and notes that the ph is 7.31, Pco2 is
50 mmHg, and the bicarbonate is 27 mEq/L. The
nurse concludes that which acid base
disturbance is present in this client?
a. Respiratory acidosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Metabolic alkalosis
35.
Allen’s test checks the patency of the:
a. Ulnar artery
b. Carotid artery
c. Radial artery
d. Brachial artery
Situation 6: Eileen, 45 years old is admitted to the
hospital with a diagnosis of renal calculi. She is
experiencing severe flank pain, nauseated and with a
temperature of 39 0C.
36.
Given the above assessment data, the most
immediate goal of the nurse would be which of
the following?
a. Prevent urinary complication
b. maintains fluid and electrolytes
c. Alleviate pain
d. Alleviating nausea
37.
After IVP a renal stone was confirmed, a left
nephrectomy was done. Her post-operative
order includes “daily urine specimen to be sent
to the laboratory”. Eileen has a foley catheter
attached to a urinary drainage system. How will
you collect the urine specimen?
a. remove urine from drainage tube with
sterile needle and syringe and empty
urine from the syringe into the
specimen container
b. empty a sample urine from the
collecting bag into the specimen
container
c. Disconnect the drainage tube from the
indwelling catheter and allow urine to
flow from catheter into the specimen
container.
d. Disconnect the drainage from the
collecting bag and allow the urine to
flow from the catheter into the
specimen container.
38.
Where would the nurse tape Eileen’s indwelling
catheter in order to reduce urethral irritation?
a. to the patient’s inner thigh
b. to the patient’ buttocks
c. to the patient’s lower thigh
d. to the patient lower abdomen
regulation is secreted in the:
a. Thyroid gland
b. Parathyroid gland
c. Hypothalamus
d. Anterior pituitary gland
45.
39.
40.
Which of the following menu is appropriate for
one with low sodium diet?
a. instant noodles, fresh fruits and ice tea
b. ham and cheese sandwich, fresh fruits
and vegetables
c. white chicken sandwich, vegetable
salad and tea
d. canned soup, potato salad, and diet soda
How will you prevent ascending infection to
Eileen who has an indwelling catheter?
a. see to it that the drainage tubing
touches the level of the urine
b. change he catheter every eight hours
c. see to it that the drainage tubing does
not touch the level of the urine
d. clean catheter may be used since
urethral meatus is not a sterile area
Situation: Hormones are secreted by the various glands
in the body. Basic knowledge of the endocrine system is
necessary.
41.
Somatocrinin or the Growth hormone releasing
hormone is secreted by the:
a. Hypothalamus
b. Posterior pituitary gland
c. Anterior pituitary gland
d. Thyroid gland
42.
All of the following are secreted by the anterior
pituitary gland except:
a. Somatotropin/Growth hormone
b. Thyroid stimulating hormone
c. Follicle stimulating hormone
d. Gonadotropin hormone releasing
hormone
43.
44.
8
All of the following hormones are hormones
secreted by the Posterior pituitary gland except:
a. Vasopressin
b. Anti-diuretic hormone
c. Oxytocin
d. Growth hormone
Calcitonin, a hormone necessary for calcium
While Parathormone, a hormone that negates
the effect of calcitonin is secreted by the:
a. Thyroid gland
b. Parathyroid gland
c. Hypothalamus
d. Anterior pituitary gland
Situation: The staff nurse supervisor requests all the staff
nurses to “brainstorm” and learn ways to instruct
diabetic clients on self-administration of insulin. She
wants to ensure that there are nurses available daily to
do health education classes.
46.
The plan of the nurse supervisor is an example of
a. in service education process
b. efficient management of human
resources
c. increasing human resources
d. primary prevention
47.
When Mrs. Guevarra, a nurse, delegates aspects
of the clients care to the nurse-aide who is an
unlicensed staff, Mrs. Guevarra
a. makes the assignment to teach the staff
member
b. is assigning the responsibility to the
aide but not the accountability for
those tasks
c. does not have to supervise or evaluate
the aide
d. most know how to perform task
delegated
48.
Connie, the new nurse, appears tired and
sluggish and lacks the enthusiasm she had six
weeks ago when she started the job. The nurse
supervisor should
a. empathize with the nurse and listen to
her
b. tell her to take the day off
c. discuss how she is adjusting to her new
job
d. ask about her family life
49.
Process of formal negotiations of working
conditions between a group of registered nurses
and employer is
9
a.
b.
c.
d.
grievance
arbitration
collective bargaining
strike
d. It should disclose previous diagnosis,
prognosis and alternative treatments
available for the client
55.
50.
You are attending a certification on
cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is
a. professional course towards credits
b. in-service education
c. advance training
d. continuing education
Situation: As a nurse, you are aware that proper
documentation in the patient chart is your responsibility.
51.
52.
53.
54.
Which of the following is not a legally binding
document but nevertheless very important in
the care of all patients in any health care
setting?
a. Bill of rights as provided in the Philippine
constitution
b. Scope of nursing practice as defined by
RA 9173
c. Board of nursing resolution adopting the
code of ethics
d. Patient’s bill of rights
A nurse gives a wrong medication to the client.
Another nurse employed by the same hospital as
a risk manager will expect to receive which of
the following communication?
a. Incident report
b. Nursing kardex
c. Oral report
d. Complain report
Performing a procedure on a client in the
absence of an informed consent can lead to
which of the following charges?
a. Fraud
b. Harassment
c. Assault and battery
d. Breach of confidentiality
Which of the following is the essence of
informed consent?
a. It should have a durable power of
attorney
b. It should have coverage from an
insurance company
c. It should respect the client’s freedom
from coercion
Delegation is the process of assigning tasks that
can be performed by a subordinate. The RN
should always be accountable and should not
lose his accountability. Which of the following is
a role included in delegation?
a. The RN must supervise all delegated
tasks
b. After a task has been delegated, it is no
longer a responsibility of the RN
c. The RN is responsible and accountable
for the delegated task in adjunct with
the delegate
d. Follow up with a delegated task is
necessary only if the assistive personnel
is not trustworthy
Situation: When creating your lesson plan for
cerebrovascular disease or STROKE. It is important to
include the risk factors of stroke.
56.
The most important risk factor is:
a. Cigarette smoking
b. binge drinking
c. Hypertension
d. heredity
57.
Part of your lesson plan is to talk about etiology
or cause of stroke. The types of stroke based on
cause are the following EXCEPT:
a. Embolic stroke
b. diabetic stroke
c. Hemorrhagic stroke
d. thrombotic stroke
58.
Hemmorhagic stroke occurs suddenly usually
when the person is active. All are causes of
hemorrhage, EXCEPT:
a. phlebitis
b. damage to blood vessel
c. trauma
d. aneurysm
59.
The nurse emphasizes that intravenous drug
abuse carries a high risk of stroke. Which drug is
closely linked to this?
a. Amphetamines
b. shabu
c. Cocaine
d. Demerol
d. Iron 75 mg/100 ml
60.
A participant in the STROKE class asks what is a
risk factor of stroke. Your best response is:
a. “More red blood cells thicken blood
and make clots more possible.”
b. “Increased RBC count is linked to high
cholesterol.”
c. “More red blood cell increases
hemoglobin content.”
d. “High RBC count increases blood
pressure.”
Situation: Recognition of normal values is vital in
assessment of clients with various disorders.
61.
A nurse is reviewing the laboratory test results
for a client with a diagnosis of severe
dehydration. The nurse would expect the
hematocrit level for this client to be which of the
following?
a. 60%
b. 47%
c. 45%
d. 32%
62.
A nurse is reviewing the electrolyte results of an
assigned client and notes that the potassium
level is 5.6 mEq/L. Which of the following would
the nurse expect to note on the ECG as a result
of this laboratory value?
a. ST depression
b. Prominent U wave
c. Inverted T wave
d. Tall peaked T waves
63.
64.
10
A nurse is reviewing the electrolyte results of an
assigned client and notes that the potassium
level is 3.2 mEq/L. Which of the following would
the nurse expect to note on the ECG as a result
of this laboratory value?
a. U waves
b. Elevated T waves
c. Absent P waves
d. Elevated ST Segment
Dorothy underwent diagnostic test and the
result of the blood examination are back. On
reviewing the result the nurse notices which of
the following as abnormal finding?
a. Neutrophils 60%
b. White blood cells (WBC) 9000/mm
c. Erythrocyte sedimentation rate (ESR) is
39 mm/hr
65.
Which of the following laboratory test result
indicate presence of an infectious process?
a. Erythrocyte sedimentation rate (ESR) 12
mm/hr
b. White blood cells (WBC) 18,000/mm3
c. Iron 90 g/100ml
d. Neutrophils 67%
Situation: Pleural effusion is the accumulation of fluid in
the pleural space. Questions 66 to 70 refer to this.
66.
Which of the following is a finding that the nurse
will be able to assess in a client with Pleural
effusion?
a. Reduced or absent breath sound at the
base of the lungs, dyspnea, tachpynea
and shortness of breath
b. Hypoxemia, hypercapnea and
respiratory acidosis
c. Noisy respiration, crackles, stridor and
wheezing
d. Tracheal deviation towards the affected
side, increased fremitus and loud breath
sounds
67.
Thoracentesis is performed to the client with
effusion. The nurse knows that the removal of
fluid should be slow. Rapid removal of fluid in
thoracentesis might cause:
a. Pneumothorax
b. Cardiovascular collapse
c. Pleurisy or Pleuritis
d. Hypertension
68.
3 Days after thoracentesis, the client again
exhibited respiratory distress. The nurse will
know that pleural effusion has reoccurred when
she noticed a sharp stabbing pain during
inspiration. The physician ordered a closed tube
thoracotomy for the client. The nurse knows
that the primary function of the chest tube is to:
a. Restore positive intrathoracic pressure
b. Restore negative intrathoracic pressure
c. To visualize the intrathoracic content
d. As a method of air administration via
ventilator
69.
The chest tube is functioning properly if:
a. There is an oscillation
b. There is no bubbling in the drainage
bottle
11
c. There is a continuous bubbling in the
waterseal
d. The suction control bottle has a
continuous bubbling
70.
In a client with pleural effusion, the nurse is
instructing appropriate breathing technique.
Which of the following is included in the
teaching?
a. Breath normally
b. Hold the breath after each inspiration
for 1 full minute
c. Practice abdominal breathing
d. Inhale slowly and hold the breath for 3
to 5 seconds after each inhalation
75.
Situation: Nursing ethics is an important part of the
nursing profession. As the ethical situation arises, so is
the need to have an accurate and ethical decision
making.
76.
The purpose of having a nurses’ code of ethics is:
a. Delineate the scope and areas of nursing
practice
b. identify nursing action recommended for
specific health care situations
c. To help the public understand
professional conduct expected of
nurses
d. To define the roles and functions of the
health care givers, nurses, clients
77.
The principles that govern right and proper
conduct of a person regarding life, biology and
the health professionals is referred to as:
a. Morality
b. Religion
c. Values
d. Bioethics
78.
A subjective feeling about what is right or wrong
is said to be:
a. Morality
b. Religion
c. Values
d. Bioethics
79.
Values are said to be the enduring believe about
a worth of a person, ideas and belief. If Values
are going to be a part of a research, this is
categorized under:
a. Qualitative
b. Experimental
c. Quantitative
d. Non Experimental
80.
The most important nursing responsibility where
ethical situations emerge in patient care is to:
a. Act only when advised that the action is
ethically sound
SITUATION: Health care delivery system affects the
health status of every filipino. As a Nurse, Knowledge of
this system is expected to ensure quality of life.
71.
When should rehabilitation commence?
a. The day before discharge
b. When the patient desires
c. Upon admission
d. 24 hours after discharge
72.
What exemplified the preventive and promotive
programs in the hospital?
a. Hospital as a center to prevent and
control infection
b. Program for smokers
c. Program for alcoholics and drug addicts
d. Hospital Wellness Center
73.
Which makes nursing dynamic?
a. Every patient is a unique physical,
emotional, social and spiritual being
b. The patient participate in the overall
nursing care plan
c. Nursing practice is expanding in the light
of modern developments that takes
place
d. The health status of the patient is
constantly changing and the nurse must
be cognizant and responsive to these
changes
74.
Prevention is an important responsibility of the
nurse in:
a. Hospitals
b. Community
c. Workplace
d. All of the above
This form of Health Insurance provides
comprehensive prepaid health services to
enrollees for a fixed periodic payment.
a. Health Maintenance Organization
b. Medicare
c. Philippine Health Insurance Act
d. Hospital Maintenance Organization
b. Not takes sides, remain neutral and fair
c. Assume that ethical questions are the
responsibility of the health team
d. Be accountable for his or her own
actions
81.
82.
83.
84.
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Why is there an ethical dilemma?
a. the choices involved do not appear to be
clearly right or wrong
b. a client’s legal right co-exist with the
nurse’s professional obligation
c. decisions has to be made based on
societal norms.
d. decisions has to be mad quickly, often
under stressful conditions
According to the code of ethics, which of the
following is the primary responsibility of the
nurse?
a. Assist towards peaceful death
b. Health is a fundamental right
c. Promotion of health, prevention of
illness, alleviation of suffering and
restoration of health
d. Preservation of health at all cost
Which of the following is TRUE about the Code
of Ethics of Filipino Nurses, except:
a. The Philippine Nurses Association for
being the accredited professional
organization was given the privilege to
formulate a Code of Ethics for Nurses
which the Board of Nursing
promulgated
b. Code for Nurses was first formulated in
1982 published in the Proceedings of the
Third Annual Convention of the PNA
House of Delegates
c. The present code utilized the Code of
Good Governance for the Professions in
the Philippines
d. Certificates of Registration of registered
nurses may be revoked or suspended for
violations of any provisions of the Code
of Ethics.
Violation of the code of ethics might equate to
the revocation of the nursing license. Who
revokes the license?
a. PRC
b. PNA
c. DOH
d. BON
85.
Based on the Code of Ethics for Filipino Nurses,
what is regarded as the hallmark of nursing
responsibility and accountability?
a. Human rights of clients, regardless of
creed and gender
b. The privilege of being a registered
professional nurse
c. Health, being a fundamental right of
every individual
d. Accurate documentation of actions and
outcomes
Situation: As a profession, nursing is dynamic and its
practice is directed by various theoretical models. To
demonstrate caring behaviour, the nurse applies various
nursing models in providing quality nursing care.
86.
When you clean the bedside unit and regularly
attend to the personal hygiene of the patient as
well as in washing your hands before and after a
procedure and in between patients, you indent
to facilitate the body’s reparative processes.
Which of the following nursing theory are you
applying in the above nursing action?
a. Hildegard Peplau
b. Dorothea Orem
c. Virginia Henderson
d. Florence Nightingale
87.
A communication skill is one of the important
competencies expected of a nurse. Interpersonal
process is viewed as human to human
relationship. This statement is an application of
whose nursing model?
a. Joyce Travelbee
b. Martha Rogers
c. Callista Roy
d. Imogene King
88.
The statement “the health status of an individual
is constantly changing and the nurse must be
cognizant and responsive to these changes” best
explains which of the following facts about
nursing?
a. Dynamic
b. Client centred
c. Holistic
d. Art
89.
Virginia Henderson professes that the goal of
nursing is to work interdependently with other
health care working in assisting the patient to
13
gain independence as quickly as possible. Which
of the following nursing actions best
demonstrates this theory in taking care of a 94
year old client with dementia who is totally
immobile?
a. Feeds the patient, brushes his teeth,
gives the sponge bath
b. Supervise the watcher in rendering
patient his morning care
c. Put the patient in semi fowler’s position,
set the over bed table so the patient can
eat by himself, brush his teeth and
sponge himself
d. Assist the patient to turn to his sides and
allow him to brush and feed himself only
when he feels ready
90.
94.
The medical records that are organized into
separate section from doctors or nurses has
more disadvantages than advantages. This is
classified as what type of recording?
a. POMR
b. Modified POMR
c. SOAPIE
d. SOMR
95.
Which of the following is the advantage of SOMR
or Traditional recording?
a. Increases efficiency in data gathering
b. Reinforces the use of the nursing
process
c. The caregiver can easily locate proper
section for making charting entries
d. Enhances effective communication
among health care team members
In the self-care deficit theory by Dorothea Orem,
nursing care becomes necessary when a patient
is unable to fulfil his physiological, psychological
and social needs. A pregnant client needing
prenatal check-up is classified as:
a. Wholly compensatory
b. Supportive Educative
c. Partially compensatory
d. Non compensatory
Situation: Documentation and reporting are just as
important as providing patient care, As such, the nurse
must be factual and accurate to ensure quality
documentation and reporting.
91.
include:
a. Prescription of the doctor to the
patient’s illness
b. Plan of care for patient
c. Patient’s perception of one’s illness
d. Nursing problem and Nursing diagnosis
Health care reports have different purposes. The
availability of patients’ record to all health team
members demonstrates which of the following
purposes:
a. Legal documentation
b. Research
c. Education
d. Vehicle for communication
92.
When a nurse commits medication error, she
should accurately document client’s response
and her corresponding action. This is very
important for which of the following purposes:
a. Research
b. Legal documentation
c. Nursing Audit
d. Vehicle for communication
93.
POMR has been widely used in many teaching
hospitals. One of its unique features is SOAPIE
charting. The P in SOAPIE charting should
Situation: June is a 24 year old client with symptoms of
dyspnea, absent breath sounds on the right lung and
chest x ray revealed pleural effusion. The physician will
perform thoracentesis.
96.
Thoracentesis is useful in treating all of the
following pulmonary disorders except:
a. Hemothorax
b. Hydrothorax
c. Tuberculosis
d. Empyema
97.
Which of the following psychological preparation
is not relevant for him?
a. Telling him that the gauge of the needle
and anesthesia to be used
b. Telling him to keep still during the
procedure to facilitate the insertion of
the needle in the correct place
c. Allow June to express his feelings and
concerns
d. Physician’s explanation on the purpose
of the procedure and how it will be done
98.
Before thoracentesis, the legal consideration you
must check is:
a. Consent is signed by the client
b. Medicine preparation is correct
c. Position of the client is correct
d. Consent is signed by relative and
physician
99.
As a nurse, you know that the position for June
before thoracentesis is:
a. Orthopneic
b. Low fowlers
c. Knee-chest
d. Sidelying position on the affected side
100.
Which of the following anaesthetics drug is used
for thoracentesis?
a. Procaine 2%
b. Demerol 75 mg
c. Valium 250 mg
d. Phenobartbital 50 mg
14
15
D. Follicle stimulating hormone
NURSING PRACTICE II
Situation: Mariah is a 31 year old lawyer who has been
married for 6 months. She consults you for guidance in
relation with her menstrual cycle and her desire to get
pregnant.
1. She wants to know the length of her menstrual
cycle. Her previous menstrual period is October
22 to 26. Her LMB is November 21. Which of the
following number of days will be your correct
response?
A. 29
B. 28
C. 30
D. 31
2. You advised her to observe and record the signs
of Ovulation. Which of the following signs will
she likely note down?
1.
A 1 degree Fahrenheit rise in basal body
temperature
2.
Cervical mucus becomes copious and
clear
3.
One pound increase in weight
4.
Mittelschmerz
A. 1, 2, 4
B. 1, 2, 3
C. 2, 3, 4
D. 1, 3, 4
3. You instruct Mariah to keep record of her basal
temperature every day, which of the following
instructions is incorrect?
A. If coitus has occurred; this should be
reflected in the chart
B. It is best to have coitus on the evening
following a drop in BBT to become
pregnant
C. Temperature should be taken
immediately after waking and before
getting out of bed
D. BBT is lowest during the secretory
phase
4. She reports an increase in BBT on December 16.
Which hormone brings about this change in her
BBT?
A. Estrogen
B. Gonadotropine
C. Progesterone
5. The following month, Mariah suspects she is
pregnant. Her urine is positive for Human
chorionic gonadotrophin. Which structure
produces Hcg?
A. Pituitary gland
B. Trophoblastic cells of the embryo
C. Uterine deciduas
D. Ovarian follicles
Situation: Mariah came back and she is now pregnant.
6. At 5 month gestation, which of the following
fetal development would probably be achieve?
A. Fetal movement are felt by Mariah
B. Vernix caseosa covers the entire body
C. Viable if delivered within this period
D. Braxton hicks contractions are observed
7. The nurse palpates the abdomen of Mariah.
Now At 5 month gestation, What level of the
abdomen can the fundic height be palpated?
A. Symphysis pubis
B. Midpoint between the umbilicus and the
xiphoid process
C. Midpoint between the symphysis pubis
and the umbilicus
D. Umbilicus
8. She worries about her small breasts, thinking
that she probably will not be able to breastfeed
her baby. Which of the following responses of
the nurse is correct?
A. “The size of your breast will not affect
your lactation”
B. “You can switch to bottle feeding”
C. “You can try to have exercise to increase
the size of your breast”
D. “Manual expression of milk is possible”
9. She tells the nurse that she does not take milk
regularly. She claims that she does not want to
gain too much weight during her pregnancy.
Which of the following nursing diagnosis is a
priority?
A. Potential self-esteem disturbance
related to physiologic changes in
pregnancy
B. Ineffective individual coping related to
physiologic changes in pregnancy
C. Fear related to the effects of pregnancy
D. Knowledge deficit regarding nutritional
requirements of pregnancies related to
lack of information sources
10. Which of the following interventions will likely
ensure compliance of Mariah?
A. Incorporate her food preferences that
are adequately nutritious in her meal
plan
B. Consistently counsel toward optimum
nutritional intake
C. Respect her right to reject dietary
information if she chooses
D. Inform her of the adverse effects of
inadequate nutrition to her fetus
Situation: Susan is a patient in the clinic where you work.
She is inquiring about pregnancy.
11. Susan tells you she is worried because she
develops breasts later than most of her friends.
Breast development is termed as:
A. Adrenarche
B. Thelarche
C. Mamarche
D. Menarche
12. Kevin, Susan’s husband tells you that he is
considering vasectomy After the birth of their
new child. Vasectomy involves the incision of
which organ?
A. The testes
B. The epididymis
C. The vas deferens
D. The scrotum
13. On examination, Susan has been found of having
a cystocele. A cystocele is:
A. A sebaceous cyst arising from the vulvar
fold
B. Protrusion of intestines into the vagina
C. Prolapse of the uterus into the vagina
D. Herniation of the bladder into the
vaginal wall
14. Susan typically has menstrual cycle of 34 days.
She told you she had coitus on days 8, 10, 15 and
20 of her menstrual cycle. Which is the day on
which she is most likely to conceive?
A. 8th day
B. Day 15
C. 10th day
D. Day 20
16
15. While talking with Susan, 2 new patients arrived
and they are covered with large towels and the
nurse noticed that there are many cameraman
and news people outside of the OPD. Upon
assessment the nurse noticed that both of them
are still nude and the male client’s penis is still
inside the female client’s vagina and the male
client said that “I can’t pull it”. Vaginismus was
your first impression. You know that The
psychological cause of Vaginismus is related to:
A. The male client inserted the penis too
deeply that it stimulates vaginal closure
B. The penis was too large that is why the
vagina triggered its defense to attempt
to close it
C. The vagina does not want to be
penetrated
D. It is due to learning patterns of the
female client where she views sex as
bad or sinful
Situation: Overpopulation is one problem in the
Philippines that causes economic drain. Most Filipinos
are against in legalizing abortion. As a nurse, Mastery of
contraception is needed to contribute to the society and
economic growth.
16. Supposed that Dana, 17 years old, tells you she
wants to use fertility awareness method of
contraception. How will she determine her
fertile days?
A. She will notice that she feels hot, as if
she has an elevated temperature.
B. She should assess whether her cervical
mucus is thin, copious, clear and
watery.
C. She should monitor her emotions for
sudden anger or crying
D. She should assess whether her breasts
feel sensitive to cool air
17. Dana chooses to use COC as her family planning
method. What is the danger sign of COC you
would ask her to report?
A. A stuffy or runny nose
B. Slight weight gain
C. Arthritis like symptoms
D. Migraine headache
18. Dana asks about subcutaneous implants and she
asks, how long will these implants be effective.
Your best answer is:
A. One month
17
B. Five years
C. Twelve months
D. 10 years
19. Dana asks about female condoms. Which of the
following is true with regards to female
condoms?
A. The hormone the condom releases
might cause mild weight gain
B. She should insert the condom before
any penile penetration
C. She should coat the condom with
spermicide before use
D. Female condoms, unlike male condoms,
are reusable
20. Dana has asked about GIFT procedure. What
makes her a good candidate for GIFT?
A. She has patent fallopian tubes, so
fertilized ova can be implanted on them
B. She is RH negative, a necessary
stipulation to rule out RH incompatibility
C. She has normal uterus, so the sperm can
be injected through the cervix into it
D. Her husband is taking sildenafil, so all
sperms will be motile
Situation: Nurse Lorena is a Family Planning and
Infertility Nurse Specialist and currently attends to
FAMILY PLANNING CLIENTS AND INFERTILE COUPLES.
The following conditions pertain to meeting the nursing
needs of this particular population group.
21. Dina, 17 years old, asks you how a tubal ligation
prevents pregnancy. Which would be the best
answer?
A. Prostaglandins released from the cut
fallopian tubes can kill sperm
B. Sperm cannot enter the uterus because
the cervical entrance is blocked.
C. Sperm can no longer reach the ova,
because the fallopian tubes are blocked
D. The ovary no longer releases ova as
there is nowhere for them to go.
22. The Dators are a couple undergoing testing for
infertility. Infertility is said to exist when:
A. A woman has no uterus
B. A woman has no children
C. A couple has been trying to conceive for
1 year
D. A couple has wanted a child for 6
months
23. Another client named Lilia is diagnosed as having
endometriosis. This condition interferes with
fertility because:
A. Endometrial implants can block the
fallopian tubes
B. The uterine cervix becomes inflamed
and swollen
C. The ovaries stop producing adequate
estrogen
D. Pressure on the pituitary leads to
decreased FSH levels
24. Lilia is scheduled to have a
hysterosalphingogram. Which of the following
instructions would you give her regarding this
procedure?
A. She will not be able to conceive for 3
months after the procedure
B. The sonogram of the uterus will reveal
any tumors present
C. Many women experience mild bleeding
as an after effect
D. She may feel some cramping when the
dye is inserted
25. Lilia’s cousin on the other hand, knowing nurse
Lorena’s specialization asks what artificial
insemination by donor entails. Which would be
your best answer if you were Nurse Lorena?
A. Donor sperm are introduced vaginally
into the uterus or cervix
B. Donor sperm are injected intraabdominally into each ovary
C. Artificial sperm are injected vaginally to
test tubal patency
D. The husband’s sperm is administered
intravenously weekly
Situation: You are assigned to take care of a group of
patients across the lifespan.
26. Pain in the elder persons requires careful
assessment because they:
A. experienced reduce sensory perception
B. have increased sensory perception
C. are expected to experience chronic pain
D. have a decreased pain threshold
27. Administration of analgesics to the older persons
requires careful patient assessment because
older people:
A. are more sensitive to drugs
B. have increased hepatic, renal and
gastrointestinal function
C. have increased sensory perception
D. mobilize drugs more rapidly
28. The elderly patient is at higher risk for urinary
incontinence because of:
A. increased glomerular filtration
B. decreased bladder capacity
C. diuretic use
D. dilated urethra
29. Which of the following is the MOST COMMON
sign of infection among the elderly?
A. decreased breath sounds with crackles
B. pain
C. fever
D. change in mental status
30. Priorities when caring for the elderly trauma
patient:
A. circulation, airway, breathing
B. airway, breathing, disability (neurologic)
C. disability (neurologic), airway, breathing
D. airway, breathing, circulation
31. Preschoolers are able to see things from which
of the following perspectives?
A. Their peers
B. Their own and their mother’s
C. Their own and their caregivers’
D. Only their own
32. In conflict management, the win-win approach
occurs when:
A. There are two conflicts and the parties
agree to each one
B. Each party gives in on 50% of the
disagreements making up the conflict
C. Both parties involved are committed to
solving the conflict
D. The conflict is settled out of court so the
legal system and the parties win
33. According to the social-interactional perspective
of child abuse and neglect, four factors place the
family members at risk for abuse. These risk
factors are the family members at risk for abuse.
These risk factors are the family itself, the
caregiver, the child, and
A. The presence of a family crisis
B. The national emphasis on sex
C. Genetics
18
D. Chronic poverty
34. Which of the following signs and symptoms
would you most likely find when assessing and
infant with Arnold-Chiari malformation?
A. Weakness of the leg muscles, loss of
sensation in the legs, and restlessness
B. Difficulty swallowing, diminished or
absent gag reflex, and respiratory
distress
C. Difficulty sleeping, hypervigilant, and an
arching of the back
D. Paradoxical irritability, diarrhea, and
vomiting.
35. A parent calls you and frantically reports that her
child has gotten into her famous ferrous sulfate
pills and ingested a number of these pills. Her
child is now vomiting, has bloody diarrhea, and is
complaining of abdominal pain. You will tell the
mother to:
A. Call emergency medical services (EMS)
and get the child to the emergency room
B. Relax because these symptoms will pass
and the child will be fine
C. Administer syrup of ipecac
D. Call the poison control center
36. A client says she heard from a friend that you
stop having periods once you are on the “pill”.
The most appropriate response would be:
A. “The pill prevents the uterus from
making such endometrial lining, that is
why periods may often be scant or
skipped occasionally.”
B. “If your friend has missed her period,
she should stop taking the pills and get a
pregnancy test as soon as possible.”
C. “The pill should cause a normal
menstrual period every month. It
sounds like your friend has not been
taking the pills properly.”
D. “Missed period can be very dangerous
and may lead to the formation of
precancerous cells.”
37. The nurse assessing newborn babies and infants
during their hospital stay after birth will notice
which of the following symptoms as a primary
manifestation of Hirschsprung’s disease?
A. A fine rash over the trunk
B. Failure to pass meconium during the
first 24 to 48 hours after birth
19
C. The skin turns yellow and then brown
over the first 48 hours of life
D. High-grade fever
38. A client is 7 months pregnant and has just been
diagnosed as having a partial placenta previa.
She is stable and has minimal spotting and is
being sent home. Which of these instructions to
the client may indicate a need for further
teaching?
A. Maintain bed rest with bathroom
privileges
B. Avoid intercourse for three days.
C. Call if contractions occur.
D. Stay on left side as much as possible
when lying down.
39. A woman has been rushed to the hospital with
ruptured membrane. Which of the following
should the nurse check first?
A. Check for the presence of infection
B. Assess for Prolapse of the umbilical
cord
C. Check the maternal heart rate
D. Assess the color of the amniotic fluid
40. The nurse notes that the infant is wearing a
plastic-coated diaper. If a topical medication
were to be prescribed and it were to go on the
stomachs or buttocks, the nurse would teach the
caregivers to:
A. avoid covering the area of the topical
medication with the diaper
B. avoid the use of clothing on top of the
diaper
C. put the diaper on as usual
D. apply an icepack for 5 minutes to the
outside of the diaper
41. Which of the following factors is most important
in determining the success of relationships used
in delivering nursing care?
A. Type of illness of the client
B. Transference and counter transference
C. Effective communication
D. Personality of the participants
42. Grace sustained a laceration on her leg from
automobile accident. Why are lacerations of
lower extremities potentially more serious
among pregnant women than other?
A. lacerations can provoke allergic
responses due to gonadotropic hormone
release
B. a woman is less able to keep the
laceration clean because of her fatigue
C. healing is limited during pregnancy so
these will not heal until after birth
D. increased bleeding can occur from
uterine pressure on leg veins
43. In working with the caregivers of a client with an
acute or chronic illness, the nurse would:
A. Teach care daily and let the caregivers
do a return demonstration just before
discharge
B. Difficulty swallowing, diminished or
absent gag reflex, and respiratory
distress.
C. Difficulty sleeping, hypervigilant, and an
arching of the back
D. Paradoxical irritability, diarrhea, and
vomiting
44. Which of the following roles BEST exemplifies
the expanded role of the nurse?
A. Circulating nurse in surgery
B. Medication nurse
C. Obstetrical nurse
D. Pediatric nurse practitioner
45. According to DeRosa and Kochura’s (2006)
article entitled “Implement Culturally Competent
Health Care in your work place,” cultures have
different patterns of verbal and nonverbal
communication. Which difference does?
A. NOT necessarily belong?
B. Personal behavior
C. Subject matter
D. Eye contact
E. Conversational style
46. You are the nurse assigned to work with a child
with acute glomerulonephritis. By following the
prescribed treatment regimen, the child
experiences a remission. You are now checking
to make sure the child does not have a relapse.
Which finding would most lead you to the
conclusion that a relapse is happening?
A. Elevated temperature, cough, sore
throat, changing complete blood count
(CBC) with diiferential
B. A urine dipstick measurement of 2+
proteinuria or more for 3 days, or the
child found to have 3-4+ proteinutria
plus edema.
C. The urine dipstick showing glucose in the
urine for 3 days, extreme thirst, increase
in urine output, and a moon face.
D. A temperature of 37.8 degrees (100
degrees F), flank pain, burning
frequency, urgency on voiding, and
cloudy urine.
47. The nurse is working with an adolescent who
complains of being lonely and having a lack of
fulfillment in her life. This adolescent shies away
from intimate relationships at times yet at other
times she appears promiscuous. The nurse will
likely work with this adolescent in which of the
following areas?
A. Isolation
B. Lack of fulfillment
C. Loneliness
D. Identity
48. The use of interpersonal decision making,
psychomotor skills, and application of
knowledge expected in the role of a licensed
health care professional in the context of public
health welfare and safety is an example of:
A. Delegation
B. Responsibility
C. Supervision
D. Competence
49. The painful phenomenon known as “back labor”
occurs in a client whose fetus in what position?
A. Brow position
B. Breech position
C. Right Occipito-Anterior Position
D. Left Occipito-Posterior Position
50. FOCUS methodology stands for:
A. Focus, Organize, Clarify, Understand
and Solution
B. Focus, Opportunity, Continuous, Utilize,
Substantiate
C. Focus, Organize, Clarify, Understand,
Substantiate
D. Focus, Opportunity, Continuous
(process), Understand, Solution
SITUATION: The infant and child mortality rate in the low
to middle income countries is ten times higher than
industrialized countries. In response to this, the WHO
and UNICEF launched the protocol Integrated
Management of Childhood Illnesses to reduce the
morbidity and mortality against childhood illnesses.
20
51. If a child with diarrhea registers two signs in the
yellow row in the IMCI chart, we can classify the
patient as:
A. Moderate dehydration
B. Severe dehydration
C. Some dehydration
D. No dehydration
52. Celeste has had diarrhea for 8 days. There is no
blood in the stool, he is irritable, his eyes are
sunken, the nurse offers fluid to Celeste and he
drinks eagerly. When the nurse pinched the
abdomen it goes back slowly. How will you
classify Celeste’s illness?
A. Moderate dehydration
B. Severe dehydration
C. Some dehydration
D. No dehydration
53. A child who is 7 weeks has had diarrhea for 14
days but has no sign of dehydration is classified
as:
A. Persistent diarrhea
B. Dysentery
C. Severe dysentery
D. Severe persistent diarrhea
54. The child with no dehydration needs home
treatment. Which of the following is not
included in the rules for home treatment in this
case?
A. Forced fluids
B. When to return
C. Give vitamin A supplement
D. Feeding more
55. Fever as used in IMCI includes:
A. Axillary temperature of 37.5 or higher
B. Rectal temperature of 38 or higher
C. Feeling hot to touch
D. All of the above
E. A and C only
Situation: Prevention of Dengue is an important nursing
responsibility and controlling it’s spread is a priority once
outbreak has been observed.
56. An important role of the community health
nurse in the prevention and control of Dengue
H-fever includes:
A. Advising the elimination of vectors by
keeping water containers covered
21
B. Conducting strong health education
drives/campaign directed towards
proper garbage disposal
C. Explaining to the individuals, families,
groups and community the nature of
the disease and its causation
D. Practicing residual spraying with
insecticides
57. Community health nurses should be alert in
observing a Dengue suspect. The following is
NOT an indicator for hospitalization of H-fever
suspects?
A. Marked anorexia, abdominal pain and
vomiting
B. Increasing hematocrit count
C. Cough of 30 days
D. Persistent headache
58. The community health nurses’ primary concern
in the immediate control of hemorrhage among
patients with dengue is:
A. Advising low fiber and non-fat diet
B. Providing warmth through light weight
covers
C. Observing closely the patient for vital
signs leading to shock
D. Keeping the patient at rest
59. Which of these signs may NOT be REGARDED as
a truly positive signs indicative of Dengue Hfever?
A. Prolonged bleeding time
B. Appearance of at least 20 petechiae
within 1cm square
C. Steadily increasing hematocrit count
D. Fall in the platelet count
60. Which of the following is the most important
treatment of patients with Dengue H-fever?
A. Give aspirin for fever
B. Replacement of body fluids
C. Avoid unnecessary movement of patient
D. Ice cap over the abdomen in case of
melena
Situation: Health education and Health promotion is an
important part of nursing responsibility in the
community. Immunization is a form of health promotion
that aims at preventing the common childhood illnesses.
61. In correcting misconceptions and myths about
certain diseases and their management, the
health worker should first:
A. Identify the myths and misconceptions
prevailing in the community
B. Identify the source of these myths and
misconceptions
C. Explain how and why these myths came
about
D. Select the appropriate IEC strategies to
correct them
62. How many percent of measles are prevented by
immunization at 9 months of age?
A. 80%
B. 99%
C. 90%
D. 95%
63. After TT3 vaccination a mother is said to be
protected to tetanus by around:
A. 80%
B. 99%
C. 85%
D. 90%
64. If ever convulsions occur after administering
DPT, what should the nurse best suggest to the
mother?
A. Do not continue DPT vaccination
anymore
B. Advise mother to comeback after 1 week
C. Give DT instead of DPT
D. Give pertussis of the DPT and remove DT
65. These vaccines are given 3 doses at one month
intervals:
A. DPT, BCG, TT
B. OPV, HEP. B, DPT
C. DPT, TT, OPV
D. Measles, OPV, DPT
Situation – With the increasing documented cases of
CANCER the best alternative to treatment still remains to
be PREVENTION. The following conditions apply.
66. Which among the following is the primary focus
of prevention of cancer?
A. Elimination of conditions causing cancer
B. Diagnosis and treatment
C. Treatment at early stage
D. Early detection
67. In the prevention and control of cancer, which of
the following activities is the most important
function of the community health nurse?
A. Conduct community assemblies.
B. Referral to cancer specialist those clients
with symptoms of cancer.
C. Use the nine warning signs of cancer as
parameters in our process of detection,
control and treatment modalities.
D. Teach woman about proper/correct
nutrition.
68. Who among the following are recipients of the
secondary level of care for cancer cases?
A. Those under early case detection
B. Those under post case treatment
C. Those scheduled for surgery
D. Those undergoing treatment
69. Who among the following are recipients of the
tertiary level of care for cancer cases?
A. Those under early treatment
B. Those under early detection
C. Those under supportive care
D. Those scheduled for surgery
70. In Community Health Nursing, despite the
availability and use of many equipment and
devices to facilitate the job of the community
health nurse, the best tool any nurse should be
wel be prepared to apply is a scientific approach.
This approach ensures quality of care even at the
community setting. This is nursing parlance is
nothing less than the:
A. nursing diagnosis
B. nursing research
C. nursing protocol
D. nursing process
Situation – Two children were brought to you. One with
chest indrawing and the other had diarrhea. The
following questions apply:
71. Using Integrated Management and Childhood
Illness (IMCI) approach, how would you classify
the 1st child?
A. Bronchopneumonia
B. Severe pneumonia
C. No pneumonia : cough or cold
D. Pneumonia
72. The 1st child who is 13 months has fast
breathing using IMCI parameters he has:
A. 40 breaths per minute or more
B. 50 breaths per minute
22
C. 30 breaths per minute or more
D. 60 breaths per minute
73. 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 offered
fluids and and the child drinks eagerly. How
would you classify Nina’s illness?
A. Some dehydration
B. Severe dehydration
C. Dysentery
D. No dehydration
74. Nina’s treatment should include the following
EXCEPT:
A. reassess the child and classify him for
dehydration
B. for infants under 6 months old who are
not breastfed, give 100-200 ml clean
water as well during this period
C. Give in the health center the
recommended amount of ORS for 4
hours.
D. Do not give any other foods to the child
for home treatment
75. While on treatment, Nina 18 months old
weighed 18 kgs. and her temperature registered
at 37 degrees C. Her mother says she developed
cough 3 days ago. Nina has no general danger
signs. She has 45 breaths/minute, no chest indrawing, no stridor. How would you classify
Nina’s manifestation?
A. No pneumonia
B. Pneumonia
C. Severe pneumonia
D. Bronchopneumonia
76. Carol is 15 months old and weighs 5.5 kgs and it
is her initial visit. Her mother says that Carol is
not eating well and unable to breastfeed, he has
no vomiting, has no convulsion and not
abnormally sleepy or difficult to awaken. Her
temperature is 38.9 deg C. Using the integrated
management of childhood illness or IMCI
strategy, if you were the nurse in charge of
Carol, how will you classify her illness?
A. a child at a general danger sign
B. severe pneumonia
C. very severe febrile disease
D. severe malnutrition
77. Why are small for gestational age newborns at
23
risk for difficulty maintaining body temperature?
A. their skin is more susceptible to
conduction of cold
B. they are preterm so are born relatively
small in size
C. they do not have as many fat stored as
other infants
D. they are more active than usual so they
throw off comes
78. Oxytocin is administered to Rita to augment
labor. What are the first symptoms of water
intoxication to observe for during this
procedure?
A. headache and vomiting
B. a high choking voice
C. a swollen tender tongue
D. abdominal bleeding and pain
79. Which of the following treatment should NOT be
considered if the child has severe dengue
hemorrhagic fever?
A. use plan C if there is bleeding from the
nose or gums
B. give ORS if there is skin Petechiae,
persistent vomiting, and positive
tourniquet test
C. give aspirin
D. prevent low blood sugar
80. In assessing the patient’s condition using the
Integrated Management of Childhood Illness
approach strategy, the first thing that a nurse
should do is to:
A. ask what are the child’s problem
B. check for the four main symptoms
C. check the patient’s level of
consciousness
D. check for the general danger signs
81. A child with diarrhea is observed for the
following EXCEPT:
A. how long the child has diarrhea
B. presence of blood in the stool
C. skin Petechiae
D. signs of dehydration
82. The child with no dehydration needs home
treatment. Which of the following is NOT
included in the care for home management at
this case?
A. give drugs every 4 hours
B. give the child more fluids
C. continue feeding the child
D. inform when to return to the health
center
83. Ms. Jordan, RN, believes that a patient should be
treated as individual. This ethical principle that
the patient referred to:
A. beneficence
B. respect for person
C. nonmaleficence
D. autonomy
84. When patients cannot make decisions for
themselves, the nurse advocate relies on the
ethical principle of:
A. justice and beneficence
B. beneficence and nonmaleficence
C. fidelity and nonmaleficence
D. fidelity and justice
85. Being a community health nurse, you have the
responsibility of participating in protecting the
health of people. Consider this situation:
Vendors selling bread with their bare hands.
They receive money with these hands. You do
not see them washing their hands. What should
you say/do?
A. “Miss, may I get the bread myself
because you have not washed your
hands”
B. All of these
C. “Miss, it is better to use a pick up
forceps/ bread tong”
D. “Miss, your hands are dirty. Wash your
hands first before getting the bread”
Situation: The following questions refer to common
clinical encounters experienced by an entry level nurse.
86. A female client asks the nurse about the use of a
cervical cap. Which statement is correct
regarding the use of the cervical cap?
A. It may affect Pap smear results.
B. It does not need to be fitted by the
physician.
C. It does not require the use of
spermicide.
D. It must be removed within 24 hours.
87. The major components of the communication
process are:
A. Verbal, written and nonverbal
B. Speaker, listener and reply
C. Facial expression, tone of voice and
gestures
D. Message, sender, channel, receiver and
feedback
88. The extent of burns in children are normally
assessed and expressed in terms of:
A. The amount of body surface that is
unburned
B. Percentages of total body surface area
(TBSA)
C. How deep the deepest burns are
D. The severity of the burns on a 1 to 5
burn scale.
89. The school nurse notices a child who is wearing
old, dirty, poor-fitting clothes; is always hungry;
has no lunch money; and is always tired. When
the nurse asks the boy his tiredness, he talks of
playing outside until midnight. The nurse will
suspect that this child is:
A. Being raised by a parent of low
intelligence quotient (IQ)
B. An orphan
C. A victim of child neglect
D. The victim of poverty
90. Which of the following indicates the type(s) of
acute renal failure?
A. Four types: hemorrhagic with and
without clotting, and nonhemorrhagic
with and without clottings
B. One type: acute
C. Three types: prerenal, intrarenal and
postrenal
D. Two types: acute and subacute
Situation: 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 to
contract AIDS?
A. Syringe and needles
B. Sexual contact
C. Body fluids
D. Transfusion
92. Causative organism in AIDS is one of the
following;
A. Fungus
B. retrovirus
C. Bacteria
24
D. Parasites
93. You are assigned in a private room of Mike.
Which procedure should be of outmost
importance;
A. Alcohol wash
B. Washing Isolation
C. Universal precaution
D. Gloving technique
94. What primary health teaching would you give to
mike;
A. Daily exercise
B. reverse isolation
C. Prevent infection
D. Proper nutrition
95. Exercise precaution must be taken to protect
health worker dealing with the AIDS patients .
which among these must be done as priority:
A. Boil used syringe and needles
B. Use gloves when handling specimen
C. Label personal belonging
D. Avoid accidental wound
Situation: Michelle is a 6 year old preschooler. She was
reported by her sister to have measles but she is at
home because of fever, upper respiratory problem and
white sports in her mouth.
96. Rubeola is an Arabic term meaning Red, the rash
appears on the skin in invasive stage prior to
eruption behind the ears. As a nurse, your
physical examination must determine
complication especially:
A. Otitis media
B. Inflammatory conjunctiva
C. Bronchial pneumonia
D. Membranous laryngitis
97. To render comfort measure is one of the
priorities, Which includes care of the skin, eyes,
ears, mouth and nose. To clean the mouth, your
antiseptic solution is in some form of which one
below?
A. Water
B. Alkaline
C. Sulfur
D. Salt
98. As a public health nurse, you teach mother and
family members the prevention of complication
of measles. Which of the following should be
25
closely watched?
A. Temperature fails to drop
B. Inflammation of the nasophraynx
C. Inflammation of the conjunctiva
D. Ulcerative stomatitis
99. Source of infection of measles is secretion of
nose and throat of infection person. Filterable
virus of measles is transmitted by:
A. Water supply
B. Food ingestion
C. Droplet
D. Sexual contact
100.
Method of prevention is to avoid
exposure to an infection person. Nursing
responsibility for rehabilitation of patient
includes the provision of:
A. Terminal disinfection
B. Immunization
C. Injection of gamma globulin
D. Comfort measures
c. 50 days
d. 14 days
NURSING PRACTICE III
Situation: Leo lives in the squatter area. He goes to
nearby school. He helps his mother gather molasses
after school. One day, he was absent because of fever,
malaise, anorexia and abdominal discomfort.
1.
2.
3.
4.
5.
26
Upon assessment, Leo was diagnosed to have
hepatitis A. Which mode of transmission has the
infection agent taken?
a. Fecal-oral
b. Droplet
c. Airborne
d. Sexual contact
Which of the following is concurrent disinfection
in the case of Leo?
a. Investigation of contact
b. Sanitary disposal of faeces, urine and
blood
c. Quarantine of the sick individual
d. removing all detachable objects in the
room, cleaning lighting and air duct
surfaces in the ceiling, and cleaning
everything downward to the floor
Which of the following must be emphasized
during mother’s class to Leo’s mother?
a. Administration of Immunoglobulin to
families
b. Thorough hand washing before and
after eating and toileting
c. Use of attenuated vaccines
d. Boiling of food especially meat
Disaster control should be undertaken when
there are 3 or more hepatitis A cases. Which of
these measures is a priority?
a. Eliminate faecal contamination from
foods
b. Mass vaccination of uninfected
individuals
c. Health promotion and education to
families and communities about the
disease it’s cause and transmission
d. Mass administration of Immunoglobulin
What is the average incubation period of
Hepatitis A?
a. 30 days
b. 60 days
Situation: As a nurse researcher you must have a very
good understanding of the common terms of concept
used in research.
6.
The information that an investigator collects
from the subjects or participants in a research
study is usually called;
a. Hypothesis
b. Variable
c. Data
d. Concept
7.
Which of the following usually refers to the
independent variables in doing research
a. Result
b. output
c. Cause
d. Effect
8.
The recipients of experimental treatment is an
experimental design or the individuals to be
observed in a non experimental design are
called;
a. Setting
b. Treatment
c. Subjects
d. Sample
9.
The device or techniques an investigator
employs to collect data is called;
a. Sample
b. hypothesis
c. Instrument
d. Concept
10.
The use of another person’s ideas or wordings
without giving appropriate credit results from
inaccurate or incomplete attribution of materials
to its sources. Which of the following is referred
to when another person’s idea is inappropriate
credited as one’s own;
a. Plagiarism
b. assumption
c. Quotation
d. Paraphrase
Situation – Mrs. Pichay is admitted to your ward. The
MD ordered “Prepare for thoracentesis this pm to
remove excess air from the pleural cavity.”
27
11.
Which of the following nursing responsibilities is
essential in Mrs. Pichay who will undergo
thoracentesis?
a. Support and reassure client during the
procedure
b. Ensure that informed consent has been
signed
c. Determine if client has allergic reaction
to local anesthesia
d. Ascertain if chest x-rays and other tests
have been prescribed and completed
12.
Mrs. Pichay who is for thoracentesis is assigned
by the nurse to which of the following positions?
a. Trendelenburg position
b. Supine position
c. Dorsal Recumbent position
d. Orthopneic position
13.
During thoracentesis, which of the following
nursing intervention will be most crucial?
a. Place patient in a quiet and cool room
b. Maintain strict aseptic technique
c. Advice patient to sit perfectly still
during needle insertion until it has been
withdrawn from the chest
d. Apply pressure over the puncture site as
soon as the needle is withdrawn
14.
To prevent leakage of fluid in the thoracic cavity,
how will you position the client after
thoracentesis?
a. Place flat in bed
b. Turn on the unaffected side
c. Turn on the affected side
d. On bed rest
15.
Chest x-ray was ordered after thoracentesis.
When your client asks what is the reason for
another chest x-ray, you will explain:
a. To rule out pneumothorax
b. To rule out any possible perforation
c. To decongest
d. To rule out any foreign body
Situation: A computer analyst, Mr. Ricardo J. Santos, 25
was brought to the hospital for diagnostic workup after
he had experienced seizure in his office.
a. Ease the patient to the floor
b. Lift the patient and put him on the bed
c. Insert a padded tongue depressor
between his jaws
d. Restraint patient’s body movement
17.
Mr Santos is scheduled for CT SCAN for the next
day, noon time. Which of the following is the
correct preparation as instructed by the nurse?
a. Shampoo hair thoroughly to remove oil
and dirt
b. No special preparation is needed.
Instruct the patient to keep his head
still and stead
c. Give a cleansing enema and give fluids
until 8 AM
d. Shave scalp and securely attach
electrodes to it
18.
Mr Santos is placed on seizure precaution.
Which of the following would be
contraindicated?
a. Obtain his oral temperature
b. Encourage to perform his own personal
hygiene
c. Allow him to wear his own clothing
d. Encourage him to be out of bed
19.
Usually, how does the patient behave after his
seizure has subsided?
a. Most comfortable walking and moving
about
b. Becomes restless and agitated
c. Sleeps for a period of time
d. Say he is thirsty and hungry
20.
Before, during and after seizure. The nurse
knows that the patient is ALWAYS placed in what
position?
a. Low fowler’s
b. Side lying
c. Modified trendelenburg
d. Supine
Situation: Mrs. Damian an immediate post op
cholecystectomy and choledocholithotomy patient,
complained of severe pain at the wound site.
21.
16.
Just as the nurse was entering the room, the
patient who was sitting on his chair begins to
have a seizure. Which of the following must the
nurse do first?
Choledocholithotomy is:
a. The removal of the gallbladder
b. The removal of the stones in the
gallbladder
c. The removal of the stones in the
common bile duct
d. The removal of the stones in the kidney
22.
23.
The simplest pain relieving technique is:
a. Distraction
b. Deep breathing exercise
c. Taking aspirin
d. Positioning
Which of the following statement on pain is
TRUE?
a. Culture and pain are not associated
b. Pain accompanies acute illness
c. Patient’s reaction to pain Varies
d. Pain produces the same reaction such as
groaning and moaning
24.
In pain assessment, which of the following
condition is a more reliable indicator?
a. Pain rating scale of 1 to 10
b. Facial expression and gestures
c. Physiological responses
d. Patients description of the pain
sensation
25.
When a client complains of pain, your initial
response is:
a. Record the description of pain
b. Verbally acknowledge the pain
c. Refer the complaint to the doctor
d. Change to a more comfortable position
alleviate anxiety
c. Avoid overdosing to prevent
dependence/tolerance
d. Monitor VS, more importantly RR
28.
The client complained of abdominal distention
and pain. Your nursing intervention that can
alleviate pain is:
a. Instruct client to go to sleep and relax
b. Advice the client to close the lips and
avoid deep breathing and talking
c. Offer hot and clear soup
d. Turn to sides frequently and avoid too
much talking
29.
Surgical pain might be minimized by which
nursing action in the O.R.
a. Skill of surgical team and lesser
manipulation
b. Appropriate preparation for the
scheduled procedure
c. Use of modern technology in closing the
wound
d. Proper positioning and draping of clients
30.
Inadequate anesthesia is said to be one of the
common cause of pain both in intra and post op
patients. If General anesthesia is desired, it will
involve loss of consciousness. Which of the
following are the 2 general types of GA?
a. Epidural and Spinal
b. Subarachnoid block and Intravenous
c. Inhalation and Regional
d. Intravenous and Inhalation
Situation: You are assigned at the surgical ward and
clients have been complaining of post pain at varying
degrees. Pain as you know, is very subjective.
26.
27.
28
A one-day postoperative abdominal surgery
client has been complaining of severe throbbing
abdominal pain described as 9 in a 1-10 pain
rating. Your assessment reveals bowel sounds on
all quadrants and the dressing is dry and intact.
What nursing intervention would you take?
a. Medicate client as prescribed
b. Encourage client to do imagery
c. Encourage deep breathing and turning
d. Call surgeon stat
Pentoxidone 5 mg IV every 8 hours was
prescribed for post abdominal pain. Which will
be your priority nursing action?
a. Check abdominal dressing for possible
swelling
b. Explain the proper use of PCA to
Situation: Nurse’s attitudes toward the pain influence
the way they perceive and interact with clients in pain.
31.
Nurses should be aware that older adults are at
risk of underrated pain. Nursing assessment and
management of pain should address the
following beliefs EXCEPT:
a. Older patients seldom tend to report
pain than the younger ones
b. Pain is a sign of weakness
c. Older patients do not believe in
analgesics, they are tolerant
d. Complaining of pain will lead to being
labeled a ‘bad’ patient
32.
Nurses should understand that when a client
responds favorably to a placebo, it is known as
the ‘placebo effect’. Placebos do not indicate
29
whether or not a client has:
a. Conscience
b. Disease
c. Real pain
d. Drug tolerance
33.
34.
35.
You are the nurse in the pain clinic where you
have client who has difficulty specifying the
location of pain. How can you assist such client?
a. The pain is vague
b. By charting-it hurts all over
c. Identify the absence and presence of
pain
d. As the client to point to the painful are
by just one finger
What symptom, more distressing than pain,
should the nurse monitor when giving opioids
especially among elderly clients who are in pain?
a. Forgetfulness
b. Drowsiness
c. Constipation
d. Allergic reactions like pruritis
Physical dependence occurs in anyone who
takes opiods over a period of time. What do you
tell a mother of a ‘dependent’ when asked for
advice?
a. Start another drug and slowly lessen the
opioid dosage
b. Indulge in recreational outdoor activities
c. Isolate opioid dependent to a restful
resort
d. Instruct slow tapering of the drug
dosage and alleviate physical
withdrawal symptoms
Situation: The nurse is performing health education
activities for Janevi Segovia, a 30 year old Dentist with
Insulin dependent diabetes Miletus.
36.
Janevi is preparing a mixed dose of insulin. The
nurse is satisfied with her performance when
she:
a. Draw insulin from the vial of clear
insulin first
b. Draw insulin from the vial of the
intermediate acting insulin first
c. Fill both syringes with the prescribed
insulin dosage then shake the bottle
vigorously
d. Withdraw the intermediate acting
insulin first before withdrawing the short
acting insulin first
37.
Janevi complains of nausea, vomiting,
diaphoresis and headache. Which of the
following nursing intervention are you going to
carry out first?
a. Withhold the client’s next insulin
injection
b. Test the client’s blood glucose level
c. Administer Tylenol as ordered
d. Offer fruit juice, gelatine and chicken
bouillon
38.
Janevi administered regular insulin at 7 A.M and
the nurse should instruct Jane to avoid
exercising at around:
a. 9 to 11 A.M
b. Between 8 A.M to 9 A.M
c. After 8 hours
d. In the afternoon, after taking lunch
39.
Janevi was brought at the emergency room after
four month because she fainted in her clinic. The
nurse should monitor which of the following test
to evaluate the overall therapeutic compliance
of a diabetic patient?
a. Glycosylated hemoglobin
b. Ketone levels
c. Fasting blood glucose
d. Urine glucose level
40.
Upon the assessment of Hba1c of Mrs. Segovia,
The nurse has been informed of a 9% Hba1c
result. In this case, she will teach the patient to:
a. Avoid infection
b. Prevent and recognize hyperglycaemia
c. Take adequate food and nutrition
d. Prevent and recognize hypoglycaemia
41.
The nurse is teaching plan of care for Jane with
regards to proper foot care. Which of the
following should be included in the plan?
a. Soak feet in hot water
b. Avoid using mild soap on the feet
c. Apply a moisturizing lotion to dry feet
but not between the toes
d. Always have a podiatrist to cut your toe
nails; never cut them yourself
42.
Another patient was brought to the emergency
room in an unresponsive state and a diagnosis of
hyperglycaemic hyperosmolar nonketotic
syndrome is made. The nurse immediately
prepares to initiate which of the following
anticipated physician’s order?
a. Endotracheal intubation
b. 100 unites of NPH insulin
c. Intravenous infusion of normal saline
d. Intravenous infusion of sodium
bicarbonate
43.
44.
45.
Jane eventually developed DKA and is being
treated in the emergency room. Which finding
would the nurse expect to note as confirming
this diagnosis?
a. Comatose state
b. Decreased urine output
c. Increased respiration and an increase in
pH
d. Elevated blood glucose level and low
plasma bicarbonate level
The nurse teaches Jane to know the difference
between hypoglycaemia and ketoacidosis. Jane
demonstrates understanding of the teaching by
stating that glucose will be taken if which of the
following symptoms develops?
a. Polyuria
b. Shakiness
c. Blurred Vision
d. Fruity breath odour
Jane has been scheduled to have a FBS taken in
the morning. The nurse tells Jane not to eat or
drink after midnight. Prior to taking the blood
specimen, the nurse noticed that Jane is holding
a bottle of distilled water. The nurse asked Jane
if she drink any, and she said “yes.” Which of the
following is the best nursing action?
a. Administer syrup of ipecac to remove
the distilled water from the stomach
b. Suction the stomach content using NGT
prior to specimen collection
c. Advice to physician to reschedule to
diagnostic examination next day
d. Continue as usual and have the FBS
analysis performed and specimen be
taken
Situation: Elderly clients usually produce unusual signs
when it comes to different diseases. The ageing process
is a complicated process and the nurse should
understand that it is an inevitable fact and she must be
prepared to care for the growing elderly population.
46.
30
Hypoxia may occur in the older patients because
of which of the following physiologic changes
associated with aging.
a. Ineffective airway clearance
b. Decreased alveolar surfaced area
c. Decreased anterior-posterior chest
diameter
d. Hyperventilation
47.
The older patient is at higher risk for
incontinence because of:
a. Dilated urethra
b. Increased glomerular filtration rate
c. Diuretic use
d. Decreased bladder capacity
48.
Merle, age 86, is complaining of dizziness when
she stands up. This may indicate:
a. Dementia
b. Functional decline
c. A visual problem
d. Drug toxicity
49.
Cardiac ischemia in an older patient usually
produces:
a. ST-T wave changes
b. Chest pain radiating to the left arm
c. Very high creatinine kinase level
d. Acute confusion
50.
The most dependable sign of infection in the
older patient is:
a. Change in mental status
b. Fever
c. Pain
d. Decreased breath sounds with crackles
Situation – In the OR, there are safety protocols that
should be followed. The OR nurse should be well versed
with all these to safeguard the safety and quality of
patient delivery outcome.
51.
Which of the following should be given highest
priority when receiving patient in the OR?
a. Assess level of consciousness
b. Verify patient identification and
informed consent
c. Assess vital signs
d. Check for jewelry, gown, manicure, and
dentures
52.
Surgeries like I and D (incision and drainage) and
debridement are relatively short procedures but
considered ‘dirty cases’. When are these
31
procedures best scheduled?
a. Last case
b. In between cases
c. According to availability of
anaesthesiologist
d. According to the surgeon’s preference
53.
OR nurses should be aware that maintaining the
client’s safety is the overall goal of nursing care
during the intraoperative phase. As the
circulating nurse, you make certain that
throughout the procedure…
a. the surgeon greets his client before
induction of anesthesia
b. the surgeon and anesthesiologist are in
tandem
c. strap made of strong non-abrasive
materials are fastened securely around
the joints of the knees and ankles and
around the 2 hands around an arm
board.
d. Client is monitored throughout the
surgery by the assistant anesthesiologist
54.
Another nursing check that should not be missed
before the induction of general anesthesia is:
a. check for presence underwear
b. check for presence dentures
c. check patient’s ID
d. check baseline vital signs
55.
Some lifetime habits and hobbies affect
postoperative respiratory function. If your client
smokes 3 packs of cigarettes a day for the past
10 years, you will anticipate increased risk for:
a. perioperative anxiety and stress
b. delayed coagulation time
c. delayed wound healing
d. postoperative respiratory infection
Situation: Sterilization is the process of removing ALL
living microorganism. To be free of ALL living
microorganism is sterility.
56.
There are 3 general types of sterilization use in
the hospital, which one is not included?
a. Steam sterilization
b. Physical sterilization
c. Chemical sterilization
d. Sterilization by boiling
57.
Autoclave or steam under pressure is the most
common method of sterilization in the hospital.
The nurse knows that the temperature and time
is set to the optimum level to destroy not only
the microorganism, but also the spores. Which
of the following is the ideal setting of the
autoclave machine?
a. 10,000 degree Celsius for 1 hour
b. 5,000 degree Celsius for 30 minutes
c. 37 degree Celsius for 15 minutes
d. 121 degree Celsius for 15 minutes
58.
It is important that before a nurse prepares the
material to be sterilized, a chemical indicator
strip should be placed above the package,
preferably, Muslin sheet. What is the color of
the striped produced after autoclaving?
a. Black
b. Blue
c. Gray
d. Purple
59.
Chemical indicators communicate that:
a. The items are sterile
b. That the items had undergone
sterilization process but not necessarily
sterile
c. The items are disinfected
d. That the items had undergone
disinfection process but not necessarily
disinfected
60.
If a nurse will sterilize a heat and moisture labile
instruments, It is according to AORN
recommendation to use which of the following
method of sterilization?
a. Ethylene oxide gas
b. Autoclaving
c. Flash sterilizer
d. Alcohol immersion
Situation 5 – Nurses hold a variety of roles when
providing care to a perioperative patient.
61.
Which of the following role would be the
responsibility of the scrub nurse?
a. Assess the readiness of the client prior
to surgery
b. Ensure that the airway is adequate
c. Account for the number of sponges,
needles, supplies, used during the
surgical procedure.
d. Evaluate the type of anesthesia
appropriate for the surgical client
62.
As a perioperative nurse, how can you best meet
the safety need of the client after administering
preoperative narcotic?
a. Put side rails up and ask the client not
to get out of bed
b. Send the client to OR with the family
c. Allow client to get up to go to the
comfort room
d. Obtain consent form
63.
It is the responsibility of the pre-op nurse to do
skin prep for patients undergoing surgery. If hair
at the operative site is not shaved, what should
be done to make suturing easy and lessen
chance of incision infection?
a. Draped
b. Pulled
c. Clipped
d. Shampooed
64.
65.
It is also the nurse’s function to determine when
infection is developing in the surgical incision.
The perioperative nurse should observe for what
signs of impending infection?
a. Localized heat and redness
b. Serosanguinous exudates and skin
blanching
c. Separation of the incision
d. Blood clots and scar tissue are visible
68.
Tess, the PACU nurse, discovered that Malou,
who weighs 110 lbs prior to surgery, is in severe
pain 3 hrs after cholecystectomy. Upon checking
the chart, Malou found out that she has an order
of Demerol 100 mg I.M. prn for pain. Tess should
verify the order with:
a. Nurse Supervisor
b. Surgeon
c. Anesthesiologist
d. Intern on duty
69.
Rosie, 57, who is diabetic is for debridement if
incision wound. When the circulating nurse
checked the present IV fluid, she found out that
there is no insulin incorporated as ordered.
What should the circulating nurse do?
a. Double check the doctor’s order and
call the attending MD
b. Communicate with the ward nurse to
verify if insulin was incorporated or not
c. Communicate with the client to verify if
insulin was incorporated
d. Incorporate insulin as ordered.
70.
The documentation of all nursing activities
performed is legally and professionally vital.
Which of the following should NOT be included
in the patient’s chart?
a. Presence of prosthetoid devices such as
dentures, artificial limbs hearing aid, etc.
b. Baseline physical, emotional, and
psychosocial data
c. Arguments between nurses and
residents regarding treatments
d. Observed untoward signs and symptoms
and interventions including contaminant
intervening factors
Which of the following nursing interventions is
done when examining the incision wound and
changing the dressing?
a. Observe the dressing and type and odor
of drainage if any
b. Get patient’s consent
c. Wash hands
d. Request the client to expose the incision
wound
Situation – The preoperative nurse collaborates with the
client significant others, and healthcare providers.
66.
To control environmental hazards in the OR, the
nurse collaborates with the following
departments EXCEPT:
a. Biomedical division
b. Infection control committee
c. Chaplaincy services
d. Pathology department
67.
An air crash occurred near the hospital leading
to a surge of trauma patient. One of the last
32
patients will need surgical amputation but there
are no sterile surgical equipments. In this case,
which of the following will the nurse expect?
a. Equipments needed for surgery need not
be sterilized if this is an emergency
necessitating life saving measures
b. Forwarding the trauma client to the
nearest hospital that has available sterile
equipments is appropriate
c. The nurse will need to sterilize the item
before using it to the client using the
regular sterilization setting at 121
degree Celsius in 15 minutes
d. In such cases, flash sterlizer will be use
at 132 degree Celsius in 3 minutes
33
Situation – Team efforts is best demonstrated in the OR.
71.
72.
73.
74.
75.
If you are the nurse in charge for scheduling
surgical cases, what important information do
you need to ask the surgeon?
a. Who is your internist
b. Who is your assistant and
anaesthesiologist, and what is your
preferred time and type of surgery?
c. Who are your anaesthesiologist,
internist, and assistant
d. Who is your anaesthesiologist
In the OR, the nursing tandem for every surgery
is:
a. Instrument technician and circulating
nurse
b. Nurse anaesthetist, nurse assistant, and
instrument technician
c. Scrub nurse and nurse anaesthetist
d. Scrub and circulating nurses
While team effort is needed in the OR for
efficient and quality patient care delivery, we
should limit the number of people in the room
for infection control. Who comprise this team?
a. Surgeon, anaesthesiologist, scrub nurse,
radiologist, orderly
b. Surgeon, assistants, scrub nurse,
circulating nurse, anaesthesiologist
c. Surgeon, assistant surgeon,
anaesthesiologist, scrub nurse,
pathologist
d. Surgeon, assistant surgeon,
anaesthesiologist, intern, scrub nurse
Who usually act as an important part of the OR
personnel by getting the wheelchair or stretcher,
and pushing/pulling them towards the operating
room?
a. Orderly/clerk
b. Nurse Supervisor
c. Circulating Nurse
d. Anaesthesiologist
The breakdown in teamwork is often times a
failure in:
a. Electricity
b. Inadequate supply
c. Leg work
d. Communication
Situation: Basic knowledge on Intravenous solutions is
necessary for care of clients with problems with fluids
and electrolytes.
76.
A client involved in a motor vehicle crash
presents to the emergency department with
severe internal bleeding. The client is severely
hypotensive and unresponsive. The nurse
anticipates which of the following intravenous
solutions will most likely be prescribed to
increase intravascular volume, replace
immediate blood loss and increase blood
pressure?
a. 0.45% sodium chloride
b. 0.33% sodium chloride
c. Normal saline solution
d. Lactated ringer’s solution
77.
The physician orders the nurse to prepare an
isotonic solution. Which of the following IV
solution would the nurse expect the intern to
prescribe?
a. 5% dextrose in water
b. 0.45% sodium chloride
c. 10% dextrose in water
d. 5% dextrose in 0.9% sodium chloride
78.
The nurse is making initial rounds on the nursing
unit 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 following
complications has been experienced by the
client?
a. Infection
b. Phlebitis
c. Infiltration
d. Thrombophelibitis
79.
A nurse reviews the client’s electrolyte
laboratory report and notes that the potassium
level is 3.2 mEq/L. Which of the following would
the nurse note on the electrocardiogram as a
result of the laboratory value?
a. U waves
b. Absend P waves
c. Elevated T waves
d. Elevated ST segment
80.
One patient had a ‘runaway’ IV of 50% dextrose.
To prevent temporary excess of insulin or
transient hyperinsulin reaction what solution
you prepare in anticipation of the doctor’s
order?
a.
b.
c.
d.
81.
82.
83.
Any IV solution available to KVO
Isotonic solution
Hypertonic solution
Hypotonic solution
An informed consent is required for:
a. closed reduction of a fracture
b. irrigation of the external ear canal
c. insertion of intravenous catheter
d. urethral catheterization
Which of the following is not true with regards
to the informed consent?
a. It should describe different treatment
alternatives
b. It should contain a thorough and
detailed explanation of the procedure
to be done
c. It should describe the client’s diagnosis
d. It should give an explanation of the
client’s prognosis
You know that the hallmark of nursing
accountability is the:
a. accurate documentation and reporting
b. admitting your mistakes
c. filing an incidence report
d. reporting a medication error
84.
A nurse is assigned to care for a group of clients.
On review of the client’s medical records, the
nurse determines that which client is at risk for
excess fluid volume?
a. The client taking diuretics
b. The client with renal failure
c. The client with an ileostomy
d. The client who requires gastrointestinal
suctioning
85.
A nurse is assigned to care for a group of clients.
On review of the client’s medical records, the
nurse determines that which client is at risk for
deficient fluid volume?
a. A client with colostomy
b. A client with congestive heart failure
c. A client with decreased kidney function
d. A client receiving frequent wound
irrigation
Situation: As a perioperative nurse, you are aware of the
correct processing methods for preparing instruments
and other devices for patient use to prevent infection.
34
86.
As an OR nurse, what are your foremost
considerations for selecting chemical agents for
disinfection?
a. Material compatibility and efficiency
b. Odor and availability
c. Cost and duration of disinfection process
d. Duration of disinfection and efficiency
87.
Before you use a disinfected instrument it is
essential that you:
a. Rinse with tap water followed by alcohol
b. Wrap the instrument with sterile water
c. Dry the instrument thoroughly
d. Rinse with sterile water
88.
You have a critical heat labile instrument to
sterilize and are considering to use high level
disinfectant. What should you do?
a. Cover the soaking vessel to contain the
vapor
b. Double the amount of high level
disinfectant
c. Test the potency of the high level
disinfectant
d. Prolong the exposure time according to
manufacturer’s direction
89.
To achieve sterilization using disinfectants,
which of the following is used?
a. Low level disinfectants immersion in 24
hours
b. Intermediate level disinfectants
immersion in 12 hours
c. High level disinfectants immersion in 1
hour
d. High level disinfectant immersion in 10
hours
90.
Bronchoscope, Thermometer, Endoscope, ET
tube, Cytoscope are all BEST sterilized using
which of the following?
a. Autoclaving at 121 degree Celsius in 15
minutes
b. Flash sterilizer at 132 degree Celsius in 3
minutes
c. Ethylene Oxide gas aeration for 20 hours
d. 2% Glutaraldehyde immersion for 10
hours
Situation: The OR is divided into three zones to control
traffic flow and contamination
35
91.
92.
93.
What OR attires are worn in the restricted area?
a. Scrub suit, OR shoes, head cap
b. Head cap, scrub suit, mask, OR shoes
c. Mask, OR shoes, scrub suit
d. Cap, mask, gloves, shoes
Nursing intervention for a patient on low dose IV
insulin therapy includes the following, EXCEPT:
a. Elevation of serum ketones to monitor
ketosis
b. Vital signs including BP
c. Estimate serum potassium
d. Elevation of blood glucose levels
The doctor ordered to incorporate 1000”u”
insulin to the remaining on-going IV. The
strength is 500 /ml. How much should you
incorporate into the IV solution?
a. 10 ml
b. 0.5 ml
c. 2 ml
d. 5 ml
94.
Multiple vial-dose-insulin when in use should be
a. Kept at room temperature
b. Kept in narcotic cabinet
c. Kept in the refrigerator
d. Store in the freezer
95.
Insulins using insulin syringe are given using how
many degrees of needle insertion?
a. 45
b. 180
c. 90
d. 15
Situation: Maintenance of sterility is an important
function a nurse should perform in any OR setting.
96.
Which of the following is true with regards to
sterility?
a. Sterility is time related, items are not
considered sterile after a period of 30
days of being not use.
b. for 9 months, sterile items are
considered sterile as long as they are
covered with sterile muslin cover and
stored in a dust proof covers.
c. Sterility is event related, not time
related
d. For 3 weeks, items double covered with
muslin are considered sterile as long as
they have undergone the sterilization
process
97.
2 organizations endorsed that sterility are
affected by factors other than the time itself,
these are:
a. The PNA and the PRC
b. AORN and JCAHO
c. ORNAP and MCNAP
d. MMDA and DILG
98.
All of these factors affect the sterility of the OR
equipments, these are the following except:
a. The material used for packaging
b. The handling of the materials as well as
its transport
c. Storage
d. The chemical or process used in
sterililzing the material
99.
When you say sterile, it means:
a. The material is clean
b. The material as well as the equipments
are sterilized and had undergone a
rigorous sterilization process
c. There is a black stripe on the paper
indicator
d. The material has no microorganism nor
spores present that might cause an
infection
100.
In using liquid sterilizer versus autoclave
machine, which of the following is true?
a. Autoclave is better in sterilizing OR
supplies versus liquid sterilizer
b. They are both capable of sterilizing the
equipments, however, it is necessary to
soak supplies in the liquid sterilizer for
a longer period of time
c. Sharps are sterilized using autoclave and
not cidex
d. If liquid sterilizer is used, rinsing it
before using is not necessary
d. CT Scan and Incidence report
NURSING PRACTICE IV
Situation: After an abdominal surgery, the circulating
and scrub nurses have critical responsibility about
sponge and instrument count.
1.
Counting is performed thrice: During the
preincision phase, the operative phase and
closing phase. Who counts the sponges, needles
and instruments?
a. The scrub nurse only
b. The circulating nurse only
c. The surgeon and the assistant surgeon
d. The scrub nurse and the circulating
nurse
2.
The layer of the abdomen is divided into 5.
Arrange the following from the first layer going
to the deepest layer:
1.
Fascia
2.
Muscle
3.
Peritoneum
4.
Subcutaneous/Fat
5.
Skin
a. 5,4,3,2,1
b. 5,4,1,3,2
c. 5,4,2,1,3
d. 5,4,1,2,3
3.
4.
5.
36
When is the first sponge/instrument count
reported?
a. Before closing the subcutaneous layer
b. Before peritoneum is closed
c. Before closing the skin
d. Before the fascia is sutured
Like any nursing interventions, counts should be
documented. To whom does the scrub nurse
report any discrepancy of counts so that
immediate and appropriate action is instituted?
a. Anaesthesiologists
b. Surgeon
c. OR nurse supervisor
d. Circulating nurse
Which of the following are 2 interventions of the
surgical team when an instrument was
confirmed missing?
a. MRI and Incidence report
b. CT Scan, MRI, Incidence report
c. X-RAY and Incidence report
Situation: An entry level nurse should be able to apply
theoretical knowledge in the performance of the basic
nursing skills.
6.
A client has an indwelling urinary catheter and
she is suspected of having urinary infection. How
should you collect a urine specimen for culture
and sensitivity?
a. clamp tubing for 60 minutes and insert a
sterile needle into the tubing above the
clamp to aspirate urine
b. drain urine from the drainage bag into
the sterile container
c. disconnect the tubing from the urinary
catheter and let urine flow into a sterile
container
d. wipe the self-sealing aspiration port
with antiseptic solution and insert a
sterile needle into the self-sealing port
7.
To obtain specimen for sputum culture and
sensitivity, which of the following instruction is
best?
a. Upon waking up, cough deeply and
expectorate into container
b. Cough after pursed lip breathing
c. Save sputum for two days in covered
container
d. After respiratory treatment, expectorate
into a container
8.
The best time for collecting the sputum
specimen for culture and sensitivity is:
a. Before retiring at night
b. Anytime of the day
c. Upon waking up in the morning
d. Before meals
9.
When suctioning the endotracheal tube, the
nurse should:
a. Explain procedure to patient; insert
catheter gently applying suction.
Withdrawn using twisting motion
b. Insert catheter until resistance is met,
and then withdraw slightly, applying
suction intermittently as catheter is
withdrawn
c. Hyperoxygenate client insert catheter
using back and forth motion
d. Insert suction catheter four inches into
the tube, suction 30 seconds using
37
twirling motion as catheter is withdrawn
10.
The purpose of NGT IMMEDIATELY after an
operation is:
a. For feeding or gavage
b. For gastric decompression
c. For lavage, or the cleansing of the
stomach content
d. For the rapid return of peristalsis
Situation - Mr. Santos, 50, is to undergo cystoscopy due
to multiple problems like scantly urination, hematuria
and dysuria.
11.
12.
13.
Nursing intervention includes:
a. Bed rest
b. Warm moist soak
c. Early ambulation
d. Hot sitz bath
Situation – Mang Felix, a 79 year old man who is brought
to the Surgical Unit from PACU after a transurethral
resection. You are assigned to receive him. You noted
that he has a 3-way indwelling urinary catheter for
continuous fast drip bladder irrigation which is
connected to a straight drainage.
16.
Immediately after surgery, what would you
expect his urine to be?
a. Light yellow
b. Bright red
c. Amber
d. Pinkish to red
17.
In the OR, you will position Mr. Santos who is
cystoscopy in:
a. Supine
b. Lithotomy
c. Semi-fowler
d. Trendelenburg
The purpose of the continuous bladder irrigation
is to:
a. Allow continuous monitoring of the fluid
output status
b. Provide continuous flushing of clots and
debris from the bladder
c. Allow for proper exchange of
electrolytes and fluid
d. Ensure accurate monitoring of intake
and output
18.
After cystoscopy, Mr. Santos asked you to
explain why there is no incision of any kind.
What do you tell him?
a. “Cystoscopy is direct visualization and
examination by urologist”.
b. “Cystoscopy is done by x-ray
visualization of the urinary tract”.
c. “Cystoscopy is done by using lasers on
the urinary tract”.
d. “Cystoscopy is an endoscopic procedure
of the urinary tract”.
Mang Felix informs you that he feels some
discomfort on the hypogastric area and he has to
void. What will be your most appropriate action?
a. Remove his catheter then allow him to
void on his own
b. Irrigate his catheter
c. Tell him to “Go ahead and void. You
have an indwelling catheter.”
d. Assess color and rate of outflow, if
there is changes refer to urologist for
possible irrigation.
19.
You decided to check on Mang Felix’s IV fluid
infusion. You noted a change in flow rate, pallor
and coldness around the insertion site. What is
your assessment finding?
a. Phlebitis
b. Infiltration to subcutaneous tissue
c. Pyrogenic reaction
d. Air embolism
20.
Knowing that proper documentation of
You are the nurse in charge in Mr. Santos. When
asked what are the organs to be examined
during cystoscopy, you will enumerate as
follows:
a. Urethra, kidney, bladder, urethra
b. Urethra, bladder wall, trigone, ureteral
opening
c. Bladder wall, uterine wall, and urethral
opening
d. Urethral opening, ureteral opening
bladder
14.
Within 24-48 hours post cystoscopy, it is normal
to observe one the following:
a. Pink-tinged urine
b. Distended bladder
c. Signs of infection
d. Prolonged hematuria
15.
Leg cramps are NOT uncommon post cystoscopy.
assessment findings and interventions are
important responsibilities of the nurse during
first post-operative day, which of the following is
the LEAST relevant to document in the case of
Mang Felix?
a. Chest pain and vital signs
b. Intravenous infusion rate
c. Amount, color, and consistency of
bladder irrigation drainage
d. Activities of daily living started
Situation: Melamine contamination in milk has brought
worldwide crisis both in the milk production sector as
well as the health and economy. Being aware of the
current events is one quality that a nurse should possess
to prove that nursing is a dynamic profession that will
adapt depending on the patient’s needs.
21.
Melamine is a synthetic resin used for
whiteboards, hard plastics and jewellery box
covers due to its fire retardant properties. Milk
and food manufacturers add melamine in order
to:
a. It has a bacteriostatic property leading
to increase food and milk life as a way of
preserving the foods
b. Gives a glazy and more edible look on
foods
c. Make milks more tasty and creamy
d. Create an illusion of a high protein
content on their products
22.
Most of the milks contaminated by Melamine
came from which country?
a. India
b. China
c. Philippines
d. Korea
23.
Which government agency is responsible for
testing the melamine content of foods and food
products?
a. DOH
b. MMDA
c. NBI
d. BFAD
24.
38
Infants are the most vulnerable to melamine
poisoning. Which of the following is NOT a sign
of melamine poisoning?
a. Irritability, Back ache, Urolithiasis
b. High blood pressure, fever
c. Anuria, Oliguria or Hematuria
d. Fever, Irritability and a large output of
diluted urine
25.
What kind of renal failure will melamine
poisoning cause?
a. Chronic, Prerenal
b. Chronic, Intrarenal
c. Acute, Postrenal
d. Acute, Prerenal
Situation: Leukemia is the most common type of
childhood cancer. Acute Lymphoid Leukemia is the cause
of almost 1/3 of all cancer that occurs in children under
age 15.
26.
The survival rate for Acute Lymphoid Leukemia is
approximately:
a. 25%
b. 40%
c. 75%
d. 95%
27.
Whereas acute nonlymphoid leukemia has a
survival rate of:
a. 25%
b. 40%
c. 75%
d. 95%
28.
The three main consequence of leukemia that
cause the most danger is:
a. Neutropenia causing infection, anemia
causing impaired oxygenation and
thrombocytopenia leading to bleeding
tendencies
b. Central nervous system infiltration,
anemia causing impaired oxygenation
and thrombocytopenia leading to
bleeding tendencies
c. Splenomegaly, hepatomegaly, fractures
d. Invasion by the leukemic cells to the
bone causing severe bone pain
29.
Gold standard in the diagnosis of leukemia is by
which of the following?
a. Blood culture and sensitivity
b. Bone marrow biopsy
c. Blood biopsy
d. CSF aspiration and examination
30.
Adriamycin,Vincristine,Prednisone and L
asparaginase are given to the client for long
term therapy. One common side effect,
39
especially of adriamycin is alopecia. The child
asks: “Will I get my hair back once again?” The
nurse best respond is by saying:
a. “Don’t be silly, ofcourse you will get your
hair 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 for
you”
d. “Your hair will regrow in 3 to 6 months
but of different color, usually darker
and of different texture”
sensitivity of the breast.
34.
Carmen, who is asking the nurse the most
appropriate time of the month to do her selfexamination of the breast. The MOST
appropriate reply by the nurse would be:
a. the 26th day of the menstrual cycle
b. 7 to 8 days after conclusion of the
menstrual period
c. during her menstruation
d. the same day each month
35.
Carmen being treated with radiation therapy.
What should be included in the plan of care to
minimize skin damage from the radiation
therapy?
a. Cover the areas with thick clothing
materials
b. Apply a heating pad to the site
c. Wash skin with water after the therapy
d. Avoid applying creams and powders to
the area
36.
Based on the DOH and World Health
Organization (WHO) guidelines, the mainstay for
early detection method for breast cancer that is
recommended for developing countries is:
a. a monthly breast self-examination (BSE)
and an annual health worker breast
examination (HWBE)
b. an annual hormone receptor assay
c. an annual mammogram
d. a physician conduct a breast clinical
examination every 2 years
37.
The purpose of performing the breast selfexamination (BSE) regularly is to discover:
a. fibrocystic masses
b. areas of thickness or fullness
c. cancerous lumps
d. changes from previous BSE
38.
If you are to instruct a postmenopausal woman
about BSE, when would you tell her to do BSE:
a. on the same day of each month
b. on the first day of her menstruation
c. right after the menstrual period
d. on the last day of her menstruation
39.
During breast self-examination, the purpose of
standing in front of the mirror it to observe the
breast for:
a. thickening of the tissue
Situation: Breast Cancer is the 2nd most common type of
cancer after lung cancer and 99% of which, occurs in
woman. Survival rate is 98% if this is detected early and
treated promptly. Carmen is a 53 year old patient in the
high risk group for breast cancer was recently diagnosed
with Breast cancer.
31.
32.
33.
All of the following are factors that said to
contribute to the development of breast cancer
except:
a. Prolonged exposure to estrogen such as
an early menarche or late menopause,
nulliparity and childbirth after age 30
b. Genetics
c. Increasing Age
d. Prolonged intake of Tamoxifen
(Nolvadex)
Protective factors for the development of breast
cancer includes which of the following except:
a. Exercise
b. Breast feeding
c. Prophylactic Tamoxifen
d. Alcohol intake
A patient diagnosed with breast cancer has been
offered the treatment choices of breast
conservation surgery with radiation or a
modified radical mastectomy. When questioned
by the patient about these options, the nurse
informs the patient that the lumpectomy with
radiation:
a. reduces the fear and anxiety that
accompany the diagnosis and treatment
of cancer
b. has about the same 10-year survival rate
as the modified radical mastectomy
c. provides a shorter treatment period with
a fewer long term complications
d. preserves the normal appearance and
b. lumps in the breast tissue
c. axillary lymphnodes
d. change in size and contour
40.
When preparing to examine the left breast in a
reclining position, the purpose of placing a small
folded towel under the client’s left shoulder is
to:
a. bring the breast closer to the examiner’s
right hand
b. tense the pectoral muscle
c. balance the breast tissue more evenly
on the chest wall
d. facilitate lateral positioning of the breast
Situation – Radiation therapy is another modality of
cancer management. With emphasis on multidisciplinary
management you have important responsibilities as
nurse.
41.
42.
43.
44.
40
Albert is receiving external radiation therapy and
he complains of fatigue and malaise. Which of
the following nursing interventions would be
most helpful for Albert?
a. Tell him that sometimes these feelings
can be psychogenic
b. Refer him to the physician
c. Reassure him that these feelings are
normal
d. Help him plan his activities
Immediately following the radiation teletherapy,
Albert is
a. Considered radioactive for 24 hrs
b. Given a complete bath
c. Placed on isolation for 6 hours
d. Free from radiation
Albert is admitted with a radiation induced
thrombocytopenia. As a nurse you should
observe the following symptoms:
a. Petechiae, ecchymosis, epistaxis
b. Weakness, easy fatigability, pallor
c. Headache, dizziness, blurred vision
d. Severe sore throat, bacteremia,
hepatomegaly
What nursing diagnosis should be of highest
priority?
a. Knowledge deficit regarding
thrombocytopenia precautions
b. Activity intolerance
c. Impaired tissue integrity
d. Ineffective tissue perfusion, peripheral,
cerebral, cardiovascular,
gastrointestinal, renal
45.
What intervention should you include in your
care plan?
a. Inspect his skin for petechiae, bruising,
GI bleeding regularly
b. Place Albert on strict isolation
precaution
c. Provide rest in between activities
d. Administer antipyretics if his
temperature exceeds 38C
Situation: Burn are cause by transfer of heat source to
the body. It can be thermal, electrical, radiation or
chemical.
46.
A burn characterized by Pale white appearance,
charred or with fat exposed and painlessness is:
a. Superficial partial thickness burn
b. Deep partial thickness burn
c. Full thickness burn
d. Deep full thickness burn
47.
Which of the following BEST describes superficial
partial thickness burn or first degree burn?
a. Structures beneath the skin are damage
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged
48.
A burn that is said to be “WEEPING” is classified
as:
a. Superficial partial thickness burn
b. Deep partial thickness burn
c. Full thickness burn
d. Deep full thickness burn
49.
During the Acute phase of the burn injury, which
of the following is a priority?
a. wound healing
b. emotional support
c. reconstructive surgery
d. fluid resuscitation
50.
While in the emergent phase, the nurse knows
that the priority is to:
a. Prevent infection
b. Prevent deformities and contractures
c. Control pain
d. Return the hemodynamic stability via
fluid resuscitation
41
51.
The MOST effective method of delivering pain
medication during the emergent phase is:
a. intramuscularly
b. orally
c. subcutaneously
d. intravenously
52.
When a client accidentally splashes chemicals to
his eyes, The initial priority care following the
chemical burn is to:
a. irrigate with normal saline for 1 to 15
minutes
b. transport to a physician immediately
c. irrigate with water for 15 minutes or
longer
d. cover the eyes with a sterile gauze
53.
Which of the following can be a fatal
complication of upper airway burns?
a. stress ulcers
b. shock
c. hemorrhage
d. laryngeal spasms and swelling
54.
When a client will rush towards you and he has a
burning clothes on, It is your priority to do which
of the following first?
a. log roll on the grass/ground
b. slap the flames with his hands
c. Try to remove the burning clothes
d. Splash the client with 1 bucket of cool
water
55.
Once the flames are extinguished, it is most
important to:
a. cover clientwith a warm blanket
b. give him sips of water
c. calculate the extent of his burns
d. assess the Sergio’s breathing
56.
57.
During the first 24 hours after the thermal injury,
you should asses Sergio for:
a. hypokalemia and hypernatremia
b. hypokalemia and hyponatremia
c. hyperkalemia and hyponatremia
d. hyperkalemia and hypernatremia
A client who sustained deep partial thickness
and full thickness burns of the face, whole
anterior chest and both upper extremities two
days ago begins to exhibit extreme restlessness.
You recognize that this most likely indicates that
the client is developing:
a. Cerebral hypoxia
b. metabolic acidosis
c. Hypervolemia
d. Renal failure
58.
A 165 lbs trauma client was rushed to the
emergency room with full thickness burns on the
whole face, right and left arm, and at the
anterior upper chest sparing the abdominal area.
He also has superficial partial thickness burn at
the posterior trunk and at the half upper portion
of the left leg. He is at the emergent phase of
burn. Using the parkland’s formula, you know
that during the first 8 hours of burn, the amount
of fluid will be given is:
a. 5,400 ml
b. 9, 450 ml
c. 10,800 ml
d. 6,750 ml
59.
The doctor incorporated insulin on the client’s
fluid during the emergent phase. The nurse
knows that insulin is given because:
a. Clients with burn also develops
Metabolic acidosis
b. Clients with burn also develops
hyperglycemia
c. Insulin is needed for additional energy
and glucose burning after the stressful
incidence to hasten wound healing,
regain of consciousness and rapid return
of hemodynamic stability
d. For hyperkalemia
60.
The IV fluid of choice for burn as well as
dehydration is:
a. 0.45% NaCl
b. Sterile water
c. NSS
d. D5LR
Situation: ENTEROSTOMAL THERAPY is now considered a
specialty in nursing. You are participating in the OSTOMY
CARE CLASS.
61.
You plan to teach Fermin how to irrigate the
colostomy when:
a. The perineal wound heals And Fermin
can sit comfortably on the commode
b. Fermin can lie on the side comfortably,
about the 3rd postoperative day
c. The abdominal incision is closed and
contamination is no longer a danger
d. The stools starts to become formed,
around the 7th postoperative day
62.
63.
64.
65.
When preparing to teach Fermin how to irrigate
colostomy, you should plan to do the procedure:
a. When Fermin would have normal bowel
movement
b. At least 2 hours before visiting hours
c. Prior to breakfast and morning care
d. After Fermin accepts alteration in body
image
When observing a return demonstration of a
colostomy irrigation, you know that more
teaching is required if Fermin:
a. Lubricates the tip of the catheter prior to
inserting into the stoma
b. Hangs the irrigating bag on the
bathroom door cloth hook during fluid
insertion
c. Discontinues the insertion of fluid after
500 ml of fluid has been instilled
d. Clamps of the flow of fluid when felling
uncomfortable
You are aware that teaching about colostomy
care is understood when Fermin states, “I will
contact my physician and report:
a. If I have any difficulty inserting the
irrigating tub into the stoma.”
b. If I noticed a loss of sensation to touch in
the stoma tissue.”
c. The expulsion of flatus while the
irrigating fluid is running out.”
d. When mucus is passed from the stoma
between the irrigations.”
You would know after teaching Fermin that
dietary instruction for him is effective when he
states, “It is important that I eat:
a. Soft food that is easily digested and
absorbed by my large intestines.”
b. Bland food so that my intestines do not
become irritated.”
c. Food low in fiber so that there are fewer
stools.”
d. Everything that I ate before the
operation, while avoiding foods that
cause gas”.
Situation: Based on studies of nurses working in special
units like the intensive care unit and coronary care unit,
42
it is important for nurses to gather as much information
to be able to address their needs for nursing care.
66.
Critically ill patients frequently complain about
which of the following when hospitalized?
a. Hospital food
b. Lack of privacy
c. Lack of blankets
d. Inadequate nursing staff
67.
Who of the following is at greatest risk of
developing sensory problem?
a. Female patient
b. Transplant patient
c. Adoloscent
d. Unresponsive patient
68.
Which of the following factors may inhibit
learning in critically ill patients?
a. Gender
b. Educational level
c. Medication
d. Previous knowledge of illness
69.
Which of the following statements does not
apply to critically ill patients?
a. Majority need extensive rehabilitation
b. All have been hospitalized previously
c. Are physically unstable
d. Most have chronic illness
70.
Families of critically ill patients desire which of
the following needs to be met first by the nurse?
a. Provision of comfortable space
b. Emotional support
c. Updated information on client’s status
d. Spiritual counselling
Situation: Johnny, sought consultation to the hospital
because of fatigability, irritability, jittery and he has been
experiencing this sign and symptoms for the past 5
months.
71.
His diagnosis was hyperthyroidism, the following
are expected symptoms except:
a. Anorexia
b. Fine tremors of the hand
c. Palpitation
d. Hyper alertness
72.
She has to take drugs to treat her
hyperthyroidism. Which of the following will you
NOT expect that the doctor will prescribe?
43
a.
b.
c.
d.
73.
74.
75.
Colace (Docusate)
Tapazole (Methimazole)
Cytomel (Liothyronine)
Synthroid (Levothyroxine)
The nurse knows that Tapazole has which of the
following side effect that will warrant immediate
withholding of the medication?
a. Death
b. Hyperthermia
c. Sore throat
d. Thrombocytosis
You asked questions as soon as she regained
consciousness from thyroidectomy primarily to
assess the evidence of:
a. Thyroid storm
b. Damage to the laryngeal nerve
c. Mediastinal shift
d. Hypocalcaemia tetany
Should you check for haemorrhage, you will:
a. Slip your hand under the nape of her
neck
b. Check for hypotension
c. Apply neck collar to prevent
haemorrhage
d. Observe the dressing if it is soaked with
blood
76.
Basal Metabolic rate is assessed on Johnny to
determine his metabolic rate. In assessing the
BMR using the standard procedure, you need to
tell Johnny that:
a. Obstructing his vision
b. Restraining his upper and lower
extremities
c. Obstructing his hearing
d. Obstructing his nostrils with a clamp
77.
The BMR is based on the measurement that:
a. Rate of respiration under different
condition of activities and rest
b. Amount of oxygen consumption under
resting condition over a measured
period of time
c. Amount of oxygen consumption under
stressed condition over a measured
period of time
d. Ratio of respiration to pulse rate over a
measured period of time
78.
Her physician ordered lugol’s solution in order
to:
a. Decrease the vascularity and size of the
thyroid gland
b. Decrease the size of the thyroid gland
only
c. Increase the vascularity and size of the
thyroid gland
d. Increase the size of the thyroid gland
only
79.
Which of the following is a side effect of Lugol’s
solution?
a. Hypokalemia
b. Enlargement of the Thryoid gland
c. Nystagmus
d. Excessive salivation
80.
In administering Lugol’s solution, the
precautionary measure should include:
a. Administer with glass only
b. Dilute with juice and administer with a
straw
c. Administer it with milk and drink it
d. Follow it with milk of magnesia
Situation: Pharmacological treatment was not effective
for Johnny’s hyperthyroidism and now, he is scheduled
for Thyroidectomy.
81.
Instruments in the surgical suite for surgery is
classified as either CRITICAL, SEMI CRITICAL and
NON CRITICAL. If the instrument are introduced
directly into the blood stream or into any
normally sterile cavity or area of the body it is
classified as:
a. Critical
b. Non Critical
c. Semi Critical
d. Ultra Critical
82.
Instruments that do not touch the patient or
have contact only to intact skin is classified as:
a. Critical
b. Non Critical
c. Semi Critical
d. Ultra Critical
83.
If an instrument is classified as Semi Critical, an
acceptable method of making the instrument
ready for surgery is through:
a. Sterilization
b. Disinfection
c. Decontamination
d. Cleaning
84.
While critical items and should be:
a. Clean
b. Sterilized
c. Decontaminated
d. Disinfected
85.
As a nurse, you know that intact skin acts as an
effective barrier to most microorganisms.
Therefore, items that come in contact with the
intact skin or mucus membranes should be:
a. Disinfected
b. Clean
c. Sterile
d. Alcoholized
86.
You are caring for Johnny who is scheduled to
undergo total thyroidectomy because of a
diagnosis of thyroid cancer. Prior to total
thyroidectomy, you should instruct Johnny to:
a. Perform range and motion exercise on
the head and neck
b. Apply gentle pressure against the
incision when swallowing
c. Cough and deep breathe every 2 hours
d. Support head with the hands when
changing position
87.
As Johnny’s nurse, you plan to set up emergency
equipment at her bedside following
thyroidectomy. You should include:
a. An airway and rebreathing tube
b. A tracheostomy set and oxygen
c. A crush cart with bed board
d. Two ampules of sodium bicarbonate
88.
Which of the following nursing interventions is
appropriate after a total thyroidectomy?
a. Place pillows under your patient’s
shoulders.
b. Raise the knee-gatch to 30 degrees
c. Keep you patient in a high-fowler’s
position.
d. Support the patient’s head and neck
with pillows and sandbags.
89.
44
If there is an accidental injury to the parathyroid
gland during a thyroidectomy which of the
following might Leda develops postoperatively?
a. Cardiac arrest
b. Respiratory failure
c. Dyspnea
d. Tetany
90.
After surgery Johnny develops peripheral
numbness, tingling and muscle twitching and
spasm. What would you anticipate to
administer?
a. Magnesium sulfate
b. Potassium iodide
c. Calcium gluconate
d. Potassium chloride
Situation: Budgeting is an important part of a nurse
managerial activity. The correct allocation and
distribution of resources is vital in the harmonious
operation of the financial balance of the agency.
91.
Which of the following best defines Budget?
a. Plan for the allocation of resources for
future use
b. The process of allocating resources for
future use
c. Estimate cost of expenses
d. Continuous process in seeing that the
goals and objective of the agency is met
92.
Which of the following best defines Capital
Budget?
a. Budget to estimate the cost of direct
labour, number of staff to be hired and
necessary number of workers to meet
the general patient needs
b. Includes the monthly and daily expenses
and expected revenue and expenses
c. These are related to long term planning
and includes major replacement or
expansion of the plant, major
equipment and inventories.
d. These are expenses that are not
dependent on the level of production or
sales. They tend to be time-related, such
as salaries or rents being paid per month
93.
Which of the following best described
Operational Budget?
a. Budget to estimate the cost of direct
labour, number of staff to be hired and
necessary number of workers to meet
the general patient needs
b. Includes the monthly and daily
expenses and expected revenue and
expenses
c. These are related to long term planning
and includes major replacement or
45
expansion of the plant, major
equipments and inventories.
d. These are expenses that are not
dependent on the level of production or
sales. They tend to be time-related, such
as rent
94.
95.
Which of the following accurately describes a
Fixed Cost in budgeting?
a. These are usually the raw materials and
labour salaries that depend on the
production or sales
b. These are expenses that change in
proportion to the activity of a business
c. These are expenses that are not
dependent on the level of production or
sales. They tend to be time-related,
such as rent
d. This is the summation of the Variable
Cost and the Fixed Cost
Which of the following accurately describes
Variable Cost in budgeting?
a. These are related to long term planning
and include major replacement or
expansion of the plant, major
equipments and inventories.
b. These are expenses that change in
proportion to the activity of a business
c. These are expenses that are not
dependent on the level of production or
sales. They tend to be time-related, such
as rent
d. This is the summation of the Variable
Cost and the Fixed Cost
Situation – Andrea is admitted to the ER following an
assault where she was hit in the face and head. She was
brought to the ER by a police woman. Emergency
measures were started.
96.
Andrea’s respiration is described as waxing and
waning. You know that this rhythm of respiration
is defined as:
a. Biot’s
b. Cheyne stokes
c. Kussmaul’s
d. Eupnea
97.
What do you call the triad of sign and symptoms
seen in a client with increasing ICP?
a. Virchow’s Triad
b. Cushing’s Triad
c. The Chinese Triad
d. Charcot’s Triad
98.
Which of the following is true with the Triad
seen in head injuries?
a. Narrowing of Pulse pressure, Cheyne
stokes respiration, Tachycardia
b. Widening Pulse pressure, Irregular
respiration, Bradycardia
c. Hypertension, Kussmaul’s respiration,
Tachycardia
d. Hypotension, Irregular respiration,
Bradycardia
99.
In a client with a Cheyne stokes respiration,
which of the following is the most appropriate
nursing diagnosis?
a. Ineffective airway clearance
b. Impaired gas exchange
c. Ineffective breathing pattern
d. Activity intolerance
100.
You know the apnea is seen in client’s with
cheyne stokes respiration, APNEA is defined as:
a. Inability to breathe in a supine position
so the patient sits up in bed to breathe
b. The patient is dead, the breathing stops
c. There is an absence of breathing for a
period of time, usually 15 seconds or
more
d. A period of hypercapnea and hypoxia
due to the cessation of respiratory effort
inspite of normal respiratory functioning
NURSING PRACTICE V
Situation: Understanding different models of care is a
necessary part of the nurse patient relationship.
1. The focus of this therapy is to have a positive
environmental manipulation, physical and social
to effect a positive change.
A. Milieu
B. Psychotherapy
C. Behaviour
D. Group
2. The client asks the nurse about Milieu therapy.
The nurse responds knowing that the primary
focus of milieu therapy can be best described by
which of the following?
A. A form of behavior modification therapy
B. A cognitive approach of changing the
behaviour
C. A living, learning or working
environment
D. A behavioural approach to changing
behaviour
3. A nurse is caring for a client with phobia who is
being treated for the condition. The client is
introduced to short periods of exposure to the
phobic object while in relaxed state. The nurse
understands that this form of behaviour
modification can be best described as:
A. Systematic desensitization
B. Self-control therapy
C. Aversion Therapy
D. Operant conditioning
4. A client with major depression is considering
cognitive therapy. The client say to the nurse,
“How does this treatment works?” The nurse
responds by telling the client that:
A. “This type of treatment helps you
examine how your thoughts and
feelings contribute to your difficulties”
B. “This type of treatment helps you
examine how your past life has
contributed to your problems.”
C. “This type of treatment helps you to
confront your fears by exposing you to
the feared object abruptly.
D. “This type of treatment will help you
relax and develop new coping skills.”
46
5. A Client state, “I get down on myself when I
make mistake.” Using Cognitive therapy
approach, the nurse should:
A. Teach the client relaxation exercise to
diminish stress
B. Provide the client with Mastery
experience to boost self esteem
C. Explore the client’s past experiences that
causes the illness
D. Help client modify the belief that
anything less than perfect is horrible
6. The most advantageous therapy for a preschool
age child with a history of physical and sexual
abuse would be:
A. Play
B. Psychoanalysis
C. Group
D. Family
7. An 18 year old client is admitted with the
diagnosis of anorexia nervosa. A cognitive
behavioural approach is used as part of her
treatment plan. The nurse understands that the
purpose of this approach is to:
A. Help the client identify and examine
dysfunctional thoughts and beliefs
B. Emphasize social interaction with clients
who withdraw
C. Provide a supportive environment and a
therapeutic community
D. Examine intrapsychic conflicts and past
events in life
8. The nurse is preparing to provide reminiscence
therapy for a group of clients. Which of the
following clients will the nurse select for this
group?
A. A client who experiences profound
depression with moderate cognitive
impairment
B. A catatonic, immobile client with
moderate cognitive impairment
C. An undifferentiated schizophrenic client
with moderate cognitive impairment
D. A client with mild depression who
exhibits who demonstrates normal
cognition
9. Which intervention would be typical of a nurse
using cognitive-behavioral approach to a client
experiencing low self-esteem?
47
A.
B.
C.
D.
Use of unconditional positive regard
Analysis of free association
Classical conditioning
Examination of negative thought
patterns
10. Which of the following therapies has been
strongly advocated for the treatment of posttraumatic stress disorders?
A. ECT
B. Group Therapy
C. Hypnotherapy
D. Psychoanalysis
11. The nurse knows that in group therapy, the
maximum number of members to include is:
A. 4
B. 8
C. 10
D. 16
12. The nurse is providing information to a client
with the use of disulfiram (antabuse) for the
treatment of alcohol abuse. The nurse
understands that this form of therapy works on
what principle?
A. Negative Reinforcement
B. Operant Conditioning
C. Aversion Therapy
D. Gestalt therapy
13. A biological or medical approach in treating
psychiatric patient is:
A. Million therapy
B. Behavioral therapy
C. Somatic therapy
D. Psychotherapy
14. Which of these nursing actions belong to the
secondary level of preventive intervention?
A. Providing mental health consultation to
health care providers
B. Providing emergency psychiatric
services
C. Being politically active in relation to
mental health issues
D. Providing mental health education to
members of the community
15. When the nurse identifies a client who has
attempted to commit suicide the nurse should:
A. call a priest
B. counsel the client
C. refer the client to the psychiatrist
D. refer the matter to the police
Situation: Rose seeks psychiatric consultation because of
intense fear of flying in an airplane which has greatly
affected her chances of success in her job.
16. The most common defense mechanism used by
phobic clients is:
A. Supression
B. Denial
C. Rationalization
D. Displacement
17. The goal of the therapy in phobia is:
A. Change her lifestyle
B. Ignore tension producing situation
C. Change her reaction towards anxiety
D. Eliminate fear producing situations
18. The therapy most effective for client’s with
phobia is:
A. Hypnotherapy
B. Cognitive therapy
C. Group therapy
D. Behavior therapy
19. The fear and anxiety related to phobia is said to
be abruptly decreased when the patient is
exposed to what is feared through:
A. Guided Imagery
B. Systematic desensitization
C. Flooding
D. Hypotherapy
20. Based on the presence of symptom, the
appropriate nursing diagnosis is:
A. Self-esteem disturbance
B. Activity intolerance
C. Impaired adjustment
D. Ineffective individual coping
Situation: Mang Jose, 39 year old farmer, unmarried, had
been confined in the National center for mental health
for three years with a diagnosis of schizophrenia.
21. The most common defense mechanism used by
a paranoid client is:
A. Displacement
B. Rationalization
C. Suppression
D. Projection
22. When Mang Jose says to you: “The voices are
telling me bad things again!” The best response
is:
A. “Whose voices are those?”
B. “I doubt what the voices are telling you”
C. “I do not hear the voice you say you
hear”
D. “Are you sure you hear these voices?”
23. A relevant nursing diagnosis for clients with
auditory hallucination is:
A. Sensory perceptual alteration
B. Altered thought process
C. Impaired social interaction
D. Impaired verbal communication
24. During mealtime, Jose refused to eat telling that
the food was poisoned. The nurse should:
A. Ignore his remark
B. Offer him food in his own container
C. Show him how irrational his thinking is
D. Respect his refusal to eat
25. When communicating with Jose, The nurse
considers the following except:
A. Be warm and enthusiastic
B. Refrain from touching Jose
C. Do not argue regarding his hallucination
and delusion
D. Use simple, clear language
Situation: Gringo seeks psychiatric counselling for his
ritualistic behavior of counting his money as many as 10
times before leaving home.
26. An initial appropriate nursing diagnosis is:
A. Impaired social interaction
B. Ineffective individual coping
C. Impaired adjustment
D. Anxiety Moderate
27. Obsessive compulsive disorder is BEST described
by:
A. Uncontrollable impulse to perform an
act or ritual repeatedly
B. Persistent thoughts
C. Recurring unwanted and disturbing
thought alternating with a behavior
D. Pathological persistence of unwilled
thought, feeling or impulse
28. The defense mechanism used by persons with
obsessive compulsive disorder is undoing and it
48
is best described in one of the following
statements:
A. Unacceptable feelings or behavior are
kept out of awareness by developing the
opposite behavior or emotion
B. Consciously unacceptable instinctual
drives are diverted into personally and
socially acceptable channels
C. Something unacceptable already done
is symbolically acted out in reverse
D. Transfer of emotions associated with a
particular person, object or situation to
another less threatening person, object
or situation
29. To be more effective, the nurse who cares for
persons with obsessive compulsive disorder
must possess one of the following qualities:
A. Compassion
B. Patience
C. Consistency
D. Friendliness
30. Persons with OCD usually manifest:
A. Fear
B. Apathy
C. Suspiciousness
D. Anxiety
Situation: The patient who is depressed will undergo
electroconvulsive therapy.
31. Studies on biological depression support
electroconvulsive therapy as a mode of
treatment. The rationale is:
A. ECT produces massive brain damage
which destroys the specific area
containing memories related to the
events surrounding the development of
psychotic condition
B. The treatment serves as a symbolic
punishment for the client who feels
guilty and worthless
C. ECT relieves depression psychologically
by increasing the norepinephrine level
D. ECT is seen as a life-threatening
experience and depressed patients
mobilize all their bodily defences to deal
with this attack.
32. The preparation of a patient for ECT ideally is
MOST similar to preparation for a patient for:
A. electroencephalogram
49
B. general anesthesia
C. X-ray
D. electrocardiogram
33. Which of the following is a possible side effect
which you will discuss with the patient?
A. hemorrhage within the brain
B. encephalitis
C. robot-like body stiffness
D. confusion, disorientation and short
term memory loss
34. Informed consent is necessary for the treatment
for involuntary clients. When this cannot be
obtained, permission may be taken from the:
A. social worker
B. next of kin or guardian
C. doctor
D. chief nurse
35. After ECT, the nurse should do this action before
giving the client fluids, food or medication:
A. assess the gag reflex
B. next of kin or guardian
C. assess the sensorium
D. check O2 Sat with a pulse oximeter
Situation: Mrs Ethel Agustin 50 y/o, teacher is afflicted
with myasthenia gravis.
36. Looking at Mrs Agustin, your assessment would
include the following except;
A. Nystagmus
B. Difficulty of hearing
C. Weakness of the levator palpebrae
D. Weakness of the ocular muscle
37. In an effort to combat complications which
might occur relatives should he taught;
A. Checking cardiac rate
B. Taking blood pressure reading
C. Techniques of oxygen inhalation
D. Administration of oxygen inhalation
38. The drug of choice for her condition is;
A. Prostigmine
B. Morphine
C. Codeine
D. Prednisone
39. As her nurse, you have to be cautious about
administration of medication, if she is under
medicated this can cause;
A.
B.
C.
D.
Emotional crisis
Cholinergic crisis
Menopausal crisis
Myasthenia crisis
40. If you are not extra careful and by chance you
give over medication, this would lead to;
A. Cholinergic crisis
B. Menopausal crisis
C. Emotional crisis
D. Myasthenia crisis
Situation: Rosanna 20 y/o unmarried patient believes
that the toilet for the female patient in contaminated
with AIDS virus and refuses to use it unless she flushes it
three times and wipes the seat same number of times
with antiseptic solution.
41. The fear of using “contaminated” toilet seat can
be attributed to Rosanna’s inability to;
A. Adjust to a strange environment
B. Express her anxiety
C. Develop the sense of trust in other
person
D. Control unacceptable impulses or
feelings
42. Assessment data upon admission help the nurse
to identify this appropriate nursing diagnosis
A. Ineffective denial
B. Impaired adjustment
C. Ineffective individual coping
D. Impaired social interaction
43. An effective nursing intervention to help Rosana
is;
A. Convincing her to use the toilet after the
nurse has used it first
B. Explaining to her that AIDS cannot be
transmitted by using the toilet
C. Allowing her to flush and clear the
toilet seat until she can manage her
anxiety
D. Explaining to her how AIDS is
transmitted
44. The goal for treatment for Rosana must be
directed toward helping her to;
A. Walk freely about her past experience
B. Develop trusting relationship with others
C. Gain insight that her behaviour is due
to feeling of anxiety
D. Accept the environment unconditionally
45. Psychotherapy which is prescribed for Rosana is
described as;
A. Establishing an environment adapted to
an individual patient needs
B. Sustained interaction between the
therapist and client to help her develop
more functional behaviour
C. Using dramatic techniques to portray
interpersonal conflicts
D. Biologic treatment for mental disorder
Situation: Dennis 40 y/o married man, an electrical
engineer was admitted with the diagnosis of paranoid
disorders. He has become suspicious and distrustful 2
months before admission. Upon admission, he kept on
saying, “my wife has been planning to kill me.”
46. A paranoid individual who cannot accept the
guilt demonstrate one of the following defense
mechanism;
A. Denial
B. Projection
C. Rationalization
D. Displacement
47. One morning, Dennis was seen tilting his head as
if he was listening to someone. An appropriate
nursing intervention would be;
A. Tell him to socialize with other patient to
divert his attention
B. Involve him in group activities
C. Address him by name to ask if he is
hearing voices again
D. Request for an order of antipsychotic
medicine
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B. Self-esteem disturbance
C. Ineffective individual coping
D. Defensive coping
50. Most appropriate nursing intervention for a
client with suspicious behavior is one of the
following;
A. Talk to the client constantly to reinforce
reality
B. Involve him in competitive activities
C. Use Non Judgmental and Consistent
approach
D. Project cheerfulness in interacting with
the patient
Situation: Clients with Bipolar disorder receives a very
high nursing attention due to the increasing rate of
suicide related to the illness.
51. The nurse is assigned to care for a recently
admitted client who has attempted suicide.
What should the nurse do?
A. Search the client's belongings and room
carefully for items that could be used to
attempt suicide.
B. Express trust that the client won't cause
self-harm while in the facility.
C. Respect the client's privacy by not
searching any belongings.
D. Remind all staff members to check on
the client frequently.
48. When he says, “these voices are telling me my
wife is going to kill me.” A therapeutic
communication of the nurse is which one of the
following;
A. “i do not hear the voices you say you
hear”
B. “are you really sure you heard those
voices?”
C. “I do not think you heard those
voices?”
D. “Whose voices are those?”
52. In planning activities for the depressed client,
especially during the early stages of
hospitalization, which of the following plan is
best?
A. Provide an activity that is quiet and
solitary to avoid increased fatigue such
as working on a puzzle and reading a
book.
B. Plan nothing until the client asks to
participate in the milieu
C. Offer the client a menu of daily activities
and ask the client to participate in all of
them
D. Provide a structured daily program of
activities and encourage the client to
participate
49. The nurse confirms that Dennis is manifesting
auditory hallucination. The appropriate nursing
diagnosis she identifiesis;
A. Sensory perceptual alteration
53. A client with a diagnosis of major depression,
recurrent with psychotic features is admitted to
the mental health unit. To create a safe
environment for the client, the nurse most
51
importantly devises a plan of care that deals
specifically with the clients:
A. Disturbed thought process
B. Imbalanced nutrition
C. Self-Care Deficit
D. Deficient Knowledge
54. The client is taking a Tricyclic anti-depressant,
which of the following is an example of TCA?
A. Paxil
B. Nardil
C. Zoloft
D. Pamelor
55. A client visits the physician's office to seek
treatment for depression, feelings of
hopelessness, poor appetite, insomnia, fatigue,
low self-esteem, poor concentration, and
difficulty making decisions. The client states that
these symptoms began at least 2 years ago.
Based on this report, the nurse suspects:
A. cyclothymic disorder.
B. Bipolar disorder
C. major depression.
D. dysthymic disorder.
56. The nurse is planning activities for a client who
has bipolar disorder, which aggressive social
behaviour. Which of the following activities
would be most appropriate for this client?
A. Ping Pong
B. Linen delivery
C. Chess
D. Basketball
57. The nurse assesses a client with admitted
diagnosis of bipolar affective disorder, mania.
The symptom presented by the client that
requires the nurse’s immediate intervention is
the client’s:
A. Outlandish behaviour and inappropriate
dress
B. Grandiose delusion of being a royal
descendant of king arthut
C. Nonstop physical activity and poor
nutritional intake
D. Constant incessant talking that includes
sexual topics and teasing the staff
58. A nurse is conducting a group therapy session
and during the session, A client with mania
consistently talks and dominates the group. The
behaviour is disrupting the group interaction.
The nurse would initially:
A. Ask the client to leave the group session
B. Tell the client that she will not be
allowed to attend any more group
sessions
C. Tell the client that she needs to allow
other client in a group time to talk
D. Ask another nurse to escort the client
out of the group session
59. A professional artist is admitted to the
psychiatric unit for treatment of bipolar
disorder. During the last 2 weeks, the client has
created 154 paintings, slept only 2 to 3 hours
every 2 days, and lost 18 lb (8.2 kg). Based on
Maslow's hierarchy of needs, what should the
nurse provide this client with first?
A. The opportunity to explore family
dynamics
B. Help with re-establishing a normal
sleep pattern
C. Experiences that build self-esteem
D. Art materials and equipment
60. The physician orders lithium carbonate
(Lithonate) for a client who's in the manic phase
of bipolar disorder. During lithium therapy, the
nurse should watch for which adverse reactions?
A. Anxiety, restlessness, and sleep
disturbance
B. Nausea, diarrhea, tremor, and lethargy
C. Constipation, lethargy, and ataxia
D. Weakness, tremor, and urine retention
Situation – Annie has a morbid fear of heights. She asks
the nurse what desensitization therapy is:
61. The accurate information of the nurse of the
goal of desensitization is:
A. To help the clients relax and
progressively work up a list of anxiety
provoking situations through imagery.
B. To provide corrective emotional
experiences through a one-to-one
intensive relationship.
C. To help clients in a group therapy setting
to take on specific roles and reenact in
front of an audience, situations in which
interpersonal conflict is involved.
D. To help clients cope with their problems
by learning behaviors that are more
functional and be better equipped to
face reality and make decisions.
62. It is essential in desensitization for the patient
to:
A. Have rapport with the therapist
B. Use deep breathing or another
relaxation technique
C. Assess one’s self for the need of an
anxiolytic drug
D. Work through unresolved unconscious
conflicts
63. In this level of anxiety, cognitive capacity
diminishes. Focus becomes limited and client
experiences tunnel vision. Physical signs of
anxiety become more pronounced.
A. Severe anxiety
B. Mild anxiety
C. Panic
D. Moderate anxiety
64. Antianxiety medications should be used with
extreme caution because long term use can lead
to:
A. Parkinsonian like syndrome
B. Hepatic failure
C. Hypertensive crisis
D. Risk of addiction
65. The nursing management of anxiety related with
post-traumatic stress disorder includes all of the
following EXCEPT:
A. Encourage participation in recreation or
sports activities
B. Reassure client’s safety while touching
client
C. Speak in a calm soothing voice
D. Remain with the client while fear level is
high
SITUATION: You are fortunate to be chosen as part of
the research team in the hospital. A review of the
following IMPORTANT nursing concepts was made.
66. As a professional, a nurse can do research for
varied reason except:
A. Professional advancement through
research participation
B. To validate results of new nursing
modalities
C. For financial gains
D. To improve nursing care
67. Each nurse participants was asked to identify a
52
problem. After the identification of the research
problem, which of the following should be done?
A. Methodology
B. Acknowledgement
C. Review of related literature
D. Formulate hypothesis
68. Which of the following communicate the results
of the research to the readers. They facilitate the
description of the data.
A. Hypothesis
B. Research problem
C. Statistics
D. Tables and Graphs
69. In Quantitative date, which of the following is
described as the distance in the scoring unites of
the variable from the highest to the lower?
A. Frequency
B. Median
C. Mean
D. Range
70. This expresses the variability of the data in
reference to the mean. It provides as with a
numerical estimate of how far, on the average
the separate observation are from the mean:
A. Mode
B. Median
C. Standard deviation
D. Frequency
Situation: Survey and Statistics are important part of
research that is necessary to explain the characteristics
of the population.
71. According to the WHO statistics on the Homeless
population around the world, which of the
following groups of people in the world
disproportionately represents the homeless
population?
A. Hispanics
B. Asians
C. African Americans
D. Caucasians
72. All but one of the following is not a measure of
Central Tendency:
A. Mode
B. Standard Deviation
C. Variance
D. Range
53
73. In the value: 87, 85, 88, 92, 90; what is the
mean?
A. 88.2
B. 88.4
C. 87
D. 90
A. There is a control group
B. There is an experimental group
C. Selection of subjects in the control group
is randomized
D. There is a careful selection of subjects
in the experimental group
74. In the value: 80, 80, 80, 82, 82, 90, 90, 100; what
is the mode?
A. 80
B. 82
C. 90
D. 85.5
75. In the value: 80, 80, 10, 10, 25, 65, 100, 200;
what is the median?
A. 71.25
B. 22.5
C. 10 and 25
D. 72.5
80. The researcher implemented a medication
regimen using a new type of combination drugs
to manic patients while another group of manic
patient receives the routine drugs. The
researcher however handpicked the
experimental group for they are the clients with
multiple episodes of bipolar disorder. The
researcher utilized which research design?
A. Quasi-experimental
B. Phenomenological
C. Pure experimental
D. Longitudinal
76. Draw Lots, Lottery, Table of random numbers or
a sampling that ensures that each element of the
population has an equal and independent
chance of being chosen is called:
A. Cluster
B. Stratified
C. Simple
D. Systematic
Situation 19: As a nurse, you are expected to participate
in initiating or participating in the conduct of research
studies to improve nursing practice. You to be updated
on the latest trends and issues affected the profession
and the best practices arrived at by the profession.
77. An investigator wants to determine some of the
problems that are experienced by diabetic
clients when using an insulin pump. The
investigator went into a clinic where he
personally knows several diabetic clients having
problem with insulin pump. The type of sampling
done by the investigator is called:
A. Probability
B. Snowball
C. Purposive
D. Incidental
78. If the researcher implemented a new structured
counselling program with a randomized group of
subject and a routine counselling program with
another randomized group of subject, the
research is utilizing which design?
A. Quasi experimental
B. Comparative
C. Experimental
D. Methodological
79. Which of the following is not true about a Pure
Experimental research?
81. You are interested to study the effects of
mediation and relaxation on the pain
experienced by cancer patients. What type of
variable is pain?
A. Dependent
B. Independent
C. Correlational
D. Demographic
82. You would like to compare the support system
of patient with chronic illness to those with
acute illness. How will you best state your
problem?
A. A descriptive study to compare the
support system of patients with chronic
illness and those with acute illness in
terms of demographic data and
knowledge about intervention.
B. The effects of the types of support
system of patients with chronic illness
and those with acute illness.
C. A comparative analysis of the support
system of patients with chronic illness
and those with acute illness.
D. A study to compare the support system
of patients with chronic illness and those
with acute illness.
E. What are the differences of the support
system being received by patient with
chronic illness and patients with acute
illness?
83. You would like to compare the support system
of patients with chronic illness to those with
acute illness. Considering that the hypothesis
was: “Client’s with chronic illness have lesser
support system than client’s with acute illness.”
What type of research is this?
A. Descriptive
B. Correlational, Non experimental
C. Experimental
D. Quasi Experimental
84. In any research study where individual persons
are involved, it is important that an informed
consent of the study is obtained. The following
are essential information about the consent that
you should disclose to the prospective subjects
except:
A. Consent to incomplete disclosure
B. Description of benefits, risks and
discomforts
C. Explanation of procedure
D. Assurance of anonymity and
confidentiality
85. In the Hypothesis: “The utilization of technology
in teaching improves the retention and attention
of the nursing students.” Which is the
dependent variable?
A. Utilization of technology
B. Improvement in the retention and
attention
C. Nursing students
D. Teaching
Situation: You are actively practicing nurse who has just
finished you graduate studies. You learned the value of
research and would like to utilize the knowledge and
skills gained in the application of research to the nursing
service. The following questions apply to research.
86. Which type of research inquiry investigates the
issues of human complexity (e.g understanding
the human expertise)?
A. Logical position
B. Positivism
C. Naturalistic inquiry
D. Quantitative research
54
87. Which of the following studies is based on
quantitative research?
A. A study examining the bereavement
process in spouse of clients with
terminal cancer
B. A study exploring the factors influencing
weight control behaviour
C. A Study measuring the effects of sleep
deprivation on wound healing
D. A study examining client’s feelings
before, during and after bone marrow
aspiration.
88. Which of the following studies is based on the
qualitative research?
A. A study examining clients’ reaction to
stress after open heart surgery
B. A study measuring nutrition and weight
loss/gain in clients with cancer
C. A study examining oxygen levels after
endotracheal suctioning
D. A study measuring differences in blood
pressure before, during and after
procedure
89. An 85 year old client in a nursing home tells a
nurse, “I signed the papers of that research
study because the doctor was so insistent and I
want him to continue taking care for me” Which
client right is being violated?
A. Right of self determination
B. Right to full disclosure
C. Right to privacy and confidentiality
D. Right not to be harmed
90. A supposition or system of ideas that is
proposed to explain a given phenomenon best
defines:
A. A paradigm
B. A theory
C. A Concept
D. A conceptual framework
Situation: Mastery of research design determination is
essential in passing the NLE.
91. Ana wants to know if the length of time she will
study for the board examination is proportional
to her board rating. During the June 2008 board
examination, she studied for 6 months and
gained 68%, On the next board exam, she
studied for 6 months again for a total of 1 year
and gained 74%, On the third board exam, She
studied for 6 months for a total of 1 and a half
55
year and gained 82%. The research design she
used is:
A. Comparative
B. Experimental
C. Correlational
D. Qualitative
92. Anton was always eating high fat diet. You want
to determine if what will be the effect of high
cholesterol food to Anton in the next 10 years.
You will use:
A. Comparative
B. Historical
C. Correlational
D. Longitudinal
93. Community A was selected randomly as well as
community B, nurse Edna conducted teaching to
community A and assess if community A will
have a better status than community B. This is
an example of:
A. Comparative
B. Experimental
C. Correlational
D. Qualitative
94. Ana researched on the development of a new
way to measure intelligence by creating a 100
item questionnaire that will assess the cognitive
skills of an individual. The design best suited for
this study is:
A. Historical
B. Survey
C. Methodological
D. Case study
95. Gen is conducting a research study on how mark,
an AIDS client lives his life. A design suited for
this is:
A. Historical
B. Phenomenological
C. Case Study
D. Ethnographic
96. Marco is to perform a study about how nurses
perform surgical asepsis during World War II. A
design best for this study is:
A. Historical
B. Phenomenological
C. Case Study
D. Ethnographic
97. Tonyo conducts sampling at barangay 412. He
collected 100 random individuals and determine
who is their favourite comedian actor. 50% said
Dolphy, 20% said Vic Sotto, while some
answered Joey de Leon, Allan K, Michael V.
Tonyo conducted what type of research study?
A. Phenomenological
B. Non experimental
C. Case Study
D. Survey
98. Jane visited a tribe located somewhere in China,
it is called the Shin Jea tribe. She studied the way
of life, tradition and the societal structure of
these people. Jane will best use which research
design?
A. Historical
B. Phenomenological
C. Case Study
D. Ethnographic
99. Anjoe researched on TB. Its transmission,
Causative agent and factors, treatment sign and
symptoms as well as medication and all other in
depth information about tuberculosis. This study
is best suited for which research design?
A. Historical
B. Phenomenological
C. Case Study
D. Ethnographic
100.
Diana is to conduct a study about the
relationship of the number of family members in
the household and the electricity bill. Which of
the following is the best research design suited
for this study?
1.
Descriptive
2.
Exploratory
3.
Explanatory
4.
Correlational
5.
Comparative
6.
Experimental
A. 1,4
B. 2,5
C. 3,6
D. 1,5
E. 2,4
TEST I - Foundation of Professional Nursing
Practice
1. The nurse In-charge in labor and delivery unit
administered a dose of terbutaline to a client
without checking the client’s pulse. The standard
that would be used to determine if the nurse
was negligent is:
a. The physician’s orders.
b. The action of a clinical nurse specialist
who is recognized expert in the field.
c. The statement in the drug literature
about administration of terbutaline.
d. The actions of a reasonably prudent
nurse with similar education and
experience.
2. Nurse Trish is caring for a female client with a
history of GI bleeding, sickle cell disease, and a
platelet count of 22,000/μl. The female client is
dehydrated and receiving dextrose 5% in halfnormal saline solution at 150 ml/hr. The client
complains of severe bone pain and is scheduled
to receive a dose of morphine sulfate. In
administering the medication, Nurse Trish
should avoid which route?
a. I.V
b. I.M
c. Oral
d. S.C
3. Dr. Garcia writes the following order for the
client who has been recently admitted “Digoxin
.125 mg P.O. once daily.” To prevent a dosage
error, how should the nurse document this order
onto 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 diagnosed
with deep vein thrombosis. Which nursing
diagnosis should receive the highest priority?
a. Ineffective peripheral tissue perfusion
related to venous congestion.
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral
vascular disease.
d. Impaired gas exchange related to
increased blood flow.
56
5. Nurse Betty is assigned to the following clients.
The client that the nurse would see first after
endorsement?
a. A 34 year-old post-operative
appendectomy client of five hours who
is complaining of pain.
b. A 44 year-old myocardial infarction (MI)
client who is complaining of nausea.
c. A 26 year-old client admitted for
dehydration whose intravenous (IV) has
infiltrated.
d. A 63 year-old post operative’s
abdominal hysterectomy client of three
days whose incisional dressing is
saturated with serosanguinous fluid.
6. Nurse Gail places a client in a four-point restraint
following orders from the physician. The client
care 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 receiving
H2 receptor antagonist therapy. The nurse Incharge knows the purpose of this therapy is to:
a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange
8. The doctor orders hourly urine output
measurement for a postoperative male client.
The nurse Trish records the following amounts of
output for 2 consecutive hours: 8 a.m.: 50 ml; 9
a.m.: 60 ml. Based on these amounts, which
action should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly
urine output
9. Tony, a basketball player twist his right ankle
while playing on the court and seeks care for
ankle pain and swelling. After the nurse applies
ice to the ankle for 30 minutes, which statement
by Tony suggests that ice application has been
effective?
a. “My ankle looks less swollen now”.
b. “My ankle feels warm”.
c. “My ankle appears redder now”.
57
d. “I need something stronger for pain
relief”
10. The physician prescribes a loop diuretic for a
client. When administering this drug, the nurse
anticipates that the client may develop which
electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia
11. She finds out that some managers have
benevolent-authoritative style of management.
Which of the following behaviors will she exhibit
most likely?
a. Have condescending trust and
confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among
subordinates.
12. Nurse Amy is aware that the following is true
about functional nursing
a. Provides continuous, coordinated and
comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group
collaboration.
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 order
b. Standard written order
c. Standing order
d. Stat order
14. A female client with a fecal impaction frequently
exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
15. Nurse Linda prepares to perform an otoscopic
examination on a female client. For proper
visualization, the nurse should position the
client's ear by:
a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a
male client who is having external radiation
therapy:
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 area
when it is red or sore.
17. In assisting a female client for immediate
surgery, the nurse In-charge is aware that she
should:
a. Encourage the client to void following
preoperative medication.
b. Explore the client’s fears and anxieties
about the surgery.
c. Assist the client in removing dentures
and nail polish.
d. Encourage the client to drink water prior
to surgery.
18. A male client is admitted and diagnosed with
acute pancreatitis after a holiday celebration of
excessive food and alcohol. Which assessment
finding reflects this diagnosis?
a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric
and back pain.
19. Which dietary guidelines are important for nurse
Oliver to implement in caring for the client with
burns?
a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate
diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.
20. Nurse Hazel will administer a unit of whole
blood, which priority information should the
nurse have about the client?
a. Blood pressure and pulse rate.
b. Height and weight.
c. Calcium and potassium levels
d. Hgb and Hct levels.
21. Nurse Michelle witnesses a female client sustain
a fall and suspects that the leg may be broken.
The nurse takes which priority action?
a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
c. Reassure the client that everything will
be alright.
d. Immobilize the leg before moving the
client.
22. A male client is being transferred to the nursing
unit for admission after receiving a radium
implant for bladder cancer. The nurse in-charge
would take which priority action in the care of
this client?
a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent
rest periods.
d. Encourage family and friends to visit.
23. A newly admitted female client was diagnosed
with agranulocytosis. The nurse formulates
which priority nursing diagnosis?
a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge
24. A male client is receiving total parenteral
nutrition suddenly demonstrates signs and
symptoms of an air embolism. What is the
priority action by the nurse?
a. Notify the physician.
b. Place the client on the left side in the
Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.
25. Nurse May attends an educational conference
on leadership styles. The nurse is sitting with a
nurse employed at a large trauma center who
states that the leadership style at the trauma
center is task-oriented and directive. The nurse
determines that the leadership style used at the
trauma center is:
a. Autocratic.
b. Laissez-faire.
c. Democratic.
d. Situational
26. The physician orders DS 500 cc with KCl 10
mEq/liter at 30 cc/hr. The nurse in-charge is
going to hang a 500 cc bag. KCl is supplied 20
mEq/10 cc. How many cc’s of KCl will be added
to the IV solution?
a. .5 cc
b. 5 cc
58
c. 1.5 cc
d. 2.5 cc
27. A child of 10 years old is to receive 400 cc of IV
fluid in an 8 hour shift. The IV drip factor is 60.
The IV rate that will deliver this amount is:
a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour
28. The nurse is aware that the most important
nursing action when a client returns from
surgery is:
a. Assess the IV for type of fluid and rate of
flow.
b. Assess the client for presence of pain.
c. Assess the Foley catheter for patency
and urine output
d. Assess the dressing for drainage.
29. Which of the following vital sign assessments
that may indicate cardiogenic shock after
myocardial infarction?
a. BP – 80/60, Pulse – 110 irregular
b. BP – 90/50, Pulse – 50 regular
c. BP – 130/80, Pulse – 100 regular
d. BP – 180/100, Pulse – 90 irregular
30. Which is the most appropriate nursing action in
obtaining a blood pressure measurement?
a. Take the proper equipment, place the
client in a comfortable position, and
record the appropriate information in
the client’s chart.
b. Measure the client’s arm, if you are not
sure of the size of cuff to use.
c. Have the client recline or sit comfortably
in a chair with the forearm at the level of
the heart.
d. Document the measurement, which
extremity was used, and the position
that the client was in during the
measurement.
31. Asking the questions to determine if the person
understands the health teaching provided by the
nurse would be included during which step of
the nursing process?
a. Assessment
b. Evaluation
c. Implementation
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d. Planning and goals
32. Which of the following item is considered the
single most important factor in assisting the
health professional in arriving at a diagnosis or
determining the person’s needs?
a. Diagnostic test results
b. Biographical date
c. History of present illness
d. Physical examination
33. In preventing the development of an external
rotation deformity of the hip in a client who
must remain in bed for any period of time, the
most appropriate nursing action would be to
use:
a. Trochanter roll extending from the crest
of the ileum to the mid-thigh.
b. Pillows under the lower legs.
c. Footboard
d. Hip-abductor pillow
34. Which stage of pressure ulcer development does
the ulcer extend into the subcutaneous tissue?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
35. When the method of wound healing is one in
which wound edges are not surgically
approximated and integumentary continuity is
restored by granulations, the wound healing is
termed
a. Second intention healing
b. Primary intention healing
c. Third intention healing
d. First intention healing
36. An 80-year-old male client is admitted to the
hospital with a diagnosis of pneumonia. Nurse
Oliver learns that the client lives alone and
hasn’t been eating or drinking. When assessing
him for dehydration, nurse Oliver would expect
to find:
a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia
37. The physician prescribes meperidine (Demerol),
75 mg I.M. every 4 hours as needed, to control a
client’s postoperative pain. The package insert is
“Meperidine, 100 mg/ml.” How many milliliters
of meperidine should the client receive?
a. 0.75
b. 0.6
c. 0.5
d. 0.25
38. A male client with diabetes mellitus is receiving
insulin. Which statement correctly describes an
insulin unit?
a. It’s a common measurement in the
metric system.
b. It’s the basis for solids in the avoirdupois
system.
c. It’s the smallest measurement in the
apothecary system.
d. It’s a measure of effect, not a standard
measure of weight or quantity.
39. Nurse Oliver measures a client’s temperature at
102° F. What is the equivalent Centigrade
temperature?
a. 40.1 °C
b. 38.9 °C
c. 48 °C
d. 38 °C
40. The nurse is assessing a 48-year-old client who
has come to the physician’s office for his annual
physical exam. One of the first physical signs of
aging is:
a. Accepting limitations while developing
assets.
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 female
client to treat a pneumothorax. The tube is
connected to water-seal drainage. The nurse incharge 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 slightly
elevated.
d. Keeping the chest drainage system
below the level of the chest.
42. Nurse Trish must verify the client’s identity
before administering medication. She is aware
that the safest way to verify identity is to:
a. Check the client’s identification band.
b. Ask the client to state his name.
c. State the client’s name out loud and
wait a client to repeat it.
d. Check the room number and the client’s
name 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 should
run the I.V. infusion at a rate of:
a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute
44. If a central venous catheter becomes
disconnected accidentally, what should the
nurse in-charge do immediately?
a. Clamp the catheter
b. Call another nurse
c. Call the physician
d. Apply a dry sterile dressing to the site.
45. A female client was recently admitted. She has
fever, weight loss, and watery diarrhea is being
admitted to the facility. While assessing the
client, Nurse Hazel inspects the client’s abdomen
and notice that it is slightly concave. Additional
assessment 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 a
client with pneumonia. For this examination,
nurse Betty should use the:
a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand
47. Which type of evaluation occurs continuously
throughout the teaching and learning process?
a. Summative
b. Informative
c. Formative
d. Retrospective
48. A 45 year old client, has no family history of
breast cancer or other risk factors for this
disease. Nurse John should instruct her to have
mammogram how often?
a. Twice per year
b. Once per year
60
c. Every 2 years
d. Once, to establish baseline
49. A male client has the following arterial blood gas
values: pH 7.30; Pao2 89 mmHg; Paco2 50
mmHg; and HCO3 26mEq/L. Based on these
values, Nurse Patricia should expect which
condition?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
50. Nurse Len refers a female client with terminal
cancer to a local hospice. What is the goal of this
referral?
a. To help the client find appropriate
treatment options.
b. To provide support for the client and
family in coping with terminal illness.
c. To ensure that the client gets counseling
regarding health care costs.
d. To teach the client and family about
cancer and its treatment.
51. When caring for a male client with a 3-cm stage I
pressure ulcer on the coccyx, which of the
following actions can the nurse institute
independently?
a. Massaging the area with an astringent
every 2 hours.
b. Applying an antibiotic cream to the area
three times per day.
c. Using normal saline solution to clean the
ulcer and applying a protective dressing
as necessary.
d. Using a povidone-iodine wash on the
ulceration three times per day.
52. Nurse Oliver must apply an elastic bandage to a
client’s ankle and calf. He should apply the
bandage beginning at the client’s:
a. Knee
b. Ankle
c. Lower thigh
d. Foot
53. A 10 year old child with type 1 diabetes develops
diabetic ketoacidosis and receives a continuous
insulin infusion. Which condition represents the
greatest risk to this child?
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
61
d. Hypercalcemia
54. Nurse Len is administering sublingual nitrglycerin
(Nitrostat) to the newly admitted client.
Immediately afterward, the client may
experience:
a. Throbbing headache or dizziness
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.
55. Nurse Michelle hears the alarm sound on the
telemetry monitor. The nurse quickly looks at
the monitor and notes that a client is in a
ventricular tachycardia. The nurse rushes to the
client’s room. Upon reaching the client’s
bedside, the nurse would take which action
first?
a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the client’s level of consciousness
56. Nurse Hazel is preparing to ambulate a female
client. The best and the safest position for the
nurse 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 care
given to the potential organ donor who has been
diagnosed with brain death. The nurse
determines that the standard of care had been
maintained if which of the following data is
observed?
a. Urine output: 45 ml/hr
b. Capillary refill: 5 seconds
c. Serum pH: 7.32
d. Blood pressure: 90/48 mmHg
58. Nurse Amy has an order to obtain a urinalysis
from a male client with an indwelling urinary
catheter. The nurse avoids which of the
following, which contaminate the specimen?
a. Wiping the port with an alcohol swab
before inserting the syringe.
b. Aspirating a sample from the port on the
drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary
drainage bag.
59. Nurse Meredith is in the process of giving a
client a bed bath. In the middle of the
procedure, the unit secretary calls the nurse on
the intercom to tell the nurse that there is an
emergency phone call. The appropriate nursing
action is to:
a. Immediately walk out of the client’s
room and answer the phone call.
b. Cover the client, place the call light
within reach, and answer the phone call.
c. Finish the bed bath before answering
the phone call.
d. Leave the client’s door open so the client
can be monitored and the nurse can
answer the phone call.
60. Nurse Janah is collecting a sputum specimen for
culture and sensitivity testing from a client who
has a productive cough. Nurse Janah plans to
implement which intervention to obtain the
specimen?
a. Ask the client to expectorate a small
amount of sputum into the emesis basin.
b. Ask the client to obtain the specimen
after breakfast.
c. Use a sterile plastic container for
obtaining the specimen.
d. Provide tissues for expectoration and
obtaining the specimen.
61. Nurse Ron is observing a male client using a
walker. The nurse determines that the client is
using the walker correctly if the client:
a. Puts all the four points of the walker flat
on the floor, puts weight on the hand
pieces, and then walks into it.
b. Puts weight on the hand pieces, moves
the walker forward, and then walks into
it.
c. Puts weight on the hand pieces, slides
the walker forward, and then walks into
it.
d. Walks into the walker, puts weight on
the hand pieces, and then puts all four
points of the walker flat on the floor.
62. Nurse Amy has documented an entry regarding
client care in the client’s medical record. When
checking the entry, the nurse realizes that
incorrect information was documented. How
does the nurse correct this error?
a. Erases the error and writes in the correct
information.
b. Uses correction fluid to cover up the
incorrect information and writes in the
correct information.
c. Draws one line to cross out the incorrect
information and then initials the change.
d. Covers up the incorrect information
completely using a black pen and writes
in the correct information
63. Nurse Ron is assisting with transferring a client
from the operating room table to a stretcher. To
provide safety to the client, the nurse should:
a. Moves the client rapidly from the table
to the stretcher.
b. Uncovers the client completely before
transferring to the stretcher.
c. Secures the client safety belts after
transferring to the stretcher.
d. Instructs the client to move self from the
table to the stretcher.
64. Nurse Myrna is providing instructions to a
nursing assistant assigned to give a bed bath to a
client who is on contact precautions. Nurse
Myrna instructs the nursing assistant to use
which of the following protective items when
giving bed bath?
a. Gown and goggles
b. Gown and gloves
c. Gloves and shoe protectors
d. Gloves and goggles
65. Nurse Oliver is caring for a client with impaired
mobility that occurred as a result of a stroke. The
client has right sided arm and leg weakness. The
nurse would suggest that the client use which of
the following assistive devices that would
provide the best stability for ambulating?
a. Crutches
b. Single straight-legged cane
c. Quad cane
d. Walker
66. A male client with a right pleural effusion noted
on a chest X-ray is being prepared for
thoracentesis. The client experiences severe
dizziness when sitting upright. To provide a safe
environment, the nurse assists the client to
which position for the procedure?
62
a. Prone with head turned toward the side
supported by a pillow.
b. Sims’ position with the head of the bed
flat.
c. Right side-lying with the head of the bed
elevated 45 degrees.
d. Left side-lying with the head of the bed
elevated 45 degrees.
67. Nurse John develops methods for data
gathering. Which of the following criteria of a
good instrument refers to the ability of the
instrument to yield the same results upon its
repeated administration?
a. Validity
b. Specificity
c. Sensitivity
d. Reliability
68. Harry knows that he has to protect the rights of
human research subjects. Which of the following
actions of Harry ensures anonymity?
a. Keep the identities of the subject secret
b. Obtain informed consent
c. Provide equal treatment to all the
subjects of the study.
d. Release findings only to the participants
of the study
69. Patient’s refusal to divulge information is a
limitation because it is beyond the control of
Tifanny”. What type of research is appropriate
for this study?
a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical
70. Nurse Ronald is aware that the best tool for data
gathering is?
a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation
71. Monica is aware that there are times when only
manipulation of study variables is possible and
the elements of control or randomization are
not attendant. Which type of research is
referred to this?
a. Field study
b. Quasi-experiment
c. Solomon-Four group design
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d. Post-test only design
72. Cherry notes down ideas that were derived from
the description of an investigation written by the
person who conducted it. Which type of
reference source refers to this?
a. Footnote
b. Bibliography
c. Primary source
d. Endnotes
73. When Nurse Trish is providing care to his
patient, she must remember that her duty is
bound not to do doing any action that will cause
the patient harm. This is the meaning of the
bioethical principle:
a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity
74. When a nurse in-charge causes an injury to a
female patient and the injury caused becomes
the proof of the negligent act, the presence of
the injury is said to exemplify the principle of:
a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine
75. Nurse Myrna is aware that the Board of Nursing
has quasi-judicial power. An example of this
power is:
a. The Board can issue rules and
regulations that will govern the practice
of nursing
b. The Board can investigate violations of
the nursing law and code of ethics
c. The Board can visit a school applying for
a permit in collaboration with CHED
d. The Board prepares the board
examinations
76. When the license of nurse Krina is revoked, it
means that she:
a. Is no longer allowed to practice the
profession for the rest of her life
b. Will never have her/his license re-issued
since it has been revoked
c. May apply for re-issuance of his/her
license based on certain conditions
stipulated in RA 9173
d. Will remain unable to practice
professional nursing
77. Ronald plans to conduct a research on the use of
a new method of pain assessment scale. Which
of the following is the second step in the
conceptualizing phase of the research process?
a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research
problem
d. Design the theoretical and conceptual
framework
78. The leader of the study knows that certain
patients who are in a specialized research setting
tend to respond psychologically to the
conditions of the study. This referred to as :
a. Cause and effect
b. Hawthorne effect
c. Halo effect
d. Horns effect
79. Mary finally decides to use judgment sampling
on her research. Which of the following actions
of is correct?
a. Plans to include whoever is there during
his study.
b. Determines the different nationality of
patients frequently admitted and
decides to get representations samples
from each.
c. Assigns numbers for each of the
patients, place these in a fishbowl and
draw 10 from it.
d. Decides to get 20 samples from the
admitted patients
80. The nursing theorist who developed
transcultural nursing theory is:
a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy
81. Marion is aware that the sampling method that
gives equal chance to all units in the population
to get picked is:
a. Random
b. Accidental
c. Quota
d. Judgment
82. John plans to use a Likert Scale to his study to
determine the:
a. Degree of agreement and disagreement
b. Compliance to expected standards
c. Level of satisfaction
d. Degree of acceptance
83. Which of the following theory addresses the four
modes of adaptation?
a. Madeleine Leininger
b. Sr. Callista Roy
c. Florence Nightingale
d. Jean Watson
84. Ms. Garcia is responsible to the number of
personnel reporting to her. This principle refers
to:
a. Span of control
b. Unity of command
c. Downward communication
d. Leader
85. Ensuring that there is an informed consent on
the part of the patient before a surgery is done,
illustrates the bioethical principle of:
a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence
86. Nurse Reese is teaching a female client with
peripheral 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 pressure
ulcers. When developing the client's diet plan,
the nurse should include:
a. Fresh orange slices
b. Steamed broccoli
c. Ice cream
d. Ground beef patties
88. The nurse prepares to administer a cleansing
enema. What is the most common client
position used for this procedure?
a. Lithotomy
b. Supine
c. Prone
d. Sims’ left lateral
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89. Nurse Marian is preparing to administer a blood
transfusion. Which action should the nurse take
first?
a. Arrange for typing and cross matching of
the client’s blood.
b. Compare the client’s identification
wristband with the tag on the unit of
blood.
c. Start an I.V. infusion of normal saline
solution.
d. Measure the client’s vital signs.
90. A 65 years old male client requests his
medication at 9 p.m. instead of 10 p.m. so that
he can go to sleep earlier. Which type of nursing
intervention is required?
a. Independent
b. Dependent
c. Interdependent
d. Intradependent
91. A female client is to be discharged from an acute
care facility after treatment for right leg
thrombophlebitis. The Nurse Betty notes that
the client's leg is pain-free, without redness or
edema. The nurse's actions reflect which step of
the nursing process?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation
92. Nursing care for a female client includes
removing elastic stockings once per day. The
Nurse Betty is aware that the rationale for this
intervention?
a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and
relax
d. To permit veins in the legs to fill with
blood.
93. Which nursing intervention takes highest priority
when caring for a newly admitted client who's
receiving a blood transfusion?
a. Instructing the client to report any
itching, swelling, or dyspnea.
b. Informing the client that the transfusion
usually take 1 ½ to 2 hours.
c. Documenting blood administration in
the client care record.
65
d. Assessing the client’s vital signs when
the transfusion ends.
94. A male client complains of abdominal discomfort
and nausea while receiving tube feedings. Which
intervention is most appropriate for this
problem?
a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the
concentration of the formula.
c. Place the client in semi-Fowler's position
while feeding.
d. Change the feeding container every 12
hours.
95. Nurse Patricia is reconstituting a powdered
medication in a vial. After adding the solution to
the powder, she nurse should:
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5
minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.
96. Which intervention should the nurse Trish use
when administering oxygen by face mask to a
female client?
a. Secure the elastic band tightly around
the client's head.
b. Assist the client to the semi-Fowler
position if possible.
c. Apply the face mask from the client's
chin up over the nose.
d. Loosen the connectors between the
oxygen equipment and humidifier.
97. The maximum transfusion time for a unit of
packed red blood cells (RBCs) is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours
98. Nurse Monique is monitoring the effectiveness
of a client's drug therapy. When should the
nurse Monique obtain a blood sample to
measure the trough drug level?
a. 1 hour before administering the next
dose.
b. Immediately before administering the
next dose.
c. Immediately after administering the
next dose.
d. 30 minutes after administering the next
dose.
99. Nurse May is aware that the main advantage of
using a floor stock system is:
a. The nurse can implement medication
orders quickly.
b. The nurse receives input from the
pharmacist.
c. The system minimizes transcription
errors.
d. The system reinforces accurate
calculations.
100. Nurse Oliver is assessing a client's abdomen.
Which finding should the nurse report as
abnormal?
a. Dullness over the liver.
b. Bowel sounds occurring every 10
seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal
arteries.
Answers and Rationale – Foundation of
Professional Nursing Practice
1.
2.
3.
4.
5.
6.
7.
66
Answer: (D) The actions of a reasonably
prudent nurse with similar education and
experience.
Rationale: The standard of care is determined
by the average degree of skill, care, and
diligence by nurses in similar circumstances.
Answer: (B) I.M
Rationale: With a platelet count of 22,000/μl,
the clients tends to bleed easily. Therefore,
the nurse should avoid using the I.M. route
because the area is a highly vascular and can
bleed readily when penetrated by a needle.
The bleeding can be difficult to stop.
Answer: (C) “Digoxin 0.125 mg P.O. once daily”
Rationale: The nurse should always place a
zero before a decimal point so that no one
misreads the figure, which could result in a
dosage error. The nurse should never insert a
zero at the end of a dosage that includes a
decimal point because this could be misread,
possibly leading to a tenfold increase in the
dosage.
Answer: (A) Ineffective peripheral tissue
perfusion related to venous congestion.
Rationale: Ineffective peripheral tissue
perfusion related to venous congestion takes
the highest priority because venous
inflammation and clot formation impede blood
flow in a client with deep vein thrombosis.
Answer: (B) A 44 year-old myocardial
infarction (MI) client who is complaining of
nausea.
Rationale: Nausea is a symptom of impending
myocardial infarction (MI) and should be
assessed immediately so that treatment can
be instituted and further damage to the heart
is avoided.
Answer: (C) Check circulation every 15-30
minutes.
Rationale: Restraints encircle the limbs, which
place the client at risk for circulation being
restricted to the distal areas of the
extremities. Checking the client’s circulation
every 15-30 minutes will allow the nurse to
adjust the restraints before injury from
decreased blood flow occurs.
Answer: (A) Prevent stress ulcer
8.
9.
10.
11.
12.
13.
14.
Rationale: Curling’s ulcer occurs as a
generalized stress response in burn patients.
This results in a decreased production of
mucus and increased secretion of gastric acid.
The best treatment for this prophylactic use of
antacids and H2 receptor blockers.
Answer: (D) Continue to monitor and record
hourly urine output
Rationale: Normal urine output for an adult is
approximately 1 ml/minute (60 ml/hour).
Therefore, this client's output is normal.
Beyond continued evaluation, no nursing
action is warranted.
Answer: (B) “My ankle feels warm”.
Rationale: Ice application decreases pain and
swelling. Continued or increased pain, redness,
and increased warmth are signs of
inflammation that shouldn't occur after ice
application
Answer: (B) Hyperkalemia
Rationale: A loop diuretic removes water and,
along with it, sodium and potassium. This may
result in hypokalemia, hypovolemia, and
hyponatremia.
Answer:(A) Have condescending trust and
confidence in their subordinates
Rationale: Benevolent-authoritative managers
pretentiously show their trust and confidence
to their followers.
Answer: (A) Provides continuous, coordinated
and comprehensive nursing services.
Rationale: Functional nursing is focused on
tasks and activities and not on the care of the
patients.
Answer: (B) Standard written order
Rationale: This is a standard written order.
Prescribers write a single order for
medications given only once. A stat order is
written for medications given immediately for
an urgent client problem. A standing order,
also known as a protocol, establishes
guidelines for treating a particular disease or
set of symptoms in special care areas such as
the coronary care unit. Facilities also may
institute medication protocols that specifically
designate drugs that a nurse may not give.
Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid
stools results from seepage of unformed
bowel contents around the impacted stool in
the rectum. Clients with fecal impaction don't
pass hard, brown, formed stools because the
feces can't move past the impaction. These
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15.
16.
17.
18.
19.
20.
21.
22.
clients typically report the urge to defecate
(although they can't pass stool) and a
decreased appetite.
Answer: (C) Pulling the helix up and back
Rationale: To perform an otoscopic
examination on an adult, the nurse grasps the
helix of the ear and pulls it up and back to
straighten the ear canal. For a child, the nurse
grasps the helix and pulls it down to straighten
the ear canal. Pulling the lobule in any
direction wouldn't straighten the ear canal for
visualization.
Answer: (A) Protect the irritated skin from
sunlight.
Rationale: Irradiated skin is very sensitive and
must be protected with clothing or sunblock.
The priority approach is the avoidance of
strong sunlight.
Answer: (C) Assist the client in removing
dentures and nail polish.
Rationale: Dentures, hairpins, and combs must
be removed. Nail polish must be removed so
that cyanosis can be easily monitored by
observing the nail beds.
Answer: (D) Sudden onset of continuous
epigastric and back pain.
Rationale: The autodigestion of tissue by the
pancreatic enzymes results in pain from
inflammation, edema, and possible
hemorrhage. Continuous, unrelieved epigastric
or back pain reflects the inflammatory process
in the pancreas.
Answer: (B) Provide high-protein, highcarbohydrate diet.
Rationale: A positive nitrogen balance is
important for meeting metabolic needs, tissue
repair, and resistance to infection. Caloric
goals may be as high as 5000 calories per day.
Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to
recognize the signs of an anaphylactic or
hemolytic reaction to the transfusion.
Answer: (D) Immobilize the leg before moving
the client.
Rationale: If the nurse suspects a fracture,
splinting the area before moving the client is
imperative. The nurse should call for
emergency help if the client is not hospitalized
and call for a physician for the hospitalized
client.
Answer: (B) Admit the client into a private
room.
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Rationale: The client who has a radiation
implant is placed in a private room and has a
limited number of visitors. This reduces the
exposure of others to the radiation.
Answer: (C) Risk for infection
Rationale: Agranulocytosis is characterized by
a reduced number of leukocytes (leucopenia)
and neutrophils (neutropenia) in the blood.
The client is at high risk for infection because
of the decreased body defenses against
microorganisms. Deficient knowledge related
to the nature of the disorder may be
appropriate diagnosis but is not the priority.
Answer: (B) Place the client on the left side in
the Trendelenburg position.
Rationale: Lying on the left side may prevent
air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic
pressure, which decreases the amount of
blood pulled into the vena cava during
aspiration.
Answer: (A) Autocratic.
Rationale: The autocratic style of leadership is
a task-oriented and directive.
Answer: (D) 2.5 cc
Rationale: 2.5 cc is to be added, because only a
500 cc bag of solution is being medicated
instead of a 1 liter.
Answer: (A) 50 cc/ hour
Rationale: A rate of 50 cc/hr. The child is to
receive 400 cc over a period of 8 hours = 50
cc/hr.
Answer: (B) Assess the client for presence of
pain.
Rationale: Assessing the client for pain is a
very important measure. Postoperative pain is
an indication of complication. The nurse
should also assess the client for pain to
provide for the client’s comfort.
Answer: (A) BP – 80/60, Pulse – 110 irregular
Rationale: The classic signs of cardiogenic
shock are low blood pressure, rapid and weak
irregular pulse, cold, clammy skin, decreased
urinary output, and cerebral hypoxia.
Answer: (A) Take the proper equipment, place
the client in a comfortable position, and
record the appropriate information in the
client’s chart.
Rationale: It is a general or comprehensive
statement about the correct procedure, and it
includes the basic ideas which are found in the
other options
Answer: (B) Evaluation
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Rationale: Evaluation includes observing the
person, asking questions, and comparing the
patient’s behavioral responses with the
expected outcomes.
Answer: (C) History of present illness
Rationale: The history of present illness is the
single most important factor in assisting the
health professional in arriving at a diagnosis or
determining the person’s needs.
Answer: (A) Trochanter roll extending from the
crest of the ileum to the mid-thigh.
Rationale: A trochanter roll, properly placed,
provides resistance to the external rotation of
the hip.
Answer: (C) Stage III
Rationale: Clinically, a deep crater or without
undermining of adjacent tissue is noted.
Answer: (A) Second intention healing
Rationale: When wounds dehisce, they will
allowed to heal by secondary Intention
Answer: (D) Tachycardia
Rationale: With an extracellular fluid or plasma
volume deficit, compensatory mechanisms
stimulate the heart, causing an increase in
heart rate.
Answer: (A) 0.75
Rationale: To determine the number of
milliliters the client should receive, the nurse
uses the fraction method in the following
equation.
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg
75 = 100X
75/100 = X
0.75 ml (or ¾ ml) = X
Answer: (D) it’s a measure of effect, not a
standard measure of weight or quantity.
Rationale: An insulin unit is a measure of
effect, not a standard measure of weight or
quantity. Different drugs measured in units
may have no relationship to one another in
quality or quantity.
Answer: (B) 38.9 °C
Rationale: To convert Fahrenheit degreed to
Centigrade, use this formula
°C = (°F – 32) ÷ 1.8
°C = (102 – 32) ÷ 1.8
°C = 70 ÷ 1.8
°C = 38.9
Answer: (C) Failing eyesight, especially close
vision.
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Rationale: Failing eyesight, especially close
vision, is one of the first signs of aging in
middle life (ages 46 to 64). More frequent
aches and pains begin in the early late years
(ages 65 to 79). Increase in loss of muscle tone
occurs in later years (age 80 and older).
Answer: (A) Checking and taping all
connections
Rationale: Air leaks commonly occur if the
system isn’t secure. Checking all connections
and taping them will prevent air leaks. The
chest drainage system is kept lower to
promote drainage – not to prevent leaks.
Answer: (A) Check the client’s identification
band.
Rationale: Checking the client’s identification
band is the safest way to verify a client’s
identity because the band is assigned on
admission and isn’t be removed at any time. (If
it is removed, it must be replaced). Asking the
client’s name or having the client repeated his
name would be appropriate only for a client
who’s alert, oriented, and able to understand
what is being said, but isn’t the safe standard
of practice. Names on bed aren’t always
reliable
Answer: (B) 32 drops/minute
Rationale: Giving 1,000 ml over 8 hours is the
same as giving 125 ml over 1 hour (60
minutes). Find the number of milliliters per
minute as follows:
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/ 15 gtt
X = 32 gtt/minute, or 32 drops/minute
Answer: (A) Clamp the catheter
Rationale: If a central venous catheter
becomes disconnected, the nurse should
immediately apply a catheter clamp, if
available. If a clamp isn’t available, the nurse
can place a sterile syringe or catheter plug in
the catheter hub. After cleaning the hub with
alcohol or povidone-iodine solution, the nurse
must replace the I.V. extension and restart the
infusion.
Answer: (D) Auscultation, percussion, and
palpation.
Rationale: The correct order of assessment for
examining the abdomen is inspection,
auscultation, percussion, and palpation. The
reason for this approach is that the less
intrusive techniques should be performed
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before the more intrusive techniques.
Percussion and palpation can alter natural
findings during auscultation.
Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or
ball, of the hand to assess tactile fremitus,
thrills, and vocal vibrations through the chest
wall. The fingertips and finger pads best
distinguish texture and shape. The dorsal
surface best feels warmth.
Answer: (C) Formative
Rationale: Formative (or concurrent)
evaluation occurs continuously throughout the
teaching and learning process. One benefit is
that the nurse can adjust teaching strategies
as necessary to enhance learning. Summative,
or retrospective, evaluation occurs at the
conclusion of the teaching and learning
session. Informative is not a type of
evaluation.
Answer: (B) Once per year
Rationale: Yearly mammograms should begin
at age 40 and continue for as long as the
woman is in good health. If health risks, such
as family history, genetic tendency, or past
breast cancer, exist, more frequent
examinations may be necessary.
Answer: (A) Respiratory acidosis
Rationale: The client has a below-normal
(acidic) blood pH value and an above-normal
partial pressure of arterial carbon dioxide
(Paco2) value, indicating respiratory acidosis.
In respiratory alkalosis, the pH value is above
normal and in the Paco2 value is below
normal. In metabolic acidosis, the pH and
bicarbonate (Hco3) values are below normal.
In metabolic alkalosis, the pH and Hco3 values
are above normal.
Answer: (B) To provide support for the client
and family in coping with terminal illness.
Rationale: Hospices provide supportive care
for terminally ill clients and their families.
Hospice care doesn’t focus on counseling
regarding health care costs. Most client
referred to hospices have been treated for
their disease without success and will receive
only palliative care in the hospice.
Answer: (C) Using normal saline solution to
clean the ulcer and applying a protective
dressing as necessary.
Rationale: Washing the area with normal
saline solution and applying a protective
dressing are within the nurse’s realm of
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interventions and will protect the area. Using a
povidone-iodine wash and an antibiotic cream
require a physician’s order. Massaging with an
astringent can further damage the skin.
Answer: (D) Foot
Rationale: An elastic bandage should be
applied form the distal area to the proximal
area. This method promotes venous return. In
this case, the nurse should begin applying the
bandage at the client’s foot. Beginning at the
ankle, lower thigh, or knee does not promote
venous return.
Answer: (B) Hypokalemia
Rationale: Insulin administration causes
glucose and potassium to move into the cells,
causing hypokalemia.
Answer: (A) Throbbing headache or dizziness
Rationale: Headache and dizziness often occur
when nitroglycerin is taken at the beginning of
therapy. However, the client usually develops
tolerance
Answer: (D) Check the client’s level of
consciousness
Rationale: Determining unresponsiveness is
the first step assessment action to take. When
a client is in ventricular tachycardia, there is a
significant decrease in cardiac output.
However, checking the unresponsiveness
ensures whether the client is affected by the
decreased cardiac output.
Answer: (B) On the affected side of the client.
Rationale: When walking with clients, the
nurse should stand on the affected side and
grasp the security belt in the midspine area of
the small of the back. The nurse should
position the free hand at the shoulder area so
that the client can be pulled toward the nurse
in the event that there is a forward fall. The
client is instructed to look up and outward
rather than at his or her feet.
Answer: (A) Urine output: 45 ml/hr
Rationale: Adequate perfusion must be
maintained to all vital organs in order for the
client to remain visible as an organ donor. A
urine output of 45 ml per hour indicates
adequate renal perfusion. Low blood pressure
and delayed capillary refill time are circulatory
system indicators of inadequate perfusion. A
serum pH of 7.32 is acidotic, which adversely
affects all body tissues.
Answer: (D ) Obtaining the specimen from the
urinary drainage bag.
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Rationale: A urine specimen is not taken from
the urinary drainage bag. Urine undergoes
chemical changes while sitting in the bag and
does not necessarily reflect the current client
status. In addition, it may become
contaminated with bacteria from opening the
system.
Answer: (B) Cover the client, place the call
light within reach, and answer the phone call.
Rationale: Because telephone call is an
emergency, the nurse may need to answer it.
The other appropriate action is to ask another
nurse to accept the call. However, is not one of
the options. To maintain privacy and safety,
the nurse covers the client and places the call
light within the client’s reach. Additionally, the
client’s door should be closed or the room
curtains pulled around the bathing area.
Answer: (C) Use a sterile plastic container for
obtaining the specimen.
Rationale: Sputum specimens for culture and
sensitivity testing need to be obtained using
sterile techniques because the test is done to
determine the presence of organisms. If the
procedure for obtaining the specimen is not
sterile, then the specimen is not sterile, then
the specimen would be contaminated and the
results of the test would be invalid.
Answer: (A) Puts all the four points of the
walker flat on the floor, puts weight on the
hand pieces, and then walks into it.
Rationale: When the client uses a walker, the
nurse stands adjacent to the affected side. The
client is instructed to put all four points of the
walker 2 feet forward flat on the floor before
putting weight on hand pieces. This will ensure
client safety and prevent stress cracks in the
walker. The client is then instructed to move
the walker forward and walk into it.
Answer: (C) Draws one line to cross out the
incorrect information and then initials the
change.
Rationale: To correct an error documented in a
medical record, the nurse draws one line
through the incorrect information and then
initials the error. An error is never erased and
correction fluid is never used in the medical
record.
Answer: (C) Secures the client safety belts
after transferring to the stretcher.
Rationale: During the transfer of the client
after the surgical procedure is complete, the
nurse should avoid exposure of the client
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because of the risk for potential heat loss.
Hurried movements and rapid changes in the
position should be avoided because these
predispose the client to hypotension. At the
time of the transfer from the surgery table to
the stretcher, the client is still affected by the
effects of the anesthesia; therefore, the client
should not move self. Safety belts can prevent
the client from falling off the stretcher.
Answer: (B) Gown and gloves
Rationale: Contact precautions require the use
of gloves and a gown if direct client contact is
anticipated. Goggles are not necessary unless
the nurse anticipates the splashes of blood,
body fluids, secretions, or excretions may
occur. Shoe protectors are not necessary.
Answer: (C) Quad cane
Rationale: Crutches and a walker can be
difficult to maneuver for a client with
weakness on one side. A cane is better suited
for client with weakness of the arm and leg on
one side. However, the quad cane would
provide the most stability because of the
structure of the cane and because a quad cane
has four legs.
Answer: (D) Left side-lying with the head of
the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from
the chest wall, the client is positioned sitting at
the edge of the bed leaning over the bedside
table with the feet supported on a stool. If the
client is unable to sit up, the client is
positioned lying in bed on the unaffected side
with the head of the bed elevated 30 to 45
degrees.
Answer: (D) Reliability
Rationale: Reliability is consistency of the
research instrument. It refers to the
repeatability of the instrument in extracting
the same responses upon its repeated
administration.
Answer: (A) Keep the identities of the subject
secret
Rationale: Keeping the identities of the
research subject secret will ensure anonymity
because this will hinder providing link between
the information given to whoever is its source.
Answer: (A) Descriptive- correlational
Rationale: Descriptive- correlational study is
the most appropriate for this study because it
studies the variables that could be the
antecedents of the increased incidence of
nosocomial infection.
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Answer: (C) Use of laboratory data
Rationale: Incidence of nosocomial infection is
best collected through the use of
biophysiologic measures, particularly in vitro
measurements, hence laboratory data is
essential.
Answer: (B) Quasi-experiment
Rationale: Quasi-experiment is done when
randomization and control of the variables are
not possible.
Answer: (C) Primary source
Rationale: This refers to a primary source
which is a direct account of the investigation
done by the investigator. In contrast to this is a
secondary source, which is written by
someone other than the original researcher.
Answer: (A) Non-maleficence
Rationale: Non-maleficence means do not
cause harm or do any action that will cause
any harm to the patient/client. To do good is
referred as beneficence.
Answer: (C) Res ipsa loquitor
Rationale: Res ipsa loquitor literally means the
thing speaks for itself. This means in
operational terms that the injury caused is the
proof that there was a negligent act.
Answer: (B) The Board can investigate
violations of the nursing law and code of ethics
Rationale: Quasi-judicial power means that the
Board of Nursing has the authority to
investigate violations of the nursing law and
can issue summons, subpoena or subpoena
duces tecum as needed.
Answer: (C) May apply for re-issuance of
his/her license based on certain conditions
stipulated in RA 9173
Rationale: RA 9173 sec. 24 states that for
equity and justice, a revoked license maybe reissued provided that the following conditions
are met: a) the cause for revocation of license
has already been corrected or removed; and,
b) at least four years has elapsed since the
license has been revoked.
Answer: (B) Review related literature
Rationale: After formulating and delimiting the
research problem, the researcher conducts a
review of related literature to determine the
extent of what has been done on the study by
previous researchers.
Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the
study of Elton Mayo and company about the
effect of an intervention done to improve the
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working conditions of the workers on their
productivity. It resulted to an increased
productivity but not due to the intervention
but due to the psychological effects of being
observed. They performed differently because
they were under observation.
Answer: (B) Determines the different
nationality of patients frequently admitted and
decides to get representations samples from
each.
Rationale: Judgment sampling involves
including samples according to the knowledge
of the investigator about the participants in
the study.
Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the
theory on transcultural theory based on her
observations on the behavior of selected
people within a culture.
Answer: (A) Random
Rationale: Random sampling gives equal
chance for all the elements in the population
to be picked as part of the sample.
Answer: (A) Degree of agreement and
disagreement
Rationale: Likert scale is a 5-point summated
scale used to determine the degree of
agreement or disagreement of the
respondents to a statement in a study
Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the
Adaptation Model which involves the
physiologic mode, self-concept mode, role
function mode and dependence mode.
Answer: (A) Span of control
Rationale: Span of control refers to the
number of workers who report directly to a
manager.
Answer: (B) Autonomy
Rationale: Informed consent means that the
patient fully understands about the surgery,
including the risks involved and the alternative
solutions. In giving consent it is done with full
knowledge and is given freely. The action of
allowing the patient to decide whether a
surgery is to be done or not exemplifies the
bioethical principle of autonomy.
Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to
avoid wearing canvas shoes. Canvas shoes
cause the feet to perspire, which may, in turn,
cause skin irritation and breakdown. Both
cotton and cornstarch absorb perspiration.
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The client should be instructed to cut toenails
straight across with nail clippers.
Answer: (D) Ground beef patties
Rationale: Meat is an excellent source of
complete protein, which this client needs to
repair the tissue breakdown caused by
pressure ulcers. Oranges and broccoli supply
vitamin C but not protein. Ice cream supplies
only some incomplete protein, making it less
helpful in tissue repair.
Answer: (D) Sims’ left lateral
Rationale: The Sims' left lateral position is the
most common position used to administer a
cleansing enema because it allows gravity to
aid the flow of fluid along the curve of the
sigmoid colon. If the client can't assume this
position nor has poor sphincter control, the
dorsal recumbent or right lateral position may
be used. The supine and prone positions are
inappropriate and uncomfortable for the
client.
Answer: (A) Arrange for typing and cross
matching of the client’s blood.
Rationale: The nurse first arranges for typing
and cross matching of the client's blood to
ensure compatibility with donor blood. The
other options, although appropriate when
preparing to administer a blood transfusion,
come later.
Answer: (A) Independent
Rationale: Nursing interventions are classified
as independent, interdependent, or
dependent. Altering the drug schedule to
coincide with the client's daily routine
represents an independent intervention,
whereas consulting with the physician and
pharmacist to change a client's medication
because of adverse reactions represents an
interdependent intervention. Administering an
already-prescribed drug on time is a
dependent intervention. An intradependent
nursing intervention doesn't exist.
Answer: (D) Evaluation
Rationale: The nursing actions described
constitute evaluation of the expected
outcomes. The findings show that the
expected outcomes have been achieved.
Assessment consists of the client's history,
physical examination, and laboratory studies.
Analysis consists of considering assessment
information to derive the appropriate nursing
diagnosis. Implementation is the phase of the
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nursing process where the nurse puts the plan
of care into action.
Answer: (B) To observe the lower extremities
Rationale: Elastic stockings are used to
promote venous return. The nurse needs to
remove them once per day to observe the
condition of the skin underneath the stockings.
Applying the stockings increases blood flow to
the heart. When the stockings are in place, the
leg muscles can still stretch and relax, and the
veins can fill with blood.
Answer :(A) Instructing the client to report any
itching, swelling, or dyspnea.
Rationale: Because administration of blood or
blood products may cause serious adverse
effects such as allergic reactions, the nurse
must monitor the client for these effects. Signs
and symptoms of life-threatening allergic
reactions include itching, swelling, and
dyspnea. Although the nurse should inform
the client of the duration of the transfusion
and should document its administration, these
actions are less critical to the client's
immediate health. The nurse should assess
vital signs at least hourly during the
transfusion.
Answer: (B) Decrease the rate of feedings and
the concentration of the formula.
Rationale: Complaints of abdominal
discomfort and nausea are common in clients
receiving tube feedings. Decreasing the rate of
the feeding and the concentration of the
formula should decrease the client's
discomfort. Feedings are normally given at
room temperature to minimize abdominal
cramping. To prevent aspiration during
feeding, the head of the client's bed should be
elevated at least 30 degrees. Also, to prevent
bacterial growth, feeding containers should be
routinely changed every 8 to 12 hours.
Answer: (D) Roll the vial gently between the
palms.
Rationale: Rolling the vial gently between the
palms produces heat, which helps dissolve the
medication. Doing nothing or inverting the vial
wouldn't help dissolve the medication. Shaking
the vial vigorously could cause the medication
to break down, altering its action.
Answer: (B) Assist the client to the semiFowler position if possible.
Rationale: By assisting the client to the semiFowler position, the nurse promotes easier
chest expansion, breathing, and oxygen intake.
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The nurse should secure the elastic band so
that the face mask fits comfortably and snugly
rather than tightly, which could lead to
irritation. The nurse should apply the face
mask from the client's nose down to the chin
— not vice versa. The nurse should check the
connectors between the oxygen equipment
and humidifier to ensure that they're airtight;
loosened connectors can cause loss of oxygen.
97. Answer: (B) 4 hours
Rationale: A unit of packed RBCs may be given
over a period of between 1 and 4 hours. It
shouldn't infuse for longer than 4 hours
because the risk of contamination and sepsis
increases after that time. Discard or return to
the blood bank any blood not given within this
time, according to facility policy.
98. Answer: (B) Immediately before administering
the next dose.
Rationale: Measuring the blood drug
concentration helps determine whether the
dosing has achieved the therapeutic goal. For
measurement of the trough, or lowest, blood
level of a drug, the nurse draws a blood
sample immediately before administering the
next dose. Depending on the drug's duration
of action and half-life, peak blood drug levels
typically are drawn after administering the
next dose.
99. Answer: (A) The nurse can implement
medication orders quickly.
Rationale: A floor stock system enables the
nurse to implement medication orders quickly.
It doesn't allow for pharmacist input, nor does
it minimize transcription errors or reinforce
accurate calculations.
100. Answer: (C) Shifting dullness over the
abdomen.
Rationale: Shifting dullness over the abdomen
indicates ascites, an abnormal finding. The
other options are normal abdominal findings.
TEST II - Community Health Nursing and Care of the
Mother and Child
1. May arrives at the health care clinic and tells the
nurse that her last menstrual period was 9
weeks ago. She also tells the nurse that a home
pregnancy test was positive but she began to
have mild cramps and is now having moderate
vaginal bleeding. During the physical
examination of the client, the nurse notes that
May has a dilated cervix. The nurse determines
that May is experiencing which type of abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic
2. Nurse Reese is reviewing the record of a
pregnant client for her first prenatal visit. Which
of the following data, if noted on the client’s
record, would alert the nurse that the client is at
risk for a spontaneous abortion?
a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who
is newly admitted to the hospital with a possible
diagnosis of ectopic pregnancy. Nurse Hazel
develops a plan of care for the client and
determines that which of the following nursing
actions is the priority?
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature
4. Nurse Oliver is teaching a diabetic pregnant
client about nutrition and insulin needs during
pregnancy. The nurse determines that the client
understands dietary and insulin needs if the
client states that the second half of pregnancy
requires:
a. Decreased caloric intake
b. Increased caloric intake
c. Decreased Insulin
d. Increase Insulin
5. Nurse Michelle is assessing a 24 year old client
with a diagnosis of hydatidiform mole. She is
aware that one of the following is unassociated
with this condition?
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a. Excessive fetal activity.
b. Larger than normal uterus for
gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic
gonadotropin.
6. A pregnant client is receiving magnesium sulfate
for severe pregnancy induced hypertension
(PIH). The clinical findings that would warrant
use 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 in
labor, the presenting part is at station plus two.
Nurse, correctly interprets it as:
a. Presenting part is 2 cm above the plane
of the ischial spines.
b. Biparietal diameter is at the level of the
ischial spines.
c. Presenting part in 2 cm below the plane
of the ischial spines.
d. Biparietal diameter is 2 cm above the
ischial spines.
8. A pregnant client is receiving oxytocin (Pitocin)
for induction of labor. A condition that warrant
the nurse in-charge to discontinue I.V. infusion
of Pitocin is:
a. Contractions every 1 ½ minutes lasting
70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart
rate.
d. Fetal heart rate baseline 140-160 bpm.
9. Calcium gluconate is being administered to a
client with pregnancy induced hypertension
(PIH). A nursing action that must be initiated as
the plan of care throughout injection of the drug
is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
10. A trial for vaginal delivery after an earlier
caesarean, would likely to be given to a gravida,
who had:
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a. First low transverse cesarean was for
active herpes type 2 infections; vaginal
culture at 39 weeks pregnancy was
positive.
b. First and second caesareans were for
cephalopelvic disproportion.
c. First caesarean through a classic incision
as a result of severe fetal distress.
d. First low transverse caesarean was for
breech position. Fetus in this pregnancy
is in a vertex presentation.
11. Nurse Ryan is aware that the best initial
approach when trying to take a crying toddler’s
temperature is:
a. Talk to the mother first and then to the
toddler.
b. Bring extra help so it can be done
quickly.
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 lip
and palate repair. What should the nurse do to
prevent trauma to operative site?
a. Avoid touching the suture line, even
when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow
restraints.
13. Which action should nurse Marian include in the
care 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 administer
medications before feeding.
d. Weigh and bathe the infant before
feeding.
14. Nurse Hazel is teaching a mother who plans to
discontinue breast feeding after 5 months. The
nurse should advise her to include which foods
in 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 is
sitting securely alone on the floor of the clinic.
The mother hides a toy behind her back and the
infant looks for it. The nurse is aware that
estimated age of the infant would be:
a. 6 months
b. 4 months
c. 8 months
d. 10 months
16. Which of the following is the most prominent
feature of public health nursing?
a. It involves providing home care to sick
people who are not confined in the
hospital.
b. Services are provided free of charge to
people within the catchments area.
c. The public health nurse functions as part
of a team providing a public health
nursing services.
d. Public health nursing focuses on
preventive, not curative, services.
17. When the nurse determines whether resources
were maximized in implementing Ligtas Tigdas,
she is evaluating
a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness
18. Vangie is a new B.S.N. graduate. She wants to
become a Public Health Nurse. Where should
she apply?
a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit
19. Tony is aware the Chairman of the Municipal
Health Board is:
a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician
20. Myra is the public health nurse in a municipality
with a total population of about 20,000. There
are 3 rural health midwives among the RHU
personnel. How many more midwife items will
the RHU need?
a. 1
b. 2
c. 3
d. The RHU does not need any more
midwife item.
21. According to Freeman and Heinrich, community
health nursing is a developmental service. Which
of the following best illustrates this statement?
a. The community health nurse
continuously develops himself
personally and professionally.
b. Health education and community
organizing are necessary in providing
community health services.
c. Community health nursing is intended
primarily for health promotion and
prevention and treatment of disease.
d. The goal of community health nursing is
to provide nursing services to people in
their own places of residence.
22. Nurse Tina is aware that the disease declared
through Presidential Proclamation No. 4 as a
target for eradication in the Philippines is?
a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus
23. May knows that the step in community
organizing that involves training of potential
leaders in the community is:
a. Integration
b. Community organization
c. Community study
d. Core group formation
24. Beth a public health nurse takes an active role in
community participation. What is the primary
goal of community organizing?
a. To educate the people regarding
community health problems
b. To mobilize the people to resolve
community health problems
c. To maximize the community’s resources
in dealing with health problems.
d. To maximize the community’s resources
in dealing with health problems.
25. Tertiary prevention is needed in which stage of
the natural history of disease?
a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal
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26. The nurse is caring for a primigravid client in the
labor and delivery area. Which condition would
place the client at risk for disseminated
intravascular 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 aware
that the fetal heart rate would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute
28. The skin in the diaper area of a 7 month old
infant is excoriated and red. Nurse Hazel should
instruct the mother to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each
diaper change.
d. Decrease the infant’s fluid intake to
decrease saturating diapers.
29. Nurse Carla knows that the common cardiac
anomalies in children with Down Syndrome (trisomy 21) is:
a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect
30. Malou was diagnosed with severe preeclampsia
is now receiving I.V. magnesium sulfate. The
adverse effects associated with magnesium
sulfate is:
a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate
31. A 23 year old client is having her menstrual
period every 2 weeks that last for 1 week. This
type of menstrual pattern is bets defined by:
a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea
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32. Jannah is admitted to the labor and delivery
unit. The critical laboratory result for this client
would be:
a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium
33. Nurse Gina is aware that the most common
condition found during the second-trimester of
pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia
34. Nurse Lynette is working in the triage area of an
emergency department. She sees that several
pediatric clients arrive simultaneously. The client
who needs to be treated first is:
a. A crying 5 year old child with a
laceration on his scalp.
b. A 4 year old child with a barking coughs
and flushed appearance.
c. A 3 year old child with Down syndrome
who is pale and asleep in his mother’s
arms.
d. A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s
arms and drooling.
35. Maureen in her third trimester arrives at the
emergency room with painless vaginal bleeding.
Which of the following conditions is suspected?
a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease
36. A young child named Richard is suspected of
having pinworms. The community nurse collects
a stool specimen to confirm the diagnosis. The
nurse should schedule the collection of this
specimen for:
a. Just before bedtime
b. After the child has been bathe
c. Any time during the day
d. Early in the morning
37. In doing a child’s admission assessment, Nurse
Betty should be alert to note which signs or
symptoms of chronic lead poisoning?
a. Irritability and seizures
b. Dehydration and diarrhea
c. Bradycardia and hypotension
d. Petechiae and hematuria
38. To evaluate a woman’s understanding about the
use of diaphragm for family planning, Nurse
Trish asks her to explain how she will use the
appliance. Which response indicates a need for
further health teaching?
a. “I should check the diaphragm carefully
for holes every time I use it”
b. “I may need a different size of
diaphragm if I gain or lose weight more
than 20 pounds”
c. “The diaphragm must be left in place for
atleast 6 hours after intercourse”
d. “I really need to use the diaphragm and
jelly most during the middle of my
menstrual cycle”.
39. Hypoxia is a common complication of
laryngotracheobronchitis. Nurse Oliver should
frequently assess a child with
laryngotracheobronchitis for:
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever
40. How should Nurse Michelle guide a child who is
blind to walk to the playroom?
a. Without touching the child, talk
continuously as the child walks down the
hall.
b. Walk one step ahead, with the child’s
hand on the nurse’s elbow.
c. Walk slightly behind, gently guiding the
child forward.
d. Walk next to the child, holding the
child’s hand.
41. When assessing a newborn diagnosed with
ductus arteriosus, Nurse Olivia should expect
that the child most likely would have an:
a. Loud, machinery-like murmur.
b. Bluish color to the lips.
c. Decreased BP reading in the upper
extremities
d. Increased BP reading in the upper
extremities.
42. The reason nurse May keeps the neonate in a
neutral thermal environment is that when a
newborn becomes too cool, the neonate
requires:
a. Less oxygen, and the newborn’s
metabolic rate increases.
b. More oxygen, and the newborn’s
metabolic rate decreases.
c. More oxygen, and the newborn’s
metabolic rate increases.
d. Less oxygen, and the newborn’s
metabolic rate decreases.
43. Before adding potassium to an infant’s I.V. line,
Nurse Ron must be sure to assess whether this
infant has:
a. Stable blood pressure
b. Patant fontanelles
c. Moro’s reflex
d. Voided
44. Nurse Carla should know that the most common
causative factor of dermatitis in infants and
younger children is:
a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch
45. During tube feeding, how far above an infant’s
stomach should the nurse hold the syringe with
formula?
a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches
46. In a mothers’ class, Nurse Lhynnete discussed
childhood diseases such as chicken pox. Which
of the following statements about chicken pox is
correct?
a. The older one gets, the more susceptible
he becomes to the complications of
chicken pox.
b. A single attack of chicken pox will
prevent future episodes, including
conditions such as shingles.
c. To prevent an outbreak in the
community, quarantine may be imposed
by health authorities.
d. Chicken pox vaccine is best given when
there is an impending outbreak in the
community.
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47. Barangay Pinoy had an outbreak of German
measles. To prevent congenital rubella, what is
the BEST advice that you can give to women in
the first trimester of pregnancy in the barangay
Pinoy?
a. Advise them on the signs of German
measles.
b. Avoid crowded places, such as markets
and movie houses.
c. Consult at the health center where
rubella vaccine may be given.
d. Consult a physician who may give them
rubella immunoglobulin.
48. Myrna a public health nurse knows that to
determine possible sources of sexually
transmitted infections, the BEST method that
may be undertaken is:
a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects
49. A 33-year old female client came for
consultation at the health center with the chief
complaint of fever for a week. Accompanying
symptoms were muscle pains and body malaise.
A week after the start of fever, the client noted
yellowish discoloration of his sclera. History
showed that he waded in flood waters about 2
weeks before the onset of symptoms. Based on
her history, which disease condition will you
suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis
50. Mickey a 3-year old client was brought to the
health center with the chief complaint of severe
diarrhea and the passage of “rice water” stools.
The client is most probably suffering from which
condition?
a. Giardiasis
b. Cholera
c. Amebiasis
d. Dysentery
51. The most prevalent form of meningitis among
children aged 2 months to 3 years is caused by
which microorganism?
a. Hemophilus influenzae
b. Morbillivirus
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c. Steptococcus pneumoniae
d. Neisseria meningitidis
52. The student nurse is aware that the
pathognomonic sign of measles is Koplik’s spot
and you may see Koplik’s spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck
53. Angel was diagnosed as having Dengue fever.
You will say that there is slow capillary refill
when the color of the nailbed that you pressed
does not return within how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds
54. In Integrated Management of Childhood Illness,
the nurse is aware that the severe conditions
generally require urgent referral to a hospital.
Which of the following severe conditions DOES
NOT always require urgent referral to a hospital?
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease
55. Myrna a public health nurse will conduct
outreach immunization in a barangay Masay
with a population of about 1500. The estimated
number of infants in the barangay would be:
a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants
56. The community nurse is aware that the
biological used in Expanded Program on
Immunization (EPI) should NOT be stored in the
freezer?
a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR
57. It is the most effective way of controlling
schistosomiasis in an endemic area?
a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
d. Use of protective footwear, such as
rubber boots
58. Several clients is newly admitted and diagnosed
with leprosy. Which of the following clients
should be classified as a case of multibacillary
leprosy?
a. 3 skin lesions, negative slit skin smear
b. 3 skin lesions, positive slit skin smear
c. 5 skin lesions, negative slit skin smear
d. 5 skin lesions, positive slit skin smear
59. Nurses are aware that diagnosis of leprosy is
highly dependent on recognition of symptoms.
Which of the following is an early sign of
leprosy?
a. Macular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge
60. Marie brought her 10 month old infant for
consultation because of fever, started 4 days
prior to consultation. In determining malaria
risk, 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 the
RHU because of cough and colds. Following the
IMCI assessment guide, which of the following is
a danger sign that indicates the need for urgent
referral to a hospital?
a. Inability to drink
b. High grade fever
c. Signs of severe dehydration
d. Cough for more than 30 days
62. Jimmy a 2-year old child revealed “baggy pants”.
As a nurse, using the IMCI guidelines, how will
you manage Jimmy?
a. Refer the child urgently to a hospital for
confinement.
b. Coordinate with the social worker to
enroll 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 health
problems like infections and intestinal
parasitism.
63. Gina is using Oresol in the management of
diarrhea of her 3-year old child. She asked you
what to do if her child vomits. As a nurse you will
tell her to:
a. Bring the child to the nearest hospital
for further assessment.
b. Bring the child to the health center for
intravenous fluid therapy.
c. Bring the child to the health center for
assessment by the physician.
d. Let the child rest for 10 minutes then
continue giving Oresol more slowly.
64. Nikki a 5-month old infant was brought by his
mother to the health center because of diarrhea
for 4 to 5 times a day. Her skin goes back slowly
after a skin pinch and her eyes are sunken. Using
the IMCI guidelines, you will classify this infant in
which category?
a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.
65. Chris a 4-month old infant was brought by her
mother to the health center because of cough.
His respiratory rate is 42/minute. Using the
Integrated Management of Child Illness (IMCI)
guidelines of assessment, his breathing is
considered as:
a. Fast
b. Slow
c. Normal
d. Insignificant
66. Maylene had just received her 4th dose of
tetanus toxoid. She is aware that her baby will
have protection against tetanus for
a. 1 year
b. 3 years
c. 5 years
d. Lifetime
67. Nurse Ron is aware that unused BCG should be
discarded after how many hours of
reconstitution?
a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day
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68. The nurse explains to a breastfeeding mother
that breast milk is sufficient for all of the baby’s
nutrient needs only up to:
a. 5 months
b. 6 months
c. 1 year
d. 2 years
69. Nurse Ron is aware that the gestational age of a
conceptus that is considered viable (able to live
outside the womb) is:
a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks
70. When teaching parents of a neonate the proper
position for the neonate’s sleep, the nurse
Patricia stresses the importance of placing the
neonate on his back to reduce the risk of which
of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
71. Which finding might be seen in baby James a
neonate suspected of having an infection?
a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level
72. Baby Jenny who is small-for-gestation is at
increased risk during the transitional period for
which complication?
a. Anemia probably due to chronic fetal
hyposia
b. Hyperthermia due to decreased
glycogen stores
c. Hyperglycemia due to decreased
glycogen stores
d. Polycythemia probably due to chronic
fetal hypoxia
73. Marjorie has just given birth at 42 weeks’
gestation. When the nurse assessing the
neonate, which physical finding is expected?
a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body
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74. After reviewing the Myrna’s maternal history of
magnesium sulfate during labor, which condition
would nurse Richard anticipate as a potential
problem in the neonate?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia
75. Which symptom would indicate the Baby
Alexandra was adapting appropriately to extrauterine life without difficulty?
a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60
breaths/minute
d. Respiratory rate 60 to 80
breaths/minute
76. When teaching umbilical cord care for Jennifer a
new mother, the nurse Jenny would include
which information?
a. Apply peroxide to the cord with each
diaper change
b. Cover the cord with petroleum jelly after
bathing
c. Keep the cord dry and open to air
d. Wash the cord with soap and water each
day during a tub bath.
77. Nurse John is performing an assessment on a
neonate. Which of the following findings is
considered common in the healthy neonate?
a. Simian crease
b. Conjunctival hemorrhage
c. Cystic hygroma
d. Bulging fontanelle
78. Dr. Esteves decides to artificially rupture the
membranes of a mother who is on labor.
Following this procedure, the nurse Hazel checks
the fetal heart tones for which the following
reasons?
a. To determine fetal well-being.
b. To assess for prolapsed cord
c. To assess fetal position
d. To prepare for an imminent delivery.
79. Which of the following would be least likely to
indicate anticipated bonding behaviors by new
parents?
a. The parents’ willingness to touch and
hold the new born.
b. The parent’s expression of interest
about the size of the new born.
c. The parents’ indication that they want to
see the newborn.
d. The parents’ interactions with each
other.
80. Following a precipitous delivery, examination of
the client's vagina reveals a fourth-degree
laceration. Which of the following would be
contraindicated when caring for this client?
a. Applying cold to limit edema during the
first 12 to 24 hours.
b. Instructing the client to use two or more
peripads to cushion the area.
c. Instructing the client on the use of sitz
baths if ordered.
d. Instructing the client about the
importance of perineal (kegel) exercises.
81. A pregnant woman accompanied by her
husband, seeks admission to the labor and
delivery area. She states that she's in labor and
says she attended the facility clinic for prenatal
care. Which question should the nurse Oliver ask
her 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 ordered
d. Aspirate the neonate’s nose and mouth
with a bulb syringe.
83. When a client states that her "water broke,"
which of the following actions would be
inappropriate for the nurse to do?
a. Observing the pooling of straw-colored
fluid.
b. Checking vaginal discharge with nitrazine
paper.
c. Conducting a bedside ultrasound for an
amniotic fluid index.
d. Observing for flakes of vernix in the
vaginal discharge.
84. A baby girl is born 8 weeks premature. At birth,
she has no spontaneous respirations but is
successfully resuscitated. Within several hours
she develops respiratory grunting, cyanosis,
tachypnea, nasal flaring, and retractions. She's
diagnosed with respiratory distress syndrome,
intubated, and placed on a ventilator. Which
nursing action should be included in the baby's
plan of care to prevent retinopathy of
prematurity?
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 newborn
calorie intake?
a. 110 to 130 calories per kg.
b. 30 to 40 calories per lb of body weight.
c. At least 2 ml per feeding
d. 90 to 100 calories per kg
86. Nurse John is knowledgeable that usually
individual twins will grow appropriately and at
the same rate as singletons until how many
weeks?
a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks
87. Which of the following classifications applies to
monozygotic twins for whom the cleavage of the
fertilized ovum occurs more than 13 days after
fertilization?
a. conjoined twins
b. diamniotic dichorionic twins
c. diamniotic monochorionic twin
d. monoamniotic monochorionic twins
88. Tyra experienced painless vaginal bleeding has
just been diagnosed as having a placenta previa.
Which of the following procedures is usually
performed to diagnose placenta previa?
a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound
89. Nurse Arnold knows that the following changes
in respiratory functioning during pregnancy is
considered normal:
a. Increased tidal volume
b. Increased expiratory volume
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c. Decreased inspiratory capacity
d. Decreased oxygen consumption
90. Emily has gestational diabetes and it is usually
managed by which of the following therapy?
a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin
91. Magnesium sulfate is given to Jemma with
preeclampsia to prevent which of the following
condition?
a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure
92. Cammile with sickle cell anemia has an increased
risk for having a sickle cell crisis during
pregnancy. Aggressive management of a sickle
cell crisis includes which of the following
measures?
a. Antihypertensive agents
b. Diuretic agents
c. I.V. fluids
d. Acetaminophen (Tylenol) for pain
93. Which of the following drugs is the antidote for
magnesium toxicity?
a. Calcium gluconate (Kalcinate)
b. Hydralazine (Apresoline)
c. Naloxone (Narcan)
d. Rho (D) immune globulin (RhoGAM)
94. Marlyn is screened for tuberculosis during her
first prenatal visit. An intradermal injection of
purified protein derivative (PPD) of the
tuberculin bacilli is given. She is considered to
have a positive test for which of the following
results?
a. An indurated wheal under 10 mm in
diameter appears in 6 to 12 hours.
b. An indurated wheal over 10 mm in
diameter appears in 48 to 72 hours.
c. A flat circumcised area under 10 mm in
diameter appears in 6 to 12 hours.
d. A flat circumcised area over 10 mm in
diameter appears in 48 to 72 hours.
95. Dianne, 24 year-old is 27 weeks’ pregnant
arrives at her physician’s office with complaints
of fever, nausea, vomiting, malaise, unilateral
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flank pain, and costovertebral angle tenderness.
Which of the following diagnoses is most likely?
a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)
96. Rh isoimmunization in a pregnant client
develops during which of the following
conditions?
a. Rh-positive maternal blood crosses into
fetal blood, stimulating fetal antibodies.
b. Rh-positive fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
c. Rh-negative fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
d. Rh-negative maternal blood crosses into
fetal blood, stimulating fetal antibodies.
97. To promote comfort during labor, the nurse John
advises a client to assume certain positions and
avoid others. Which position may cause
maternal hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
d. Standing position
98. Celeste who used heroin during her pregnancy
delivers a neonate. When assessing the neonate,
the nurse Lhynnette expects to find:
a. Lethargy 2 days after birth.
b. Irritability and poor sucking.
c. A flattened nose, small eyes, and thin
lips.
d. Congenital defects such as limb
anomalies.
99. The uterus returns to the pelvic cavity in which
of the following time frames?
a. 7th to 9th day postpartum.
b. 2 weeks postpartum.
c. End of 6th week postpartum.
d. When the lochia changes to alba.
100.
Maureen, a primigravida client, age 20, has
just completed a difficult, forceps-assisted
delivery of twins. Her labor was unusually
long and required oxytocin (Pitocin)
augmentation. The nurse who's caring for her
should stay alert for:
a.
b.
c.
d.
Uterine inversion
Uterine atony
Uterine involution
Uterine discomfort
Answers and Rationale – Community Health
Nursing and Care of the Mother and Child
1.
2.
3.
4.
5.
6.
7.
8.
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Answer: (A) Inevitable
Rationale: An inevitable abortion is termination
of pregnancy that cannot be prevented.
Moderate to severe bleeding with mild
cramping and cervical dilation would be noted
in this type of abortion.
Answer: (B) History of syphilis
Rationale: Maternal infections such as syphilis,
toxoplasmosis, and rubella are causes of
spontaneous abortion.
Answer: (C) Monitoring apical pulse
Rationale: Nursing care for the client with a
possible ectopic pregnancy is focused on
preventing or identifying hypovolemic shock
and controlling pain. An elevated pulse rate is
an indicator of shock.
Answer: (B) Increased caloric intake
Rationale: Glucose crosses the placenta, but
insulin does not. High fetal demands for
glucose, combined with the insulin resistance
caused by hormonal changes in the last half of
pregnancy can result in elevation of maternal
blood glucose levels. This increases the
mother’s demand for insulin and is referred to
as the diabetogenic effect of pregnancy.
Answer: (A) Excessive fetal activity.
Rationale: The most common signs and
symptoms of hydatidiform mole includes
elevated levels of human chorionic
gonadotropin, vaginal bleeding, larger than
normal uterus for gestational age, failure to
detect fetal heart activity even with sensitive
instruments, excessive nausea and vomiting,
and early development of pregnancy-induced
hypertension. Fetal activity would not be noted.
Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an
indicator of hypermagnesemia, which requires
administration of calcium gluconate.
Answer: (C) Presenting part in 2 cm below the
plane of the ischial spines.
Rationale: Fetus at station plus two indicates
that the presenting part is 2 cm below the
plane of the ischial spines.
Answer: (A) Contractions every 1 ½ minutes
lasting 70-80 seconds.
Rationale: Contractions every 1 ½ minutes
lasting 70-80 seconds, is indicative of
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hyperstimulation of the uterus, which could
result in injury to the mother and the fetus if
Pitocin is not discontinued.
Answer: (C) EKG tracings
Rationale: A potential side effect of calcium
gluconate administration is cardiac arrest.
Continuous monitoring of cardiac activity (EKG)
throught administration of calcium gluconate is
an essential part of care.
Answer: (D) First low transverse caesarean was
for breech position. Fetus in this pregnancy is in
a vertex presentation.
Rationale: This type of client has no obstetrical
indication for a caesarean section as she did
with her first caesarean delivery.
Answer: (A) Talk to the mother first and then to
the toddler.
Rationale: When dealing with a crying toddler,
the best approach is to talk to the mother and
ignore the toddler first. This approach helps the
toddler get used to the nurse before she
attempts any procedures. It also gives the
toddler an opportunity to see that the mother
trusts the nurse.
Answer: (D) Place the infant’s arms in soft
elbow restraints.
Rationale: Soft restraints from the upper arm to
the wrist prevent the infant from touching her
lip but allow him to hold a favorite item such as
a blanket. Because they could damage the
operative site, such as objects as pacifiers,
suction catheters, and small spoons shouldn’t
be placed in a baby’s mouth after cleft repair. A
baby in a prone position may rub her face on
the sheets and traumatize the operative site.
The suture line should be cleaned gently to
prevent infection, which could interfere with
healing and damage the cosmetic appearance
of the repair.
Answer: (B) Allow the infant to rest before
feeding.
Rationale: Because feeding requires so much
energy, an infant with heart failure should rest
before feeding.
Answer: (C) Iron-rich formula only.
Rationale: The infants at age 5 months should
receive iron-rich formula and that they
shouldn’t receive solid food, even baby food
until age 6 months.
Answer: (D) 10 months
Rationale: A 10 month old infant can sit alone
and understands object permanence, so he
would look for the hidden toy. At age 4 to 6
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months, infants can’t sit securely alone. At age
8 months, infants can sit securely alone but
cannot understand the permanence of objects.
Answer: (D) Public health nursing focuses on
preventive, not curative, services.
Rationale: The catchments area in PHN consists
of a residential community, many of whom are
well individuals who have greater need for
preventive rather than curative services.
Answer: (B) Efficiency
Rationale: Efficiency is determining whether the
goals were attained at the least possible cost.
Answer: (D) Rural Health Unit
Rationale: R.A. 7160 devolved basic health
services to local government units (LGU’s ). The
public health nurse is an employee of the LGU.
Answer: (A) Mayor
Rationale: The local executive serves as the
chairman of the Municipal Health Board.
Answer: (A) 1
Rationale: Each rural health midwife is given a
population assignment of about 5,000.
Answer: (B) Health education and community
organizing are necessary in providing
community health services. Rationale: The
community health nurse develops the health
capability of people through health education
and community organizing activities.
Answer: (B) Measles
Rationale: Presidential Proclamation No. 4 is on
the Ligtas Tigdas Program.
Answer: (D) Core group formation
Rationale: In core group formation, the nurse is
able to transfer the technology of community
organizing to the potential or informal
community leaders through a training program.
Answer: (D) To maximize the community’s
resources in dealing with health problems.
Rationale: Community organizing is a
developmental service, with the goal of
developing the people’s self-reliance in dealing
with community health problems. A, B and C
are objectives of contributory objectives to this
goal.
Answer: (D) Terminal
Rationale: Tertiary prevention involves
rehabilitation, prevention of permanent
disability and disability limitations appropriate
for convalescents, the disabled, complicated
cases and the terminally ill (those in the
terminal stage of a disease).
Answer: (A) Intrauterine fetal death.
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Rationale: Intrauterine fetal death, abruptio
placentae, septic shock, and amniotic fluid
embolism may trigger normal clotting
mechanisms; if clotting factors are depleted,
DIC may occur. Placenta accreta, dysfunctional
labor, and premature rupture of the
membranes aren't associated with DIC.
Answer: (C) 120 to 160 beats/minute
Rationale: A rate of 120 to 160 beats/minute in
the fetal heart appropriate for filling the heart
with blood and pumping it out to the system.
Answer: (A) Change the diaper more often.
Rationale: Decreasing the amount of time the
skin comes contact with wet soiled diapers will
help heal the irritation.
Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen
most in children with Down syndrome,
asplenia, or polysplenia.
Answer: (B) Decreased urine output
Rationale: Decreased urine output may occur in
clients receiving I.V. magnesium and should be
monitored closely to keep urine output at
greater than 30 ml/hour, because magnesium is
excreted through the kidneys and can easily
accumulate to toxic levels.
Answer: (A) Menorrhagia
Rationale: Menorrhagia is an excessive
menstrual period.
Answer: (C) Blood typing
Rationale: Blood type would be a critical value
to have because the risk of blood loss is always
a potential complication during the labor and
delivery process. Approximately 40% of a
woman’s cardiac output is delivered to the
uterus, therefore, blood loss can occur quite
rapidly in the event of uncontrolled bleeding.
Answer: (D) Physiologic anemia
Rationale: Hemoglobin values and hematocrit
decrease during pregnancy as the increase in
plasma volume exceeds the increase in red
blood cell production.
Answer: (D) A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s arms
and drooling.
Rationale: The infant with the airway
emergency should be treated first, because of
the risk of epiglottitis.
Answer: (A) Placenta previa
Rationale: Placenta previa with painless vaginal
bleeding.
Answer: (D) Early in the morning
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Rationale: Based on the nurse’s knowledge of
microbiology, the specimen should be collected
early in the morning. The rationale for this
timing is that, because the female worm lays
eggs at night around the perineal area, the first
bowel movement of the day will yield the best
results. The specific type of stool specimen
used in the diagnosis of pinworms is called the
tape test.
Answer: (A) Irritability and seizures
Rationale: Lead poisoning primarily affects the
CNS, causing increased intracranial pressure.
This condition results in irritability and changes
in level of consciousness, as well as seizure
disorders, hyperactivity, and learning
disabilities.
Answer: (D) “I really need to use the diaphragm
and jelly most during the middle of my
menstrual cycle”.
Rationale: The woman must understand that,
although the “fertile” period is approximately
mid-cycle, hormonal variations do occur and
can result in early or late ovulation. To be
effective, the diaphragm should be inserted
before every intercourse.
Answer: (C) Restlessness
Rationale: In a child, restlessness is the earliest
sign of hypoxia. Late signs of hypoxia in a child
are associated with a change in color, such as
pallor or cyanosis.
Answer: (B) Walk one step ahead, with the
child’s hand on the nurse’s elbow.
Rationale: This procedure is generally
recommended to follow in guiding a person
who is blind.
Answer: (A) Loud, machinery-like murmur.
Rationale: A loud, machinery-like murmur is a
characteristic finding associated with patent
ductus arteriosus.
Answer: (C) More oxygen, and the newborn’s
metabolic rate increases.
Rationale: When cold, the infant requires more
oxygen and there is an increase in metabolic
rate. Non-shievering thermogenesis is a
complex process that increases the metabolic
rate and rate of oxygen consumption,
therefore, the newborn increase heat
production.
Answer: (D) Voided
Rationale: Before administering potassium I.V.
to any client, the nurse must first check that the
client’s kidneys are functioning and that the
client is voiding. If the client is not voiding, the
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nurse should withhold the potassium and notify
the physician.
Answer: (c) Laundry detergent
Rationale: Eczema or dermatitis is an allergic
skin reaction caused by an offending allergen.
The topical allergen that is the most common
causative factor is laundry detergent.
Answer: (A) 6 inches
Rationale: This distance allows for easy flow of
the formula by gravity, but the flow will be slow
enough not to overload the stomach too
rapidly.
Answer: (A) The older one gets, the more
susceptible he becomes to the complications of
chicken pox.
Rationale: Chicken pox is usually more severe in
adults than in children. Complications, such as
pneumonia, are higher in incidence in adults.
Answer: (D) Consult a physician who may give
them rubella immunoglobulin.
Rationale: Rubella vaccine is made up of
attenuated German measles viruses. This is
contraindicated in pregnancy. Immune globulin,
a specific prophylactic against German measles,
may be given to pregnant women.
Answer: (A) Contact tracing
Rationale: Contact tracing is the most practical
and reliable method of finding possible sources
of person-to-person transmitted infections,
such as sexually transmitted diseases.
Answer: (D) Leptospirosis
Rationale: Leptospirosis is transmitted through
contact with the skin or mucous membrane
with water or moist soil contaminated with
urine of infected animals, like rats.
Answer: (B) Cholera
Rationale: Passage of profuse watery stools is
the major symptom of cholera. Both amebic
and bacillary dysentery are characterized by the
presence of blood and/or mucus in the stools.
Giardiasis is characterized by fat malabsorption
and, therefore, steatorrhea.
Answer: (A) Hemophilus influenzae
Rationale: Hemophilus meningitis is unusual
over the age of 5 years. In developing countries,
the peak incidence is in children less than 6
months of age. Morbillivirus is the etiology of
measles. Streptococcus pneumonia and
Neisseria meningitidis may cause meningitis,
but age distribution is not specific in young
children.
Answer: (B) Buccal mucosa
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Rationale: Koplik’s spot may be seen on the
mucosa of the mouth or the throat.
Answer: (A) 3 seconds
Rationale: Adequate blood supply to the area
allows the return of the color of the nailbed
within 3 seconds.
Answer: (B) Severe dehydration
Rationale: The order of priority in the
management of severe dehydration is as
follows: intravenous fluid therapy, referral to a
facility where IV fluids can be initiated within 30
minutes, Oresol or nasogastric tube. When the
foregoing measures are not possible or
effective, then urgent referral to the hospital is
done.
Answer: (A) 45 infants
Rationale: To estimate the number of infants,
multiply total population by 3%.
Answer: (A) DPT
Rationale: DPT is sensitive to freezing. The
appropriate storage temperature of DPT is 2 to
8° C only. OPV and measles vaccine are highly
sensitive to heat and require freezing. MMR is
not an immunization in the Expanded Program
on Immunization.
Answer: (C) Proper use of sanitary toilets
Rationale: The ova of the parasite get out of the
human body together with feces. Cutting the
cycle at this stage is the most effective way of
preventing the spread of the disease to
susceptible hosts.
Answer: (D) 5 skin lesions, positive slit skin
smear
Rationale: A multibacillary leprosy case is one
who has a positive slit skin smear and at least 5
skin lesions.
Answer: (C) Thickened painful nerves
Rationale: 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 late
symptoms.
Answer: (B) Ask where the family resides.
Rationale: Because malaria is endemic, the first
question to determine malaria risk is where the
client’s family resides. If the area of residence is
not a known endemic area, ask if the child had
traveled within the past 6 months, where she
was brought and whether she stayed overnight
in that area.
Answer: (A) Inability to drink
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Rationale: A sick child aged 2 months to 5 years
must be referred urgently to a hospital if
he/she has one or more of the following signs:
not able to feed or drink, vomits everything,
convulsions, abnormally sleepy or difficult to
awaken.
Answer: (A) Refer the child urgently to a
hospital for confinement.
Rationale: “Baggy pants” is a sign of severe
marasmus. The best management is urgent
referral to a hospital.
Answer: (D) Let the child rest for 10 minutes
then continue giving Oresol more slowly.
Rationale: If the child vomits persistently, that
is, he vomits everything that he takes in, he has
to be referred urgently to a hospital. Otherwise,
vomiting is managed by letting the child rest for
10 minutes and then continuing with Oresol
administration. Teach the mother to give Oresol
more slowly.
Answer: (B) Some dehydration
Rationale: Using the assessment guidelines of
IMCI, a child (2 months to 5 years old) with
diarrhea is classified as having SOME
DEHYDRATION if he shows 2 or more of the
following signs: restless or irritable, sunken
eyes, the skin goes back slow after a skin pinch.
Answer: (C) Normal
Rationale: In IMCI, a respiratory rate of
50/minute or more is fast breathing for an
infant aged 2 to 12 months.
Answer: (A) 1 year
Rationale: The baby will have passive natural
immunity by placental transfer of antibodies.
The mother will have active artificial immunity
lasting for about 10 years. 5 doses will give the
mother lifetime protection.
Answer: (B) 4 hours
Rationale: While the unused portion of other
biologicals in EPI may be given until the end of
the day, only BCG is discarded 4 hours after
reconstitution. This is why BCG immunization is
scheduled only in the morning.
Answer: (B) 6 months
Rationale: After 6 months, the baby’s nutrient
needs, especially the baby’s iron requirement,
can no longer be provided by mother’s milk
alone.
Answer: (C) 24 weeks
Rationale: At approximately 23 to 24 weeks’
gestation, the lungs are developed enough to
sometimes maintain extrauterine life. The lungs
are the most immature system during the
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gestation period. Medical care for premature
labor begins much earlier (aggressively at 21
weeks’ gestation)
Answer: (B) Sudden infant death syndrome
(SIDS)
Rationale: Supine positioning is recommended
to reduce the risk of SIDS in infancy. The risk of
aspiration is slightly increased with the supine
position. Suffocation would be less likely with
an infant supine than prone and the position
for GER requires the head of the bed to be
elevated.
Answer: (C) Decreased temperature
Rationale: Temperature instability, especially
when it results in a low temperature in the
neonate, may be a sign of infection. The
neonate’s color often changes with an infection
process but generally becomes ashen or
mottled. The neonate with an infection will
usually show a decrease in activity level or
lethargy.
Answer: (D) Polycythemia probably due to
chronic fetal hypoxia
Rationale: The small-for-gestation neonate is at
risk for developing polycythemia during the
transitional period in an attempt to decrease
hypoxia. The neonates are also at increased risk
for developing hypoglycemia and hypothermia
due to decreased glycogen stores.
Answer: (C) Desquamation of the epidermis
Rationale: Postdate fetuses lose the vernix
caseosa, and the epidermis may become
desquamated. These neonates are usually very
alert. Lanugo is missing in the postdate
neonate.
Answer: (C) Respiratory depression
Rationale: Magnesium sulfate crosses the
placenta and adverse neonatal effects are
respiratory depression, hypotonia, and
bradycardia. The serum blood sugar isn’t
affected by magnesium sulfate. The neonate
would be floppy, not jittery.
Answer: (C) Respiratory rate 40 to 60
breaths/minute
Rationale: A respiratory rate 40 to 60
breaths/minute is normal for a neonate during
the transitional period. Nasal flaring,
respiratory rate more than 60 breaths/minute,
and audible grunting are signs of respiratory
distress.
Answer: (C) Keep the cord dry and open to air
Rationale: Keeping the cord dry and open to air
helps reduce infection and hastens drying.
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Infants aren’t given tub bath but are sponged
off until the cord falls off. Petroleum jelly
prevents the cord from drying and encourages
infection. Peroxide could be painful and isn’t
recommended.
Answer: (B) Conjunctival hemorrhage
Rationale: Conjunctival hemorrhages are
commonly seen in neonates secondary to the
cranial pressure applied during the birth
process. Bulging fontanelles are a sign of
intracranial pressure. Simian creases are
present in 40% of the neonates with trisomy 21.
Cystic hygroma is a neck mass that can affect
the airway.
Answer: (B) To assess for prolapsed cord
Rationale: After a client has an amniotomy, the
nurse should assure that the cord isn't
prolapsed and that the baby tolerated the
procedure well. The most effective way to do
this is to check the fetal heart rate. Fetal wellbeing is assessed via a nonstress test. Fetal
position is determined by vaginal examination.
Artificial rupture of membranes doesn't
indicate an imminent delivery.
Answer: (D) The parents’ interactions with each
other.
Rationale: Parental interaction will provide the
nurse with a good assessment of the stability of
the family's home life but it has no indication
for parental bonding. Willingness to touch and
hold the newborn, expressing interest about
the newborn's size, and indicating a desire to
see the newborn are behaviors indicating
parental bonding.
Answer: (B) Instructing the client to use two or
more peripads to cushion the area
Rationale: Using two or more peripads would
do little to reduce the pain or promote perineal
healing. Cold applications, sitz baths, and Kegel
exercises are important measures when the
client has a fourth-degree laceration.
Answer: (C) “What is your expected due date?”
Rationale: When obtaining the history of a
client who may be in labor, the nurse's highest
priority is to determine her current status,
particularly her due date, gravidity, and parity.
Gravidity and parity affect the duration of labor
and the potential for labor complications. Later,
the nurse should ask about chronic illnesses,
allergies, and support persons.
Answer: (D) Aspirate the neonate’s nose and
mouth with a bulb syringe.
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Rationale: The nurse's first action should be to
clear the neonate's airway with a bulb syringe.
After the airway is clear and the neonate's color
improves, the nurse should comfort and calm
the neonate. If the problem recurs or the
neonate's color doesn't improve readily, the
nurse should notify the physician.
Administering oxygen when the airway isn't
clear would be ineffective.
Answer: (C) Conducting a bedside ultrasound
for an amniotic fluid index.
Rationale: It isn't within a nurse's scope of
practice to perform and interpret a bedside
ultrasound under these conditions and without
specialized training. Observing for pooling of
straw-colored fluid, checking vaginal discharge
with nitrazine paper, and observing for flakes of
vernix are appropriate assessments for
determining whether a client has ruptured
membranes.
Answer: (C) Monitor partial pressure of oxygen
(Pao2) levels.
Rationale: Monitoring PaO2 levels and reducing
the oxygen concentration to keep PaO2 within
normal limits reduces the risk of retinopathy of
prematurity in a premature infant receiving
oxygen. Covering the infant's eyes and
humidifying the oxygen don't reduce the risk of
retinopathy of prematurity. Because cooling
increases the risk of acidosis, the infant should
be kept warm so that his respiratory distress
isn't aggravated.
Answer: (A) 110 to 130 calories per kg.
Rationale: Calories per kg is the accepted way
of determined appropriate nutritional intake
for a newborn. The recommended calorie
requirement is 110 to 130 calories per kg of
newborn body weight. This level will maintain a
consistent blood glucose level and provide
enough calories for continued growth and
development.
Answer: (C) 30 to 32 weeks
Rationale: Individual twins usually grow at the
same rate as singletons until 30 to 32 weeks’
gestation, then twins don’t’ gain weight as
rapidly as singletons of the same gestational
age. The placenta can no longer keep pace with
the nutritional requirements of both fetuses
after 32 weeks, so there’s some growth
retardation in twins if they remain in utero at
38 to 40 weeks.
Answer: (A) conjoined twins
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Rationale: The type of placenta that develops in
monozygotic twins depends on the time at
which cleavage of the ovum occurs. Cleavage in
conjoined twins occurs more than 13 days after
fertilization. Cleavage that occurs less than 3
day after fertilization results in diamniotic
dicchorionic twins. Cleavage that occurs
between days 3 and 8 results in diamniotic
monochorionic twins. Cleavage that occurs
between days 8 to 13 result in monoamniotic
monochorionic twins.
Answer: (D) Ultrasound
Rationale: Once the mother and the fetus are
stabilized, ultrasound evaluation of the
placenta should be done to determine the
cause of the bleeding. Amniocentesis is
contraindicated in placenta previa. A digital or
speculum examination shouldn’t be done as
this may lead to severe bleeding or
hemorrhage. External fetal monitoring won’t
detect a placenta previa, although it will detect
fetal distress, which may result from blood loss
or placenta separation.
Answer: (A) Increased tidal volume
Rationale: A pregnant client breathes deeper,
which increases the tidal volume of gas moved
in and out of the respiratory tract with each
breath. The expiratory volume and residual
volume decrease as the pregnancy progresses.
The inspiratory capacity increases during
pregnancy. The increased oxygen consumption
in the pregnant client is 15% to 20% greater
than in the nonpregnant state.
Answer: (A) Diet
Rationale: Clients with gestational diabetes are
usually managed by diet alone to control their
glucose intolerance. Oral hypoglycemic drugs
are contraindicated in pregnancy. Long-acting
insulin usually isn’t needed for blood glucose
control in the client with gestational diabetes.
Answer: (D) Seizure
Rationale: The anticonvulsant mechanism of
magnesium is believes to depress seizure foci in
the brain and peripheral neuromuscular
blockade. Hypomagnesemia isn’t a
complication of preeclampsia. Antihypertensive
drug other than magnesium are preferred for
sustained hypertension. Magnesium doesn’t
help prevent hemorrhage in preeclamptic
clients.
Answer: (C) I.V. fluids
Rationale: A sickle cell crisis during pregnancy is
usually managed by exchange transfusion
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oxygen, and L.V. Fluids. The client usually needs
a stronger analgesic than acetaminophen to
control the pain of a crisis. Antihypertensive
drugs usually aren’t necessary. Diuretic
wouldn’t be used unless fluid overload resulted.
Answer: (A) Calcium gluconate (Kalcinate)
Rationale: Calcium gluconate is the antidote for
magnesium toxicity. Ten milliliters of 10%
calcium gluconate is given L.V. push over 3 to 5
minutes. Hydralazine is given for sustained
elevated blood pressure in preeclamptic clients.
Rho (D) immune globulin is given to women
with Rh-negative blood to prevent antibody
formation from RH-positive conceptions.
Naloxone is used to correct narcotic toxicity.
Answer: (B) An indurated wheal over 10 mm in
diameter appears in 48 to 72 hours.
Rationale: A positive PPD result would be an
indurated wheal over 10 mm in diameter that
appears in 48 to 72 hours. The area must be a
raised wheal, not a flat circumcised area to be
considered positive.
Answer: (C) Pyelonephritis
Rationale The symptoms indicate acute
pyelonephritis, a serious condition in a
pregnant client. UTI symptoms include dysuria,
urgency, frequency, and suprapubic
tenderness. Asymptomatic bacteriuria doesn’t
cause symptoms. Bacterial vaginosis causes
milky white vaginal discharge but no systemic
symptoms.
Answer: (B) Rh-positive fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
Rationale: Rh isoimmunization occurs when Rhpositive fetal blood cells cross into the maternal
circulation and stimulate maternal antibody
production. In subsequent pregnancies with Rhpositive fetuses, maternal antibodies may cross
back into the fetal circulation and destroy the
fetal blood cells.
Answer: (C) Supine position
Rationale: The supine position causes
compression of the client's aorta and inferior
vena cava by the fetus. This, in turn, inhibits
maternal circulation, leading to maternal
hypotension and, ultimately, fetal hypoxia. The
other positions promote comfort and aid labor
progress. For instance, the lateral, or side-lying,
position improves maternal and fetal
circulation, enhances comfort, increases
maternal relaxation, reduces muscle tension,
and eliminates pressure points. The squatting
position promotes comfort by taking advantage
of gravity. The standing position also takes
advantage of gravity and aligns the fetus with
the pelvic angle.
98. Answer: (B) Irritability and poor sucking.
Rationale: Neonates of heroin-addicted
mothers are physically dependent on the drug
and experience withdrawal when the drug is no
longer supplied. Signs of heroin withdrawal
include irritability, poor sucking, and
restlessness. Lethargy isn't associated with
neonatal heroin addiction. A flattened nose,
small eyes, and thin lips are seen in infants with
fetal alcohol syndrome. Heroin use during
pregnancy hasn't been linked to specific
congenital anomalies.
99. Answer: (A) 7th to 9th day postpartum
Rationale: The normal involutional process
returns the uterus to the pelvic cavity in 7 to 9
days. A significant involutional complication is
the failure of the uterus to return to the pelvic
cavity within the prescribed time period. This is
known as subinvolution.
100. Answer: (B) Uterine atony
Rationale: Multiple fetuses, extended labor
stimulation with oxytocin, and traumatic
delivery commonly are associated with uterine
atony, which may lead to postpartum
hemorrhage. Uterine inversion may precede or
follow delivery and commonly results from
apparent excessive traction on the umbilical
cord and attempts to deliver the placenta
manually. Uterine involution and some uterine
discomfort are normal after delivery.
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TEST III - Care of Clients with Physiologic and
Psychosocial Alterations
1. Nurse Michelle should know that the drainage is
normal 4 days after a sigmoid colostomy when
the stool is:
a. Green liquid
b. Solid formed
c. Loose, bloody
d. Semiformed
2. Where would nurse Kristine place the call light
for a male client with a right-sided brain attack
and left homonymous hemianopsia?
a. On the client’s right side
b. On the client’s left side
c. Directly in front of the client
d. Where the client like
3. A male client is admitted to the emergency
department following an accident. What are the
first nursing actions of the nurse?
a. Check respiration, circulation,
neurological response.
b. Align the spine, check pupils, and check
for hemorrhage.
c. Check respirations, stabilize spine, and
check circulation.
d. Assess level of consciousness and
circulation.
4. In evaluating the effect of nitroglycerin, Nurse
Arthur should know that it reduces preload and
relieves angina by:
a. Increasing contractility and slowing
heart rate.
b. Increasing AV conduction and heart rate.
c. Decreasing contractility and oxygen
consumption.
d. Decreasing venous return through
vasodilation.
5. Nurse Patricia finds a female client who is postmyocardial infarction (MI) slumped on the side
rails of the bed and unresponsive to shaking or
shouting. Which is the nurse next action?
a. Call for help and note the time.
b. Clear the airway
c. Give two sharp thumps to the
precordium, and check the pulse.
d. Administer two quick blows.
6. Nurse Monett is caring for a client recovering
from gastro-intestinal bleeding. The nurse
should:
a. Plan care so the client can receive 8
hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and
medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before
admission, 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 and
notify the physician.
b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is
lower than normal.
8. A client undergone ileostomy, when should the
drainage appliance be applied to the stoma?
a. 24 hours later, when edema has
subsided.
b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care
procedures.
9. A client undergone spinal anesthetic, it will be
important that the nurse immediately position
the client in:
a. On the side, to prevent obstruction of
airway by tongue.
b. Flat on back.
c. On the back, with knees flexed 15
degrees.
d. Flat on the stomach, with the head
turned to the side.
10. While monitoring a male client several hours
after a motor vehicle accident, which
assessment data suggest increasing intracranial
pressure?
a. Blood pressure is decreased from
160/90 to 110/70.
b. Pulse is increased from 87 to 95, with an
occasional skipped beat.
c. The client is oriented when aroused
from sleep, and goes back to sleep
immediately.
d. The client refuses dinner because of
anorexia.
11. Mrs. Cruz, 80 years old is diagnosed with
pneumonia. Which of the following symptoms
may appear first?
a. Altered mental status and dehydration
b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough
12. A male client has active tuberculosis (TB). Which
of the following symptoms will be exhibit?
a. Chest and lower back pain
b. Chills, fever, night sweats, and
hemoptysis
c. Fever of more than 104°F (40°C) and
nausea
d. Headache and photophobia
13. Mark, a 7-year-old client is brought to the
emergency department. He’s tachypneic and
afebrile and has a respiratory rate of 36
breaths/minute and has a nonproductive cough.
He recently had a cold. Form this history; the
client may have which of the following
conditions?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease
(COPD)
d. Emphysema
14. Marichu was given morphine sulfate for pain.
She is sleeping and her respiratory rate is 4
breaths/minute. If action isn’t taken quickly, she
might have which of the following reactions?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own
15. A 77-year-old male client is admitted for elective
knee surgery. Physical examination reveals
shallow respirations but no sign of respiratory
distress. Which of the following is a normal
physiologic change related to aging?
a. Increased elastic recoil of the lungs
b. Increased number of functional
capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity
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16. Nurse John is caring for a male client receiving
lidocaine I.V. Which factor is the most relevant
to administration of this medication?
a. Decrease in arterial oxygen saturation
(SaO2) when measured with a pulse
oximeter.
b. Increase in systemic blood pressure.
c. Presence of premature ventricular
contractions (PVCs) on a cardiac
monitor.
d. Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client taking an
anticoagulant. The nurse should teach the client
to:
a. Report incidents of diarrhea.
b. Avoid foods high in vitamin K
c. Use a straight razor when shaving.
d. Take aspirin to pain relief.
18. Nurse Lhynnette is preparing a site for the
insertion of an I.V. catheter. The nurse should
treat excess hair at the site by:
a. Leaving the hair intact
b. Shaving the area
c. Clipping the hair in the area
d. Removing the hair with a depilatory.
19. Nurse Michelle is caring for an elderly female
with osteoporosis. When teaching the client, the
nurse should include information about which
major complication:
a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowager’s hump
20. Nurse Len is teaching a group of women to
perform BSE. The nurse should explain that the
purpose of performing the examination is to
discover:
a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses
21. When caring for a female client who is being
treated for hyperthyroidism, it is important to:
a. Provide extra blankets and clothing to
keep the client warm.
b. Monitor the client for signs of
restlessness, sweating, and excessive
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weight loss during thyroid replacement
therapy.
c. Balance the client’s periods of activity
and rest.
d. Encourage the client to be active to
prevent constipation.
22. Nurse Kris is teaching a client with history of
atherosclerosis. To decrease the risk of
atherosclerosis, the nurse should encourage the
client 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. Nurse
Greta must logroll a client following a:
a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.
24. A 55-year old client underwent cataract removal
with intraocular lens implant. Nurse Oliver is
giving the client discharge instructions. These
instructions should include which of the
following?
a. Avoid lifting objects weighing more than
5 lb (2.25 kg).
b. Lie on your abdomen when in bed
c. Keep rooms brightly lit.
d. Avoiding straining during bowel
movement or bending at the waist.
25. George should be taught about testicular
examinations during:
a. when sexual activity starts
b. After age 69
c. After age 40
d. Before age 20.
26. A male client undergone a colon resection. While
turning him, wound dehiscence with
evisceration occurs. Nurse Trish first response is
to:
a. Call the physician
b. Place a saline-soaked sterile dressing on
the wound.
c. Take a blood pressure and pulse.
d. Pull the dehiscence closed.
27. Nurse Audrey is caring for a client who has
suffered a severe cerebrovascular accident.
During routine assessment, the nurse notices
Cheyne- Strokes respirations. Cheyne-strokes
respirations are:
a. A progressively deeper breaths followed
by shallower breaths with apneic
periods.
b. Rapid, deep breathing with abrupt
pauses between each breath.
c. Rapid, deep breathing and irregular
breathing without pauses.
d. Shallow breathing with an increased
respiratory rate.
28. Nurse Bea is assessing a male client with heart
failure. The breath sounds commonly
auscultated in clients with heart failure are:
a. Tracheal
b. Fine crackles
c. Coarse crackles
d. Friction rubs
29. The nurse is caring for Kenneth experiencing an
acute asthma attack. The client stops wheezing
and breath sounds aren’t audible. The reason for
this change is that:
a. The attack is over.
b. The airways are so swollen that no air
cannot get through.
c. The swelling has decreased.
d. Crackles have replaced wheezes.
30. Mike with epilepsy is having a seizure. During
the active seizure phase, the nurse should:
a. Place the client on his back remove
dangerous objects, and insert a bite
block.
b. Place the client on his side, remove
dangerous objects, and insert a bite
block.
c. Place the client o his back, remove
dangerous objects, and hold down his
arms.
d. Place the client on his side, remove
dangerous objects, and protect his head.
31. After insertion of a cheat tube for a
pneumothorax, a client becomes hypotensive
with neck vein distention, tracheal shift, absent
breath sounds, and diaphoresis. Nurse Amanda
suspects a tension pneumothorax has occurred.
What cause of tension pneumothorax should the
nurse check for?
a. Infection of the lung.
b. Kinked or obstructed chest tube
c. Excessive water in the water-seal
chamber
d. Excessive chest tube drainage
32. Nurse Maureen is talking to a male client; the
client begins choking on his lunch. He’s coughing
forcefully. The nurse should:
a. Stand him up and perform the
abdominal thrust maneuver from
behind.
b. Lay him down, straddle him, and
perform the abdominal thrust
maneuver.
c. Leave him to get assistance
d. Stay with him but not intervene at this
time.
33. Nurse Ron is taking a health history of an 84 year
old client. Which information will be most useful
to 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 lips
at 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 hydrogen
peroxide.
35. A 77-year-old male client is admitted with a
diagnosis of dehydration and change in mental
status. He’s being hydrated with L.V. fluids.
When the nurse takes his vital signs, she notes
he has a fever of 103°F (39.4°C) a cough
producing yellow sputum and pleuritic chest
pain. The nurse suspects this client may have
which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Myocardial infarction (MI)
c. Pneumonia
d. Tuberculosis
36. Nurse Oliver is working in an outpatient clinic.
He has been alerted that there is an outbreak of
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tuberculosis (TB). Which of the following clients
entering the clinic today most likely to have TB?
a. A 16-year-old female high school
student
b. A 33-year-old day-care worker
c. A 43-yesr-old homeless man with a
history of alcoholism
d. A 54-year-old businessman
37. Virgie with a positive Mantoux test result will be
sent for a chest X-ray. The nurse is aware that
which of the following reasons this is done?
a. To confirm the diagnosis
b. To determine if a repeat skin test is
needed
c. To determine the extent of lesions
d. To determine if this is a primary or
secondary infection
38. Kennedy with acute asthma showing inspiratory
and expiratory wheezes and a decreased forced
expiratory volume should be treated with which
of the following classes of medication right
away?
a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year
history of smoking one to two packs of cigarettes
per day has a chronic cough producing thick
sputum, peripheral edema and cyanotic nail
beds. Based on this information, he most likely
has which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
Situation: Francis, age 46 is admitted to the hospital with
diagnosis of Chronic Lymphocytic Leukemia.
40. The treatment for patients with leukemia is bone
marrow transplantation. Which statement about
bone marrow transplantation is not correct?
a. The patient is under local anesthesia
during the procedure
b. The aspirated bone marrow is mixed
with heparin.
c. The aspiration site is the posterior or
anterior iliac crest.
95
d. The recipient receives
cyclophosphamide (Cytoxan) for 4
consecutive days before the procedure.
41. After several days of admission, Francis becomes
disoriented and complains of frequent
headaches. The nurse in-charge first action
would be:
a. Call the physician
b. Document the patient’s status in his
charts.
c. Prepare oxygen treatment
d. Raise the side rails
42. During routine care, Francis asks the nurse,
“How can I be anemic if this disease causes
increased my white blood cell production?” The
nurse in-charge best response would be that the
increased number of white blood cells (WBC) is:
a. Crowd red blood cells
b. Are not responsible for the anemia.
c. Uses nutrients from other cells
d. Have an abnormally short life span of
cells.
43. Diagnostic assessment of Francis would probably
not reveal:
a. Predominance of lymhoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial
occlusion of the left leg undergoes an
emergency embolectomy. Six hours later, the
nurse isn’t able to obtain pulses in his left foot
using Doppler ultrasound. The nurse
immediately notifies the physician, and asks her
to prepare the client for surgery. As the nurse
enters the client’s room to prepare him, he
states that he won’t have any more surgery.
Which of the following is the best initial
response by the nurse?
a. Explain the risks of not having the
surgery
b. Notifying the physician immediately
c. Notifying the nursing supervisor
d. Recording the client’s refusal in the
nurses’ notes
45. During the endorsement, which of the following
clients should the on-duty nurse assess first?
a. The 58-year-old client who was admitted
2 days ago with heart failure, blood
pressure of 126/76 mm Hg, and a
respiratory rate of 22 breaths/ minute.
b. The 89-year-old client with end-stage
right-sided heart failure, blood pressure
of 78/50 mm Hg, and a “do not
resuscitate” order
c. The 62-year-old client who was admitted
1 day ago with thrombophlebitis and is
receiving L.V. heparin
d. The 75-year-old client who was admitted
1 hour ago with new-onset atrial
fibrillation and is receiving L.V. dilitiazem
(Cardizem)
46. Honey, a 23-year old client complains of
substernal chest pain and states that her heart
feels like “it’s racing out of the chest”. She
reports no history of cardiac disorders. The
nurse attaches her to a cardiac monitor and
notes sinus tachycardia with a rate of
136beats/minutes. Breath sounds are clear and
the respiratory rate is 26 breaths/minutes.
Which of the following drugs should the nurse
question the client about using?
a. Barbiturates
b. Opioids
c. Cocaine
d. Benzodiazepines
47. A 51-year-old female client tells the nurse incharge that she has found a painless lump in her
right breast during her monthly selfexamination. Which assessment finding would
strongly suggest that this client's lump is
cancerous?
a. Eversion of the right nipple and mobile
mass
b. Nonmobile mass with irregular edges
c. Mobile mass that is soft and easily
delineated
d. Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks the
nurse, "What is the usual treatment for this type
of cancer?" Which treatment should the nurse
name?
a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy
49. Cristina undergoes a biopsy of a suspicious
lesion. The biopsy report classifies the lesion
according to the TNM staging system as follows:
TIS, N0, M0. What does this classification mean?
a. No evidence of primary tumor, no
abnormal regional lymph nodes, and no
evidence of distant metastasis
b. Carcinoma in situ, no abnormal regional
lymph nodes, and no evidence of distant
metastasis
c. Can't assess tumor or regional lymph
nodes and no evidence of metastasis
d. Carcinoma in situ, no demonstrable
metastasis of the regional lymph nodes,
and ascending degrees of distant
metastasis
50. Lydia undergoes a laryngectomy to treat
laryngeal cancer. When teaching the client how
to care for the neck stoma, the nurse should
include which instruction?
a. "Keep the stoma uncovered."
b. "Keep the stoma dry."
c. "Have a family member perform stoma
care initially until you get used to the
procedure."
d. "Keep the stoma moist."
51. A 37-year-old client with uterine cancer asks the
nurse, "Which is the most common type of
cancer in women?" The nurse replies that it's
breast cancer. Which type of cancer causes the
most deaths in women?
a. Breast cancer
b. Lung cancer
c. Brain cancer
d. Colon and rectal cancer
52. Antonio with lung cancer develops Horner's
syndrome when the tumor invades the ribs and
affects the sympathetic nerve ganglia. When
assessing for signs and symptoms of this
syndrome, the nurse should note:
a. miosis, partial eyelid ptosis, and
anhidrosis on the affected side of the
face.
b. chest pain, dyspnea, cough, weight loss,
and fever.
c. arm and shoulder pain and atrophy of
arm and hand muscles, both on the
affected side.
d. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should
reply that it stands for:
96
a. prostate-specific antigen, which is used
to screen for prostate cancer.
b. protein serum antigen, which is used to
determine protein levels.
c. pneumococcal strep antigen, which is a
bacteria that causes pneumonia.
d. Papanicolaou-specific antigen, which is
used to screen for cervical cancer.
54. What is the most important postoperative
instruction that nurse Kate must give a client
who has just returned from the operating room
after receiving a subarachnoid block?
a. "Avoid drinking liquids until the gag
reflex returns."
b. "Avoid eating milk products for 24
hours."
c. "Notify a nurse if you experience blood
in your urine."
d. "Remain supine for the time specified by
the physician."
55. A male client suspected of having colorectal
cancer will require which diagnostic study to
confirm the diagnosis?
a. Stool Hematest
b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy
d. Abdominal computed tomography (CT)
scan
56. During a breast examination, which finding most
strongly suggests that the Luz has breast cancer?
a. Slight asymmetry of the breasts.
b. A fixed nodular mass with dimpling of
the overlying skin
c. Bloody discharge from the nipple
d. Multiple firm, round, freely movable
masses that change with the menstrual
cycle
57. A female client with cancer is being evaluated
for possible metastasis. Which of the following is
one of the most common metastasis sites for
cancer cells?
a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic
resonance imaging (MRI) to confirm or rule out a
97
spinal cord lesion. During the MRI scan, which of
the 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 wedding
band.
59. Nurse Cecile is teaching a female client about
preventing osteoporosis. Which of the following
teaching points is correct?
a. Obtaining an X-ray of the bones every 3
years is recommended to detect bone
loss.
b. To avoid fractures, the client should
avoid strenuous exercise.
c. The recommended daily allowance of
calcium may be found in a wide variety
of foods.
d. Obtaining the recommended daily
allowance of calcium requires taking a
calcium supplement.
60. Before Jacob undergoes arthroscopy, the nurse
reviews the assessment findings for
contraindications for this procedure. Which
finding is a contraindication?
a. Joint pain
b. Joint deformity
c. Joint flexion of less than 50%
d. Joint stiffness
61. Mr. Rodriguez is admitted with severe pain in
the knees. Which form of arthritis is
characterized by urate deposits and joint pain,
usually in the feet and legs, and occurs primarily
in men over age 30?
a. Septic arthritis
b. Traumatic arthritis
c. Intermittent arthritis
d. Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered
for a 64-year-old client with stroke in evolution.
The infusion contains 25,000 units of heparin in
500 ml of saline solution. How many milliliters
per hour should be given?
a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour
63. A 76-year-old male client had a thromboembolic
right stroke; his left arm is swollen. Which of the
following conditions may cause swelling after a
stroke?
a. Elbow contracture secondary to
spasticity
b. Loss of muscle contraction decreasing
venous return
c. Deep vein thrombosis (DVT) due to
immobility of the ipsilateral side
d. Hypoalbuminemia due to protein
escaping from an inflamed glomerulus
64. Heberden’s nodes are a common sign of
osteoarthritis. Which of the following statement
is correct about this deformity?
a. It appears only in men
b. It appears on the distal interphalangeal
joint
c. It appears on the proximal
interphalangeal joint
d. It appears on the dorsolateral aspect of
the interphalangeal joint.
65. Which of the following statements explains the
main difference between rheumatoid arthritis
and osteoarthritis?
a. Osteoarthritis is gender-specific,
rheumatoid arthritis isn’t
b. Osteoarthritis is a localized disease
rheumatoid arthritis is systemic
c. Osteoarthritis is a systemic disease,
rheumatoid arthritis is localized
d. Osteoarthritis has dislocations and
subluxations, rheumatoid arthritis
doesn’t
66. Mrs. Cruz uses a cane for assistance in walking.
Which of the following statements is true about
a cane or other assistive devices?
a. A walker is a better choice than a cane.
b. The cane should be used on the affected
side
c. The cane should be used on the
unaffected side
d. A client with osteoarthritis should be
encouraged to ambulate without the
cane
67. A male client with type 1 diabetes is scheduled
to receive 30 U of 70/30 insulin. There is no
70/30 insulin available. As a substitution, the
nurse may give the client:
a. 9 U regular insulin and 21 U neutral
protamine 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 which
medication to a client with gout?
a. aspirin
b. furosemide (Lasix)
c. colchicines
d. calcium gluconate (Kalcinate)
69. Mr. Domingo with a history of hypertension is
diagnosed with primary hyperaldosteronism.
This diagnosis indicates that the client's
hypertension is caused by excessive hormone
secretion from which of the following glands?
a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid
70. For a diabetic male client with a foot ulcer, the
doctor orders bed rest, a wet-to-dry dressing
change every shift, and blood glucose
monitoring before meals and bedtime. Why are
wet-to-dry dressings used for this client?
a. They contain exudate and provide a
moist wound environment.
b. They protect the wound from
mechanical trauma and promote
healing.
c. They debride the wound and promote
healing by secondary intention.
d. They prevent the entrance of
microorganisms and minimize wound
discomfort.
71. Nurse Zeny is caring for a client in acute
addisonian crisis. Which laboratory data would
the nurse expect to find?
a. Hyperkalemia
b. Reduced blood urea nitrogen (BUN)
c. Hypernatremia
d. Hyperglycemia
72. A client is admitted for treatment of the
syndrome of inappropriate antidiuretic hormone
(SIADH). Which nursing intervention is
appropriate?
a. Infusing I.V. fluids rapidly as ordered
b. Encouraging increased oral intake
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c. Restricting fluids
d. Administering glucose-containing I.V.
fluids as ordered
73. A female client tells nurse Nikki that she has
been working hard for the last 3 months to
control her type 2 diabetes mellitus with diet
and exercise. To determine the effectiveness of
the client's 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 protamine
Hagedorn (NPH) insulin to a diabetic client at 7
a.m. At what time would the nurse expect the
client to be most at risk for a hypoglycemic
reaction?
a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm
75. The adrenal cortex is responsible for producing
which substances?
a. Glucocorticoids and androgens
b. Catecholamines and epinephrine
c. Mineralocorticoids and catecholamines
d. Norepinephrine and epinephrine
76. On the third day after a partial thyroidectomy,
Proserfina exhibits muscle twitching and
hyperirritability of the nervous system. When
questioned, the client reports numbness and
tingling of the mouth and fingertips. Suspecting
a life-threatening electrolyte disturbance, the
nurse notifies the surgeon immediately. Which
electrolyte disturbance most commonly follows
thyroid surgery?
a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
d. Hypermagnesemia
77. Which laboratory test value is elevated in clients
who smoke and can't be used as a general
indicator of cancer?
a. Acid phosphatase level
b. Serum calcitonin level
c. Alkaline phosphatase level
d. Carcinoembryonic antigen level
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78. Francis with anemia has been admitted to the
medical-surgical unit. Which assessment findings
are characteristic of iron-deficiency anemia?
a. Nights sweats, weight loss, and diarrhea
b. Dyspnea, tachycardia, and pallor
c. Nausea, vomiting, and anorexia
d. Itching, rash, and jaundice
79. In teaching a female client who is HIV-positive
about pregnancy, the nurse would know more
teaching is necessary when the client says:
a. The baby can get the virus from my
placenta."
b. "I'm planning on starting on birth control
pills."
c. "Not everyone who has the virus gives
birth to a baby who has the virus."
d. "I'll need to have a C-section if I become
pregnant and have a baby."
80. When preparing Judy with acquired
immunodeficiency syndrome (AIDS) for
discharge to the home, the nurse should be sure
to include which instruction?
a. "Put on disposable gloves before
bathing."
b. "Sterilize all plates and utensils in boiling
water."
c. "Avoid sharing such articles as
toothbrushes and razors."
d. "Avoid eating foods from serving dishes
shared by other family members."
81. Nurse Marie is caring for a 32-year-old client
admitted with pernicious anemia. Which set of
findings should the nurse expect when assessing
the client?
a. Pallor, bradycardia, and reduced pulse
pressure
b. Pallor, tachycardia, and a sore tongue
c. Sore tongue, dyspnea, and weight gain
d. Angina, double vision, and anorexia
82. After receiving a dose of penicillin, a client
develops dyspnea and hypotension. Nurse
Celestina suspects the client is experiencing
anaphylactic shock. What should the nurse do
first?
a. Page an anesthesiologist immediately
and prepare to intubate the client.
b. Administer epinephrine, as prescribed,
and prepare to intubate the client if
necessary.
c. Administer the antidote for penicillin, as
prescribed, and continue to monitor the
client's vital signs.
d. Insert an indwelling urinary catheter and
begin to infuse I.V. fluids as ordered.
83. Mr. Marquez with rheumatoid arthritis is about
to begin aspirin therapy to reduce inflammation.
When teaching the client about aspirin, the
nurse discusses adverse reactions to prolonged
aspirin 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 human
immunodeficiency virus (HIV). After recovering
from the initial shock of the diagnosis, the client
expresses a desire to learn as much as possible
about HIV and acquired immunodeficiency
syndrome (AIDS). When teaching the client
about the immune system, the nurse states that
adaptive immunity is provided by which type of
white blood cell?
a. Neutrophil
b. Basophil
c. Monocyte
d. Lymphocyte
85. In an individual with Sjögren's syndrome, nursing
care 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 most
important for the nurse to advise the physician
to order:
a. enzyme-linked immunosuppressant
assay (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 for
fatigue, night sweats, and a 20-lb weight loss in 6
weeks. To confirm that the client has been
infected with the human immunodeficiency virus
(HIV), the nurse expects the physician to order:
a. 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 performed
before a Joe goes into surgery. What does this
test seek to identify?
a. Potential hepatic dysfunction indicated
by decreased blood urea nitrogen (BUN)
and creatinine levels
b. Low levels of urine constituents normally
excreted in the urine
c. Abnormally low hematocrit (HCT) and
hemoglobin (Hb) levels
d. Electrolyte imbalance that could affect
the blood's ability to coagulate properly
89. While monitoring a client for the development
of disseminated intravascular coagulation (DIC),
the nurse should take note of what assessment
parameters?
a. Platelet count, prothrombin time, and
partial thromboplastin time
b. Platelet count, blood glucose levels, and
white blood cell (WBC) count
c. Thrombin time, calcium levels, and
potassium levels
d. Fibrinogen level, WBC, and platelet
count
90. When taking a dietary history from a newly
admitted female client, Nurse Len should
remember that which of the following foods is a
common allergen?
a. Bread
b. Carrots
c. Orange
d. Strawberries
91. Nurse John is caring for clients in the outpatient
clinic. Which of the following phone calls should
the nurse return first?
a. A client with hepatitis A who states, “My
arms and legs are itching.”
b. A client with cast on the right leg who
states, “I have a funny feeling in my right
leg.”
c. A client with osteomyelitis of the spine
who states, “I am so nauseous that I
can’t eat.”
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d. A client with rheumatoid arthritis who
states, “I am having trouble sleeping.”
92. Nurse Sarah is caring for clients on the surgical
floor and has just received report from the
previous shift. Which of the following clients
should the nurse see first?
a. A 35-year-old admitted three hours ago
with a gunshot wound; 1.5 cm area of
dark drainage noted on the dressing.
b. A 43-year-old who had a mastectomy
two days ago; 23 ml of serosanguinous
fluid noted in the Jackson-Pratt drain.
c. A 59-year-old with a collapsed lung due
to an accident; no drainage noted in the
previous eight hours.
d. A 62-year-old who had an abdominalperineal resection three days ago; client
complaints of chills.
93. Nurse Eve is caring for a client who had a
thyroidectomy 12 hours ago for treatment of
Grave’s disease. The nurse would be most
concerned if which of the following was
observed?
a. Blood pressure 138/82, respirations 16,
oral temperature 99 degrees Fahrenheit.
b. The client supports his head and neck
when turning his head to the right.
c. The client spontaneously flexes his wrist
when the blood pressure is obtained.
d. The client is drowsy and complains of
sore throat.
94. Julius is admitted with complaints of severe pain
in the lower right quadrant of the abdomen. To
assist with pain relief, the nurse should take
which of the following actions?
a. Encourage the client to change positions
frequently in bed.
b. Administer Demerol 50 mg IM q 4 hours
and PRN.
c. Apply warmth to the abdomen with a
heating pad.
d. Use comfort measures and pillows to
position the client.
95. Nurse Tina prepares a client for peritoneal
dialysis. Which of the following actions should
the nurse take first?
a. Assess for a bruit and a thrill.
b. Warm the dialysate solution.
c. Position the client on the left side.
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d. Insert a Foley catheter
96. Nurse Jannah teaches an elderly client with
right-sided weakness how to use cane. Which of
the following behaviors, if demonstrated by the
client to the nurse, indicates that the teaching
was effective?
a. The client holds the cane with his right
hand, moves the can forward followed
by the right leg, and then moves the left
leg.
b. The client holds the cane with his right
hand, moves the cane forward followed
by his left leg, and then moves the right
leg.
c. The client holds the cane with his left
hand, moves the cane forward followed
by the right leg, and then moves the left
leg.
d. The client holds the cane with his left
hand, moves the cane forward followed
by his left leg, and then moves the right
leg.
97. An elderly client is admitted to the nursing home
setting. The client is occasionally confused and
her gait is often unsteady. Which of the
following actions, if taken by the nurse, is most
appropriate?
a. Ask the woman’s family to provide
personal items such as photos or
mementos.
b. Select a room with a bed by the door so
the woman can look down the hall.
c. Suggest the woman eat her meals in the
room with her roommate.
d. Encourage the woman to ambulate in
the halls twice a day.
98. Nurse Evangeline teaches an elderly client how
to use a standard aluminum walker. Which of
the following behaviors, if demonstrated by the
client, indicates that the nurse’s teaching was
effective?
a. The client slowly pushes the walker
forward 12 inches, then takes small
steps forward while leaning on the
walker.
b. The client lifts the walker, moves it
forward 10 inches, and then takes
several small steps forward.
c. The client supports his weight on the
walker while advancing it forward, then
takes small steps while balancing on the
walker.
d. The client slides the walker 18 inches
forward, then takes small steps while
holding onto the walker for balance.
99. Nurse Deric is supervising a group of elderly
clients in a residential home setting. The nurse
knows that the elderly are at greater risk of
developing sensory deprivation for what reason?
a. Increased sensitivity to the side effects
of medications.
b. Decreased visual, auditory, and
gustatory abilities.
c. Isolation from their families and familiar
surroundings.
d. Decrease musculoskeletal function and
mobility.
100.
A male client with emphysema becomes
restless and confused. What step should
nurse Jasmine take next?
a. Encourage the client to perform pursed
lip breathing.
b. Check the client’s temperature.
c. Assess the client’s potassium level.
d. Increase the client’s oxygen flow rate.
Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations
1.
2.
3.
4.
5.
6.
7.
8.
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Answer: (C) Loose, bloody
Rationale: Normal bowel function and softformed stool usually do not occur until around
the seventh day following surgery. The stool
consistency is related to how much water is
being absorbed.
Answer: (A) On the client’s right side
Rationale: The client has left visual field
blindness. The client will see only from the
right side.
Answer: (C) Check respirations, stabilize spine,
and check circulation
Rationale: Checking the airway would be
priority, and a neck injury should be
suspected.
Answer: (D) Decreasing venous return through
vasodilation.
Rationale: The significant effect of
nitroglycerin is vasodilation and decreased
venous return, so the heart does not have to
work hard.
Answer: (A) Call for help and note the time.
Rationale: Having established, by stimulating
the client, that the client is unconscious rather
than sleep, the nurse should immediately call
for help. This may be done by dialing the
operator from the client’s phone and giving
the hospital code for cardiac arrest and the
client’s room number to the operator, of if the
phone is not available, by pulling the
emergency call button. Noting the time is
important baseline information for cardiac
arrest procedure
Answer: (C) Make sure that the client takes
food and medications at prescribed intervals.
Rationale: Food and drug therapy will prevent
the accumulation of hydrochloric acid, or will
neutralize and buffer the acid that does
accumulate.
Answer: (B) Continue treatment as ordered.
Rationale: The effects of heparin are
monitored by the PTT is normally 30 to 45
seconds; the therapeutic level is 1.5 to 2 times
the normal level.
Answer: (B) In the operating room.
Rationale: The stoma drainage bag is applied
in the operating room. Drainage from the
ileostomy contains secretions that are rich in
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10.
11.
12.
13.
14.
15.
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.
Answer: (B) Flat on back.
Rationale: To avoid the complication of a
painful spinal headache that can last for
several days, the client is kept in flat in a
supine position for approximately 4 to 12
hours postoperatively. Headaches are
believed to be causes by the seepage of
cerebral spinal fluid from the puncture site. By
keeping the client flat, cerebral spinal fluid
pressures are equalized, which avoids trauma
to the neurons.
Answer: (C) The client is oriented when
aroused from sleep, and goes back to sleep
immediately.
Rationale: This finding suggest that the level
of consciousness is decreasing.
Answer: (A) Altered mental status and
dehydration
Rationale: Fever, chills, hemortysis, dyspnea,
cough, and pleuritic chest pain are the
common symptoms of pneumonia, but elderly
clients may first appear with only an altered
lentil status and dehydration due to a blunted
immune response.
Answer: (B) Chills, fever, night sweats, and
hemoptysis
Rationale: Typical signs and symptoms are
chills, fever, night sweats, and hemoptysis.
Chest pain may be present from coughing, but
isn’t usual. Clients with TB typically have lowgrade fevers, not higher than 102°F (38.9°C).
Nausea, headache, and photophobia aren’t
usual TB symptoms.
Answer:(A) Acute asthma
Rationale: Based on the client’s history and
symptoms, acute asthma is the most likely
diagnosis. He’s unlikely to have bronchial
pneumonia without a productive cough and
fever and he’s too young to have developed
(COPD) and emphysema.
Answer: (B) Respiratory arrest
Rationale: Narcotics can cause respiratory
arrest if given in large quantities. It’s unlikely
the client will have asthma attack or a seizure
or wake up on his own.
Answer: (D) Decreased vital capacity
Rationale: Reduction in vital capacity is a
normal physiologic change includes decreased
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16.
17.
18.
19.
20.
21.
elastic recoil of the lungs, fewer functional
capillaries in the alveoli, and an increased in
residual volume.
Answer: (C) Presence of premature ventricular
contractions (PVCs) on a cardiac monitor.
Rationale: Lidocaine drips are commonly used
to treat clients whose arrhythmias haven’t
been controlled with oral medication and who
are having PVCs that are visible on the cardiac
monitor. SaO2, blood pressure, and ICP are
important factors but aren’t as significant as
PVCs in the situation.
Answer: (B) Avoid foods high in vitamin K
Rationale: The client should avoid consuming
large amounts of vitamin K because vitamin K
can interfere with anticoagulation. The client
may need to report diarrhea, but isn’t effect
of taking an anticoagulant. An electric razornot a straight razor-should be used to prevent
cuts that cause bleeding. Aspirin may increase
the risk of bleeding; acetaminophen should be
used to pain relief.
Answer: (C) Clipping the hair in the area
Rationale: Hair can be a source of infection
and should be removed by clipping. Shaving
the area can cause skin abrasions and
depilatories can irritate the skin.
Answer: (A) Bone fracture
Rationale: Bone fracture is a major
complication of osteoporosis that results
when loss of calcium and phosphate increased
the fragility of bones. Estrogen deficiencies
result from menopause-not osteoporosis.
Calcium and vitamin D supplements may be
used to support normal bone metabolism, But
a negative calcium balance isn’t a
complication of osteoporosis. Dowager’s
hump results from bone fractures. It develops
when repeated vertebral fractures increase
spinal curvature.
Answer: (C) Changes from previous
examinations.
Rationale: Women are instructed to examine
themselves to discover changes that have
occurred in the breast. Only a physician can
diagnose lumps that are cancerous, areas of
thickness or fullness that signal the presence
of a malignancy, or masses that are fibrocystic
as opposed to malignant.
Answer: (C) Balance the client’s periods of
activity and rest.
Rationale: A client with hyperthyroidism
needs to be encouraged to balance periods of
22.
23.
24.
25.
26.
27.
activity and rest. Many clients with
hyperthyroidism are hyperactive and complain
of feeling very warm.
Answer: (B) Increase his activity level.
Rationale: The client should be encouraged to
increase his activity level. aintaining an ideal
weight; following a low-cholesterol, low
sodium diet; and avoiding stress are all
important factors in decreasing the risk of
atherosclerosis.
Answer: (A) Laminectomy
Rationale: The client who has had spinal
surgery, such as laminectomy, must be log
rolled to keep the spinal column straight when
turning. Thoracotomy and cystectomy may
turn themselves or may be assisted into a
comfortable position. Under normal
circumstances, hemorrhoidectomy is an
outpatient procedure, and the client may
resume normal activities immediately after
surgery.
Answer: (D) Avoiding straining during bowel
movement or bending at the waist.
Rationale: The client should avoid straining,
lifting heavy objects, and coughing harshly
because these activities increase intraocular
pressure. Typically, the client is instructed to
avoid lifting objects weighing more than 15 lb
(7kg) – not 5lb. instruct the client when lying
in bed to lie on either the side or back. The
client should avoid bright light by wearing
sunglasses.
Answer: (D) Before age 20.
Rationale: Testicular cancer commonly occurs
in men between ages 20 and 30. A male client
should be taught how to perform testicular
self- examination before age 20, preferably
when he enters his teens.
Answer: (B) Place a saline-soaked sterile
dressing on the wound.
Rationale: The nurse should first place salinesoaked sterile dressings on the open wound to
prevent tissue drying and possible infection.
Then the nurse should call the physician and
take the client’s vital signs. The dehiscence
needs to be surgically closed, so the nurse
should never try to close it.
Answer: (A) A progressively deeper breaths
followed by shallower breaths with apneic
periods.
Rationale: Cheyne-Strokes respirations are
breaths that become progressively deeper
fallowed by shallower respirations with
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29.
30.
31.
32.
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apneas periods. Biot’s respirations are rapid,
deep breathing with abrupt pauses between
each breath, and equal depth between each
breath. Kussmaul’s respirationa are rapid,
deep breathing without pauses. Tachypnea is
shallow breathing with increased respiratory
rate.
Answer: (B) Fine crackles
Rationale: Fine crackles are caused by fluid in
the alveoli and commonly occur in clients with
heart failure. Tracheal breath sounds are
auscultated over the trachea. Coarse crackles
are caused by secretion accumulation in the
airways. Friction rubs occur with pleural
inflammation.
Answer: (B) The airways are so swollen that no
air cannot get through
Rationale: During an acute attack, wheezing
may stop and breath sounds become
inaudible because the airways are so swollen
that air can’t get through. If the attack is over
and swelling has decreased, there would be
no more wheezing and less emergent concern.
Crackles do not replace wheezes during an
acute asthma attack.
Answer: (D) Place the client on his side,
remove dangerous objects, and protect his
head.
Rationale: During the active seizure phase,
initiate precautions by placing the client on his
side, removing dangerous objects, and
protecting his head from injury. A bite block
should never be inserted during the active
seizure phase. Insertion can break the teeth
and lead to aspiration.
Answer: (B) Kinked or obstructed chest tube
Rationales: Kinking and blockage of the chest
tube is a common cause of a tension
pneumothorax. Infection and excessive
drainage won’t cause a tension
pneumothorax. Excessive water won’t affect
the chest tube drainage.
Answer: (D) Stay with him but not intervene at
this time.
Rationale: If the client is coughing, he should
be able to dislodge the object or cause a
complete obstruction. If complete obstruction
occurs, the nurse should perform the
abdominal thrust maneuver with the client
standing. If the client is unconscious, she
should lay him down. A nurse should never
leave a choking client alone.
33.
34.
35.
36.
37.
Answer: (B) Current health promotion
activities
Rationale: Recognizing an individual’s positive
health measures is very useful. General health
in the previous 10 years is important,
however, the current activities of an 84 year
old client are most significant in planning care.
Family history of disease for a client in later
years is of minor significance. Marital status
information may be important for discharge
planning but is not as significant for
addressing the immediate medical problem.
Answer: (C) Place the client in a side lying
position, with the head of the bed lowered.
Rationale: The client should be positioned in a
side-lying position with the head of the bed
lowered to prevent aspiration. A small amount
of toothpaste should be used and the mouth
swabbed or suctioned to remove pooled
secretions. Lemon glycerin can be drying if
used for extended periods. Brushing the teeth
with the client lying supine may lead to
aspiration. Hydrogen peroxide is caustic to
tissues and should not be used.
Answer: (C) Pneumonia
Rationale: Fever productive cough and
pleuritic chest pain are common signs and
symptoms of pneumonia. The client with
ARDS has dyspnea and hypoxia with
worsening hypoxia over time, if not treated
aggressively. Pleuritic chest pain varies with
respiration, unlike the constant chest pain
during an MI; so this client most likely isn’t
having an MI. the client with TB typically has a
cough producing blood-tinged sputum. A
sputum culture should be obtained to confirm
the nurse’s suspicions.
Answer: (C) A 43-yesr-old homeless man with
a history of alcoholism
Rationale: Clients who are economically
disadvantaged, malnourished, and have
reduced immunity, such as a client with a
history of alcoholism, are at extremely high
risk for developing TB. A high school student,
day- care worker, and businessman probably
have a much low risk of contracting TB.
Answer: (C ) To determine the extent of
lesions
Rationale: If the lesions are large enough, the
chest X-ray will show their presence in the
lungs. Sputum culture confirms the diagnosis.
There can be false-positive and false-negative
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38.
39.
40.
41.
42.
43.
44.
45.
skin test results. A chest X-ray can’t determine
if this is a primary or secondary infection.
Answer: (B) Bronchodilators
Rationale: Bronchodilators are the first line of
treatment for asthma because bronchoconstriction is the cause of reduced airflow.
Beta- adrenergic blockers aren’t used to treat
asthma and can cause broncho- constriction.
Inhaled oral steroids may be given to reduce
the inflammation but aren’t used for
emergency relief.
Answer: (C) Chronic obstructive bronchitis
Rationale: Because of this extensive smoking
history and symptoms the client most likely
has chronic obstructive bronchitis. Client with
ARDS have acute symptoms of hypoxia and
typically need large amounts of oxygen.
Clients with asthma and emphysema tend not
to have chronic cough or peripheral edema.
Answer: (A) The patient is under local
anesthesia during the procedure Rationale:
Before the procedure, the patient is
administered with drugs that would help to
prevent infection and rejection of the
transplanted cells such as antibiotics,
cytotoxic, and corticosteroids. During the
transplant, the patient is placed under general
anesthesia.
Answer: (D) Raise the side rails
Rationale: A patient who is disoriented is at
risk of falling out of bed. The initial action of
the nurse should be raising the side rails to
ensure patients safety.
Answer: (A) Crowd red blood cells
Rationale: The excessive production of white
blood cells crowd out red blood cells
production which causes anemia to occur.
Answer: (B) Leukocytosis
Rationale: Chronic Lymphocytic leukemia (CLL)
is characterized by increased production of
leukocytes and lymphocytes resulting in
leukocytosis, and proliferation of these cells
within the bone marrow, spleen and liver.
Answer: (A) Explain the risks of not having the
surgery
Rationale: The best initial response is to
explain the risks of not having the surgery. If
the client understands the risks but still
refuses the nurse should notify the physician
and the nurse supervisor and then record the
client’s refusal in the nurses’ notes.
Answer: (D) The 75-year-old client who was
admitted 1 hour ago with new-onset atrial
46.
47.
48.
49.
fibrillation and is receiving L.V. dilitiazem
(Cardizem)
Rationale: The client with atrial fibrillation has
the greatest potential to become unstable and
is on L.V. medication that requires close
monitoring. After assessing this client, the
nurse should assess the client with
thrombophlebitis who is receiving a heparin
infusion, and then the 58- year-old client
admitted 2 days ago with heart failure (his
signs and symptoms are resolving and don’t
require immediate attention). The lowest
priority is the 89-year-old with end-stage
right-sided heart failure, who requires timeconsuming supportive measures.
Answer: (C) Cocaine
Rationale: Because of the client’s age and
negative medical history, the nurse should
question her about cocaine use. Cocaine
increases myocardial oxygen consumption and
can cause coronary artery spasm, leading to
tachycardia, ventricular fibrillation, myocardial
ischemia, and myocardial infarction.
Barbiturate overdose may trigger respiratory
depression and slow pulse. Opioids can cause
marked respiratory depression, while
benzodiazepines can cause drowsiness and
confusion.
Answer: (B) Nonmobile mass with irregular
edges
Rationale: Breast cancer tumors are fixed,
hard, and poorly delineated with irregular
edges. A mobile mass that is soft and easily
delineated is most often a fluid-filled benign
cyst. Axillary lymph nodes may or may not be
palpable on initial detection of a cancerous
mass. Nipple retraction — not eversion —
may be a sign of cancer.
Answer: (C) Radiation
Rationale: The usual treatment for vaginal
cancer is external or intravaginal radiation
therapy. Less often, surgery is performed.
Chemotherapy typically is prescribed only if
vaginal cancer is diagnosed in an early stage,
which is rare. Immunotherapy isn't used to
treat vaginal cancer.
Answer: (B) Carcinoma in situ, no abnormal
regional lymph nodes, and no evidence of
distant metastasis
Rationale: TIS, N0, M0 denotes carcinoma in
situ, no abnormal regional lymph nodes, and
no evidence of distant metastasis. No
evidence of primary tumor, no abnormal
50.
51.
52.
53.
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regional lymph nodes, and no evidence of
distant metastasis is classified as T0, N0, M0. If
the tumor and regional lymph nodes can't be
assessed and no evidence of metastasis exists,
the lesion is classified as TX, NX, M0. A
progressive increase in tumor size, no
demonstrable metastasis of the regional
lymph nodes, and ascending degrees of
distant metastasis is classified as T1, T2, T3, or
T4; N0; and M1, M2, or M3.
Answer: (D) "Keep the stoma moist."
Rationale: The nurse should instruct the client
to keep the stoma moist, such as by applying a
thin layer of petroleum jelly around the edges,
because a dry stoma may become irritated.
The nurse should recommend placing a stoma
bib over the stoma to filter and warm air
before it enters the stoma. The client should
begin performing stoma care without
assistance as soon as possible to gain
independence in self-care activities.
Answer: (B) Lung cancer
Rationale: Lung cancer is the most deadly type
of cancer in both women and men. Breast
cancer ranks second in women, followed (in
descending order) by colon and rectal cancer,
pancreatic cancer, ovarian cancer, uterine
cancer, lymphoma, leukemia, liver cancer,
brain cancer, stomach cancer, and multiple
myeloma.
Answer: (A) miosis, partial eyelid ptosis, and
anhidrosis on the affected side of the face.
Rationale: Horner's syndrome, which occurs
when a lung tumor invades the ribs and
affects the sympathetic nerve ganglia, is
characterized by miosis, partial eyelid ptosis,
and anhidrosis on the affected side of the
face. Chest pain, dyspnea, cough, weight loss,
and fever are associated with pleural tumors.
Arm and shoulder pain and atrophy of the arm
and hand muscles on the affected side suggest
Pancoast's tumor, a lung tumor involving the
first thoracic and eighth cervical nerves within
the brachial plexus. Hoarseness in a client
with lung cancer suggests that the tumor has
extended to the recurrent laryngeal nerve;
dysphagia suggests that the lung tumor is
compressing the esophagus.
53. Answer: (A) prostate-specific antigen,
which is used to screen for prostate cancer.
Rationale: PSA stands for prostate-specific
antigen, which is used to screen for prostate
cancer. The other answers are incorrect.
54.
55.
56.
57.
58.
59.
Answer: (D) "Remain supine for the time
specified by the physician." Rationale: The
nurse should instruct the client to remain
supine for the time specified by the physician.
Local anesthetics used in a subarachnoid block
don't alter the gag reflex. No interactions
between local anesthetics and food occur.
Local anesthetics don't cause hematuria.
Answer: (C) Sigmoidoscopy
Rationale: Used to visualize the lower GI tract,
sigmoidoscopy and proctoscopy aid in the
detection of two-thirds of all colorectal
cancers. Stool Hematest detects blood, which
is a sign of colorectal cancer; however, the
test doesn't confirm the diagnosis. CEA may
be elevated in colorectal cancer but isn't
considered a confirming test. An abdominal CT
scan is used to stage the presence of
colorectal cancer.
Answer: (B) A fixed nodular mass with
dimpling of the overlying skin
Rationale: A fixed nodular mass with dimpling
of the overlying skin is common during late
stages of breast cancer. Many women have
slightly asymmetrical breasts. Bloody nipple
discharge is a sign of intraductal papilloma, a
benign condition. Multiple firm, round, freely
movable masses that change with the
menstrual cycle indicate fibrocystic breasts, a
benign condition.
Answer: (A) Liver
Rationale: The liver is one of the five most
common cancer metastasis sites. The others
are the lymph nodes, lung, bone, and brain.
The colon, reproductive tract, and WBCs are
occasional metastasis sites.
Answer: (D) The client wears a watch and
wedding band.
Rationale: During an MRI, the client should
wear no metal objects, such as jewelry,
because the strong magnetic field can pull on
them, causing injury to the client and (if they
fly off) to others. The client must lie still
during the MRI but can talk to those
performing the test by way of the microphone
inside the scanner tunnel. The client should
hear thumping sounds, which are caused by
the sound waves thumping on the magnetic
field.
Answer: (C) The recommended daily
allowance of calcium may be found in a wide
variety of foods.
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Rationale: Premenopausal women require
1,000 mg of calcium per day. Postmenopausal
women require 1,500 mg per day. It's often,
though not always, possible to get the
recommended daily requirement in the foods
we eat. Supplements are available but not
always necessary. Osteoporosis doesn't show
up on ordinary X-rays until 30% of the bone
loss has occurred. Bone densitometry can
detect bone loss of 3% or less. This test is
sometimes recommended routinely for
women over 35 who are at risk. Strenuous
exercise won't cause fractures.
Answer: (C) Joint flexion of less than 50%
Rationale: Arthroscopy is contraindicated in
clients with joint flexion of less than 50%
because of technical problems in inserting the
instrument into the joint to see it clearly.
Other contraindications for this procedure
include skin and wound infections. Joint pain
may be an indication, not a contraindication,
for arthroscopy. Joint deformity and joint
stiffness aren't contraindications for this
procedure.
Answer: (D) Gouty arthritis
Rationale: Gouty arthritis, a metabolic disease,
is characterized by urate deposits and pain in
the joints, especially those in the feet and
legs. Urate deposits don't occur in septic or
traumatic arthritis. Septic arthritis results from
bacterial invasion of a joint and leads to
inflammation of the synovial lining. Traumatic
arthritis results from blunt trauma to a joint or
ligament. Intermittent arthritis is a rare,
benign condition marked by regular, recurrent
joint effusions, especially in the knees.
Answer: (B) 30 ml/hou
Rationale: An infusion prepared with 25,000
units of heparin in 500 ml of saline solution
yields 50 units of heparin per milliliter of
solution. The equation is set up as 50 units
times X (the unknown quantity) equals 1,500
units/hour, X equals 30 ml/hour.
Answer: (B) Loss of muscle contraction
decreasing venous return
Rationale: In clients with hemiplegia or
hemiparesis loss of muscle contraction
decreases venous return and may cause
swelling of the affected extremity.
Contractures, or bony calcifications may occur
with a stroke, but don’t appear with swelling.
DVT may develop in clients with a stroke but is
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more likely to occur in the lower extremities.
A stroke isn’t linked to protein loss.
Answer: (B) It appears on the distal
interphalangeal joint
Rationale: Heberden’s nodes appear on the
distal interphalageal joint on both men and
women. Bouchard’s node appears on the
dorsolateral aspect of the proximal
interphalangeal joint.
Answer: (B) Osteoarthritis is a localized
disease rheumatoid arthritis is systemic
Rationale: Osteoarthritis is a localized disease,
rheumatoid arthritis is systemic. Osteoarthritis
isn’t gender-specific, but rheumatoid arthritis
is. Clients have dislocations and subluxations
in both disorders.
Answer: (C) The cane should be used on the
unaffected side
Rationale: A cane should be used on the
unaffected side. A client with osteoarthritis
should be encouraged to ambulate with a
cane, walker, or other assistive device as
needed; their use takes weight and stress off
joints.
Answer: (A) a. 9 U regular insulin and 21 U
neutral protamine Hagedorn (NPH).
Rationale: A 70/30 insulin preparation is 70%
NPH and 30% regular insulin. Therefore, a
correct substitution requires mixing 21 U of
NPH and 9 U of regular insulin. The other
choices are incorrect dosages for the
prescribed insulin.
Answer: (C) colchicines
Rationale: A disease characterized by joint
inflammation (especially in the great toe),
gout is caused by urate crystal deposits in the
joints. The physician prescribes colchicine to
reduce these deposits and thus ease joint
inflammation. Although aspirin is used to
reduce joint inflammation and pain in clients
with osteoarthritis and rheumatoid arthritis, it
isn't indicated for gout because it has no
effect on urate crystal formation. Furosemide,
a diuretic, doesn't relieve gout. Calcium
gluconate is used to reverse a negative
calcium balance and relieve muscle cramps,
not to treat gout.
Answer: (A) Adrenal cortex
Rationale: Excessive secretion of aldosterone
in the adrenal cortex is responsible for the
client's hypertension. This hormone acts on
the renal tubule, where it promotes
reabsorption of sodium and excretion of
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potassium and hydrogen ions. The pancreas
mainly secretes hormones involved in fuel
metabolism. The adrenal medulla secretes the
catecholamines — epinephrine and
norepinephrine. The parathyroids secrete
parathyroid hormone.
Answer: (C) They debride the wound and
promote healing by secondary intention
Rationale: For this client, wet-to-dry dressings
are most appropriate because they clean the
foot ulcer by debriding exudate and necrotic
tissue, thus promoting healing by secondary
intention. Moist, transparent dressings
contain exudate and provide a moist wound
environment. Hydrocolloid dressings prevent
the entrance of microorganisms and minimize
wound discomfort. Dry sterile dressings
protect the wound from mechanical trauma
and promote healing.
Answer: (A) Hyperkalemia
Rationale: In adrenal insufficiency, the client
has hyperkalemia due to reduced aldosterone
secretion. BUN increases as the glomerular
filtration rate is reduced. Hyponatremia is
caused by reduced aldosterone secretion.
Reduced cortisol secretion leads to impaired
glyconeogenesis and a reduction of glycogen
in the liver and muscle, causing hypoglycemia.
Answer: (C) Restricting fluids
Rationale: To reduce water retention in a
client with the SIADH, the nurse should
restrict fluids. Administering fluids by any
route would further increase the client's
already heightened fluid load.
Answer: (D) glycosylated hemoglobin level.
Rationale: Because some of the glucose in the
bloodstream attaches to some of the
hemoglobin and stays attached during the
120-day life span of red blood cells,
glycosylated hemoglobin levels provide
information about blood glucose levels during
the previous 3 months. Fasting blood glucose
and urine glucose levels only give information
about glucose levels at the point in time when
they were obtained. Serum fructosamine
levels provide information about blood
glucose control over the past 2 to 3 weeks.
Answer: (C) 4:00 pm
Rationale: NPH is an intermediate-acting
insulin that peaks 8 to 12 hours after
administration. Because the nurse
administered NPH insulin at 7 a.m., the client
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is at greatest risk for hypoglycemia from 3
p.m. to 7 p.m.
Answer: (A) Glucocorticoids and androgens
Rationale: The adrenal glands have two
divisions, the cortex and medulla. The cortex
produces three types of hormones:
glucocorticoids, mineralocorticoids, and
androgens. The medulla produces
catecholamines— epinephrine and
norepinephrine.
Answer: (A) Hypocalcemia
Rationale: Hypocalcemia may follow thyroid
surgery if the parathyroid glands were
removed accidentally. Signs and symptoms of
hypocalcemia may be delayed for up to 7 days
after surgery. Thyroid surgery doesn't directly
cause serum sodium, potassium, or
magnesium abnormalities. Hyponatremia may
occur if the client inadvertently received too
much fluid; however, this can happen to any
surgical client receiving I.V. fluid therapy, not
just one recovering from thyroid surgery.
Hyperkalemia and hypermagnesemia usually
are associated with reduced renal excretion of
potassium and magnesium, not thyroid
surgery.
Answer: (D) Carcinoembryonic antigen level
Rationale: In clients who smoke, the level of
carcinoembryonic antigen is elevated.
Therefore, it can't be used as a general
indicator of cancer. However, it is helpful in
monitoring cancer treatment because the
level usually falls to normal within 1 month if
treatment is successful. An elevated acid
phosphatase level may indicate prostate
cancer. An elevated alkaline phosphatase level
may reflect bone metastasis. An elevated
serum calcitonin level usually signals thyroid
cancer.
Answer: (B) Dyspnea, tachycardia, and pallor
Rationale: Signs of iron-deficiency anemia
include dyspnea, tachycardia, and pallor as
well as fatigue, listlessness, irritability, and
headache. Night sweats, weight loss, and
diarrhea may signal acquired
immunodeficiency syndrome (AIDS). Nausea,
vomiting, and anorexia may be signs of
hepatitis B. Itching, rash, and jaundice may
result from an allergic or hemolytic reaction.
Answer: (D) "I'll need to have a C-section if I
become pregnant and have a baby."
Rationale: The human immunodeficiency virus
(HIV) is transmitted from mother to child via
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the transplacental route, but a Cesarean
section delivery isn't necessary when the
mother is HIV-positive. The use of birth
control will prevent the conception of a child
who might have HIV. It's true that a mother
who's HIV positive can give birth to a baby
who's HIV negative.
Answer: (C) "Avoid sharing such articles as
toothbrushes and razors."
Rationale: The human immunodeficiency virus
(HIV), which causes AIDS, is most
concentrated in the blood. For this reason, the
client shouldn't share personal articles that
may be blood-contaminated, such as
toothbrushes and razors, with other family
members. HIV isn't transmitted by bathing or
by eating from plates, utensils, or serving
dishes used by a person with AIDS.
Answer: (B) Pallor, tachycardia, and a sore
tongue
Rationale: Pallor, tachycardia, and a sore
tongue are all characteristic findings in
pernicious anemia. Other clinical
manifestations include anorexia; weight loss; a
smooth, beefy red tongue; a wide pulse
pressure; palpitations; angina; weakness;
fatigue; and paresthesia of the hands and feet.
Bradycardia, reduced pulse pressure, weight
gain, and double vision aren't characteristic
findings in pernicious anemia.
Answer: (B) Administer epinephrine, as
prescribed, and prepare to intubate the client
if necessary.
Rationale: To reverse anaphylactic shock, the
nurse first should administer epinephrine, a
potent bronchodilator as prescribed. The
physician is likely to order additional
medications, such as antihistamines and
corticosteroids; if these medications don't
relieve the respiratory compromise associated
with anaphylaxis, the nurse should prepare to
intubate the client. No antidote for penicillin
exists; however, the nurse should continue to
monitor the client's vital signs. A client who
remains hypotensive may need fluid
resuscitation and fluid intake and output
monitoring; however, administering
epinephrine is the first priority.
Answer: (D) bilateral hearing loss.
Rationale: Prolonged use of aspirin and other
salicylates sometimes causes bilateral hearing
loss of 30 to 40 decibels. Usually, this adverse
effect resolves within 2 weeks after the
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therapy is discontinued. Aspirin doesn't lead
to weight gain or fine motor tremors. Large or
toxic salicylate doses may cause respiratory
alkalosis, not respiratory acidosis.
Answer: (D) Lymphocyte
Rationale: The lymphocyte provides adaptive
immunity — recognition of a foreign antigen
and formation of memory cells against the
antigen. Adaptive immunity is mediated by B
and T lymphocytes and can be acquired
actively or passively. The neutrophil is crucial
to phagocytosis. The basophil plays an
important role in the release of inflammatory
mediators. The monocyte functions in
phagocytosis and monokine production.
Answer: (A) moisture replacement.
Rationale: Sjogren's syndrome is an
autoimmune disorder leading to progressive
loss of lubrication of the skin, GI tract, ears,
nose, and vagina. Moisture replacement is the
mainstay of therapy. Though malnutrition and
electrolyte imbalance may occur as a result of
Sjogren's syndrome's effect on the GI tract, it
isn't the predominant problem. Arrhythmias
aren't a problem associated with Sjogren's
syndrome.
Answer: (C) stool for Clostridium difficile test.
Rationale: Immunosuppressed clients — for
example, clients receiving chemotherapy, —
are at risk for infection with C. difficile, which
causes "horse barn" smelling diarrhea.
Successful treatment begins with an accurate
diagnosis, which includes a stool test. The
ELISA test is diagnostic for human
immunodeficiency virus (HIV) and isn't
indicated in this case. An electrolyte panel and
hemogram may be useful in the overall
evaluation of a client but aren't diagnostic for
specific causes of diarrhea. A flat plate of the
abdomen may provide useful information
about bowel function but isn't indicated in the
case of "horse barn" smelling diarrhea.
Answer: (D) Western blot test with ELISA.
Rationale: HIV infection is detected by
analyzing blood for antibodies to HIV, which
form approximately 2 to 12 weeks after
exposure to HIV and denote infection. The
Western blot test — electrophoresis of
antibody proteins — is more than 98%
accurate in detecting HIV antibodies when
used in conjunction with the ELISA. It isn't
specific when used alone. E-rosette
immunofluorescence is used to detect viruses
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in general; it doesn't confirm HIV infection.
Quantification of T-lymphocytes is a useful
monitoring test but isn't diagnostic for HIV.
The ELISA test detects HIV antibody particles
but may yield inaccurate results; a positive
ELISA result must be confirmed by the
Western blot test.
Answer: (C) Abnormally low hematocrit (HCT)
and hemoglobin (Hb) levels
Rationale: Low preoperative HCT and Hb
levels indicate the client may require a blood
transfusion before surgery. If the HCT and Hb
levels decrease during surgery because of
blood loss, the potential need for a
transfusion increases. Possible renal failure is
indicated by elevated BUN or creatinine levels.
Urine constituents aren't found in the blood.
Coagulation is determined by the presence of
appropriate clotting factors, not electrolytes.
Answer: (A) Platelet count, prothrombin time,
and partial thromboplastin time
Rationale: The diagnosis of DIC is based on the
results of laboratory studies of prothrombin
time, platelet count, thrombin time, partial
thromboplastin time, and fibrinogen level as
well as client history and other assessment
factors. Blood glucose levels, WBC count,
calcium levels, and potassium levels aren't
used to confirm a diagnosis of DIC.
Answer: (D) Strawberries
Rationale: Common food allergens include
berries, peanuts, Brazil nuts, cashews,
shellfish, and eggs. Bread, carrots, and
oranges rarely cause allergic reactions.
Answer: (B) A client with cast on the right leg
who states, “I have a funny feeling in my right
leg.”
Rationale: It may indicate neurovascular
compromise, requires immediate assessment.
Answer: (D) A 62-year-old who had an
abdominal-perineal resection three days ago;
client complaints of chills.
Rationale: The client is at risk for peritonitis;
should be assessed for further symptoms and
infection.
Answer: (C) The client spontaneously flexes
his wrist when the blood pressure is obtained.
Rationale: Carpal spasms indicate
hypocalcemia.
Answer: (D) Use comfort measures and
pillows to position the client.
Rationale: Using comfort measures and
pillows to position the client is a nonpharmacological methods of pain relief.
95. Answer: (B) Warm the dialysate solution.
Rationale: Cold dialysate increases discomfort.
The solution should be warmed to body
temperature in warmer or heating pad; don’t
use microwave oven.
96. Answer: (C) The client holds the cane with his
left hand, moves the cane forward followed
by the right leg, and then moves the left leg.
Rationale: The cane acts as a support and aids
in weight bearing for the weaker right leg.
97. Answer: (A) Ask the woman’s family to
provide personal items such as photos or
mementos.
Rationale: Photos and mementos provide
visual stimulation to reduce sensory
deprivation.
98. Answer: (B) The client lifts the walker, moves
it forward 10 inches, and then takes several
small steps forward.
Rationale: A walker needs to be picked up,
placed down on all legs.
99. Answer: (C) Isolation from their families and
familiar surroundings.
Rationale: Gradual loss of sight, hearing, and
taste interferes with normal functioning.
100. Answer: (A) Encourage the client to perform
pursed lip breathing.
Rationale: Purse lip breathing prevents the
collapse of lung unit and helps client control
rate and depth of breathing.
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TEST IV - Care of Clients with Physiologic and
Psychosocial Alterations
1. Randy has undergone kidney transplant, what
assessment would prompt Nurse Katrina to
suspect organ rejection?
a. Sudden weight loss
b. Polyuria
c. Hypertension
d. Shock
2. The immediate objective of nursing care for an
overweight, mildly hypertensive male client with
ureteral colic and hematuria is to decrease:
a. Pain
b. Weight
c. Hematuria
d. Hypertension
3. Matilda, with hyperthyroidism is to receive
Lugol’s iodine solution before a subtotal
thyroidectomy is performed. The nurse is aware
that this medication is given to:
a. Decrease the total basal metabolic rate.
b. Maintain the function of the parathyroid
glands.
c. Block the formation of thyroxine by the
thyroid gland.
d. Decrease the size and vascularity of the
thyroid gland.
4. Ricardo, was diagnosed with type I diabetes. The
nurse is aware that acute hypoglycemia also can
develop in the client who is diagnosed with:
a. Liver disease
b. Hypertension
c. Type 2 diabetes
d. Hyperthyroidism
5. Tracy is receiving combination chemotherapy for
treatment of metastatic carcinoma. Nurse Ruby
should monitor the client for the systemic side
effect of:
a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia
6. Norma, with recent colostomy expresses
concern about the inability to control the
passage of gas. Nurse Oliver should suggest that
the client plan to:
a. Eliminate foods high in cellulose.
b. Decrease fluid intake at meal times.
c. Avoid foods that in the past caused
flatus.
d. Adhere to a bland diet prior to social
events.
7. Nurse Ron begins to teach a male client how to
perform colostomy irrigations. The nurse would
evaluate that the instructions were understood
when the client states, “I should:
a. Lie on my left side while instilling the
irrigating solution.”
b. Keep the irrigating container less than
18 inches above the stoma.”
c. Instill a minimum of 1200 ml of irrigating
solution to stimulate evacuation of the
bowel.”
d. Insert the irrigating catheter deeper into
the stoma if cramping occurs during the
procedure.”
8. Patrick is in the oliguric phase of acute tubular
necrosis and is experiencing fluid and electrolyte
imbalances. The client is somewhat confused
and complains of nausea and muscle weakness.
As part of the prescribed therapy to correct this
electrolyte imbalance, the nurse would expect
to:
a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal
saline via I.V.
9. Mario has burn injury. After Forty48 hours, the
physician orders for Mario 2 liters of IV fluid to
be administered q12 h. The drop factor of the
tubing is 10 gtt/ml. The nurse should set the
flow to provide:
a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min
10. Terence suffered from burn injury. Using the rule
of nines, which has the largest percent of burns?
a. Face and neck
b. Right upper arm and penis
c. Right thigh and penis
d. Upper trunk
11. Herbert, a 45 year old construction engineer is
brought to the hospital unconscious after falling
from a 2-story building. When assessing the
client, the nurse would be most concerned if the
assessment revealed:
a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature
12. Nurse Sherry is teaching male client regarding
his permanent artificial pacemaker. Which
information given by the nurse shows her
knowledge deficit about the artificial cardiac
pacemaker?
a. take the pulse rate once a day, in the
morning upon awakening
b. May be allowed to use electrical
appliances
c. Have regular follow up care
d. May engage in contact sports
13. The nurse is ware that the most relevant
knowledge about oxygen administration to a
male client with COPD is
a. Oxygen at 1-2L/min is given to maintain
the hypoxic stimulus for breathing.
b. Hypoxia stimulates the central
chemoreceptors in the medulla that
makes the client breath.
c. Oxygen is administered best using a nonrebreathing mask
d. Blood gases are monitored using a pulse
oximeter.
14. Tonny has undergoes a left thoracotomy and a
partial pneumonectomy. Chest tubes are
inserted, and one-bottle water-seal drainage is
instituted in the operating room. In the
postanesthesia care unit Tonny is placed in
Fowler's position on either his right side or on
his 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 return
15. Kristine is scheduled for a bronchoscopy. When
teaching Kristine what to expect afterward, the
nurse's highest priority of information would be:
a. Food and fluids will be withheld for at
least 2 hours.
b. Warm saline gargles will be done q 2h.
c. Coughing and deep-breathing exercises
will be done q2h.
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d. Only ice chips and cold liquids will be
allowed initially.
16. Nurse Tristan is caring for a male client in acute
renal failure. The nurse should expect hypertonic
glucose, insulin infusions, and sodium
bicarbonate to be used to treat:
a. hypernatremia.
b. hypokalemia.
c. hyperkalemia.
d. hypercalcemia.
17. Ms. X has just been diagnosed with condylomata
acuminata (genital warts). What information is
appropriate to tell this client?
a. This condition puts her at a higher risk
for cervical cancer; therefore, she should
have a Papanicolaou (Pap) smear
annually.
b. The most common treatment is
metronidazole (Flagyl), which should
eradicate the problem within 7 to 10
days.
c. The potential for transmission to her
sexual partner will be eliminated if
condoms are used every time they have
sexual intercourse.
d. The human papillomavirus (HPV), which
causes condylomata acuminata, can't be
transmitted during oral sex.
18. Maritess was recently diagnosed with a
genitourinary problem and is being examined in
the emergency department. When palpating her
kidneys, the nurse should keep which anatomical
fact in mind?
a. The left kidney usually is slightly higher
than the right one.
b. The kidneys are situated just above the
adrenal glands.
c. The average kidney is approximately 5
cm (2") long and 2 to 3 cm (¾" to 1-1/8")
wide.
d. The kidneys lie between the 10th and
12th thoracic vertebrae.
19. Jestoni with chronic renal failure (CRF) is
admitted to the urology unit. The nurse is aware
that the diagnostic test are consistent with CRF if
the result is:
a. Increased pH with decreased hydrogen
ions.
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b. Increased serum levels of potassium,
magnesium, and calcium.
c. Blood urea nitrogen (BUN) 100 mg/dl
and serum creatinine 6.5 mg/ dl.
d. Uric acid analysis 3.5 mg/dl and
phenolsulfonphthalein (PSP) excretion
75%.
20. Katrina has an abnormal result on a
Papanicolaou test. After admitting that she read
her chart while the nurse was out of the room,
Katrina asks what dysplasia means. Which
definition should the nurse provide?
a. Presence of completely undifferentiated
tumor cells that don't resemble cells of
the tissues of their origin.
b. Increase in the number of normal cells in
a normal arrangement in a tissue or an
organ.
c. Replacement of one type of fully
differentiated cell by another in tissues
where the second type normally isn't
found.
d. Alteration in the size, shape, and
organization of differentiated cells.
21. During a routine checkup, Nurse Mariane
assesses a male client with acquired
immunodeficiency syndrome (AIDS) for signs and
symptoms of cancer. What is the most common
AIDS-related cancer?
a. Squamous cell carcinoma
b. Multiple myeloma
c. Leukemia
d. Kaposi's sarcoma
22. Ricardo is scheduled for a prostatectomy, and
the anesthesiologist plans to use a spinal
(subarachnoid) block during surgery. In the
operating room, the nurse positions the client
according to the anesthesiologist's instructions.
Why does the client require special positioning
for this type of anesthesia?
a. To prevent confusion
b. To prevent seizures
c. To prevent cerebrospinal fluid (CSF)
leakage
d. To prevent cardiac arrhythmias
23. A male client had a nephrectomy 2 days ago and
is now complaining of abdominal pressure and
nausea. The first nursing action should be to:
a. Auscultate bowel sounds.
b. Palpate the abdomen.
c. Change the client's position.
d. Insert a rectal tube.
24. Wilfredo with a recent history of rectal bleeding
is being prepared for a colonoscopy. How should
the nurse Patricia position the client for this test
initially?
a. Lying on the right side with legs straight
b. Lying on the left side with knees bent
c. Prone with the torso elevated
d. Bent over with hands touching the floor
25. A male client with inflammatory bowel disease
undergoes an ileostomy. On the first day after
surgery, Nurse Oliver notes that the client's
stoma appears dusky. How should the nurse
interpret this finding?
a. Blood supply to the stoma has been
interrupted.
b. This is a normal finding 1 day after
surgery.
c. The ostomy bag should be adjusted.
d. An intestinal obstruction has occurred.
26. Anthony suffers burns on the legs, which nursing
intervention helps prevent contractures?
a. Applying knee splints
b. Elevating the foot of the bed
c. Hyperextending the client's palms
d. Performing shoulder range-of-motion
exercises
27. Nurse Ron is assessing a client admitted with
second- and third-degree burns on the face,
arms, and chest. Which finding indicates a
potential 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 a
cerebrovascular accident (CVA) is too weak to
move on his own. To help the client avoid
pressure ulcers, Nurse Celia should:
a. Turn him frequently.
b. Perform passive range-of-motion (ROM)
exercises.
c. Reduce the client's fluid intake.
d. Encourage the client to use a footboard.
29. Nurse Maria plans to administer dexamethasone
cream to a female client who has dermatitis over
the anterior chest. How should the nurse apply
this topical agent?
a. With a circular motion, to enhance
absorption.
b. With an upward motion, to increase
blood supply to the affected area
c. In long, even, outward, and downward
strokes in the direction of hair growth
d. In long, even, outward, and upward
strokes in the direction opposite hair
growth
30. Nurse Kate is aware that one of the following
classes of medication protects the ischemic
myocardium by blocking catecholamines and
sympathetic nerve stimulation is:
a. Beta -adrenergic blockers
b. Calcium channel blocker
c. Narcotics
d. Nitrates
31. A male client has jugular distention. On what
position should the nurse place the head of the
bed to obtain the most accurate reading of
jugular vein distention?
a. High Fowler’s
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position
32. The nurse is aware that one of the following
classes of medications maximizes cardiac
performance in clients with heart failure by
increasing ventricular contractility?
a. Beta-adrenergic blockers
b. Calcium channel blocker
c. Diuretics
d. Inotropic agents
33. A male client has a reduced serum high-density
lipoprotein (HDL) level and an elevated lowdensity lipoprotein (LDL) level. Which of the
following dietary modifications is not
appropriate for this client?
a. Fiber intake of 25 to 30 g daily
b. Less than 30% of calories from fat
c. Cholesterol intake of less than 300 mg
daily
d. Less than 10% of calories from saturated
fat
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34. A 37-year-old male client was admitted to the
coronary care unit (CCU) 2 days ago with an
acute myocardial infarction. Which of the
following actions would breach the client
confidentiality?
a. The CCU nurse gives a verbal report to
the nurse on the telemetry unit before
transferring the client to that unit
b. The CCU nurse notifies the on-call
physician about a change in the client’s
condition
c. The emergency department nurse calls
up the latest electrocardiogram results
to check the client’s progress.
d. At the client’s request, the CCU nurse
updates the client’s wife on his condition
35. A male client arriving in the emergency
department is receiving cardiopulmonary
resuscitation from paramedics who are giving
ventilations through an endotracheal (ET) tube
that they placed in the client’s home. During a
pause in compressions, the cardiac monitor
shows narrow QRS complexes and a heart rate
of beats/minute with a palpable pulse. Which of
the following actions should the nurse take first?
a. Start an L.V. line and administer
amiodarone (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 pressure
measures 126/80 mm Hg. Nurse Katrina
determines that mean arterial pressure (MAP) is
which of the following?
a. 46 mm Hg
b. 80 mm Hg
c. 95 mm Hg
d. 90 mm Hg
37. A female client arrives at the emergency
department with chest and stomach pain and a
report of black tarry stool for several months.
Which of the following order should the nurse
Oliver anticipate?
a. Cardiac monitor, oxygen, creatine kinase
and lactate dehydrogenase levels
b. Prothrombin time, partial
thromboplastin time, fibrinogen and
fibrin split product values.
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c. Electrocardiogram, complete blood
count, testing for occult blood,
comprehensive serum metabolic panel.
d. Electroencephalogram, alkaline
phosphatase and aspartate
aminotransferase levels, basic serum
metabolic panel
38. Macario had coronary artery bypass graft (CABG)
surgery 3 days ago. Which of the following
conditions is suspected by the nurse when a
decrease in platelet count from 230,000 ul to
5,000 ul is noted?
a. Pancytopenia
b. Idiopathic thrombocytopemic purpura
(ITP)
c. Disseminated intravascular coagulation
(DIC)
d. Heparin-associated thrombosis and
thrombocytopenia (HATT)
39. Which of the following drugs would be ordered
by the physician to improve the platelet count in
a male client with idiopathic thrombocytopenic
purpura (ITP)?
a. Acetylsalicylic acid (ASA)
b. Corticosteroids
c. Methotrezate
d. Vitamin K
40. A female client is scheduled to receive a heart
valve replacement with a porcine valve. Which
of the following types of transplant is this?
a. Allogeneic
b. Autologous
c. Syngeneic
d. Xenogeneic
41. Marco falls off his bicycle and injuries his ankle.
Which of the following actions shows the initial
response to the injury in the extrinsic pathway?
a. Release of Calcium
b. Release of tissue thromboplastin
c. Conversion of factors XII to factor XIIa
d. Conversion of factor VIII to factor VIIIa
42. Instructions for a client with systemic lupus
erythematosus (SLE) would include information
about which of the following blood dyscrasias?
a. Dressler’s syndrome
b. Polycythemia
c. Essential thrombocytopenia
d. Von Willebrand’s disease
43. The nurse is aware that the following symptom
is most commonly an early indication of stage 1
Hodgkin’s disease?
a. Pericarditis
b. Night sweat
c. Splenomegaly
d. Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of
the following functions must frequently
assessed?
a. Blood pressure
b. Bowel sounds
c. Heart sounds
d. Breath sounds
45. The nurse knows that neurologic complications
of multiple myeloma (MM) usually involve which
of the following body system?
a. Brain
b. Muscle spasm
c. Renal dysfunction
d. Myocardial irritability
46. Nurse Patricia is aware that the average length
of time from human immunodeficiency virus
(HIV) infection to the development of acquired
immunodeficiency syndrome (AIDS)?
a. Less than 5 years
b. 5 to 7 years
c. 10 years
d. More than 10 years
47. An 18-year-old male client admitted with heat
stroke begins to show signs of disseminated
intravascular coagulation (DIC). Which of the
following laboratory findings is most consistent
with DIC?
a. Low platelet count
b. Elevated fibrinogen levels
c. Low levels of fibrin degradation products
d. Reduced prothrombin time
48. Mario comes to the clinic complaining of fever,
drenching night sweats, and unexplained weight
loss over the past 3 months. Physical
examination reveals a single enlarged
supraclavicular lymph node. Which of the
following is the most probable diagnosis?
a. Influenza
b. Sickle cell anemia
c. Leukemia
d. Hodgkin’s disease
49. A male client with a gunshot wound requires an
emergency blood transfusion. His blood type is
AB negative. Which blood type would be the
safest for him to receive?
a. AB Rh-positive
b. A Rh-positive
c. A Rh-negative
d. O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid
leukemia (ALL) and beginning chemotherapy.
50. Stacy is discharged from the hospital following
her chemotherapy treatments. Which statement
of Stacy’s mother indicated that she understands
when she will contact the physician?
a. “I should contact the physician if Stacy
has difficulty in sleeping”.
b. “I will call my doctor if Stacy has
persistent vomiting and diarrhea”.
c. “My physician should be called if Stacy is
irritable and unhappy”.
d. “Should Stacy have continued hair loss, I
need to call the doctor”.
51. Stacy’s mother states to the nurse that it is hard
to see Stacy with no hair. The best response for
the 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 up
your feelings when you are with her or
else she may be upset”.
d. “This is only temporary; Stacy will regrow new hair in 3-6 months, but may
be different in texture”.
52. Stacy has beginning stomatitis. To promote oral
hygiene and comfort, the nurse in-charge
should:
a. Provide frequent mouthwash with
normal saline.
b. Apply viscous Lidocaine to oral ulcers as
needed.
c. Use lemon glycerine swabs every 2
hours.
d. Rinse mouth with Hydrogen Peroxide.
53. During the administration of chemotherapy
agents, Nurse Oliver observed that the IV site is
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red and swollen, when the IV is touched Stacy
shouts in pain. The first nursing action to take is:
a. Notify the physician
b. Flush the IV line with saline solution
c. Immediately discontinue the infusion
d. Apply an ice pack to the site, followed by
warm compress.
54. The term “blue bloater” refers to a male client
which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
55. The term “pink puffer” refers to the female
client with which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
56. Jose is in danger of respiratory arrest following
the administration of a narcotic analgesic. An
arterial blood gas value is obtained. Nurse Oliver
would expect the paco2 to be which of the
following values?
a. 15 mm Hg
b. 30 mm Hg
c. 40 mm Hg
d. 80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as
follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm
Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
represents which of the following conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
58. Norma has started a new drug for hypertension.
Thirty minutes after she takes the drug, she
develops chest tightness and becomes short of
breath and tachypneic. She has a decreased level
of consciousness. These signs indicate which of
the following conditions?
a. Asthma attack
b. Pulmonary embolism
c. Respiratory failure
d. Rheumatoid arthritis
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Situation: Mr. Gonzales was admitted to the hospital
with ascites and jaundice. To rule out cirrhosis of the
liver:
59. Which laboratory test indicates liver cirrhosis?
a. Decreased red blood cell count
b. Decreased serum acid phosphate level
c. Elevated white blood cell count
d. Elevated serum aminotransferase
60. 60.The biopsy of Mr. Gonzales confirms the
diagnosis of cirrhosis. Mr. Gonzales is at
increased risk for excessive bleeding primarily
because of:
a. Impaired clotting mechanism
b. Varix formation
c. Inadequate nutrition
d. Trauma of invasive procedure
61. Mr. Gonzales develops hepatic encephalopathy.
Which clinical manifestation is most common
with this condition?
a. Increased urine output
b. Altered level of consciousness
c. Decreased tendon reflex
d. Hypotension
62. When Mr. Gonzales regained consciousness, the
physician orders 50 ml of Lactose p.o. every 2
hours. Mr. Gozales develops diarrhea. The nurse
best action would be:
a. “I’ll see if your physician is in the
hospital”.
b. “Maybe you’re reacting to the drug; I
will withhold the next dose”.
c. “I’ll lower the dosage as ordered so the
drug causes only 2 to 4 stools a day”.
d. “Frequently, bowel movements are
needed to reduce sodium level”.
63. Which of the following groups of symptoms
indicates a ruptured abdominal aortic
aneurysm?
a. Lower back pain, increased blood
pressure, decreased red blood cell (RBC)
count, increased white blood (WBC)
count.
b. Severe lower back pain, decreased blood
pressure, decreased RBC count,
increased WBC count.
c. Severe lower back pain, decreased blood
pressure, decreased RBC count,
decreased RBC count, decreased WBC
count.
d. Intermitted lower back pain, decreased
blood pressure, decreased RBC count,
increased WBC count.
64. After undergoing a cardiac catheterization, Tracy
has a large puddle of blood under his buttocks.
Which of the following steps should the nurse
take first?
a. Call for help.
b. Obtain vital signs
c. Ask the client to “lift up”
d. Apply gloves and assess the groin site
65. Which of the following treatment is a suitable
surgical intervention for a client with unstable
angina?
a. Cardiac catheterization
b. Echocardiogram
c. Nitroglycerin
d. Percutaneous transluminal coronary
angioplasty (PTCA)
66. The nurse is aware that the following terms used
to describe reduced cardiac output and
perfusion impairment due to ineffective
pumping of the heart is:
a. Anaphylactic shock
b. Cardiogenic shock
c. Distributive shock
d. Myocardial infarction (MI)
67. A client with hypertension asks the nurse which
factors can cause blood pressure to drop to
normal levels?
a. Kidneys’ excretion to sodium only.
b. Kidneys’ retention of sodium and water
c. Kidneys’ excretion of sodium and water
d. Kidneys’ retention of sodium and
excretion of water
68. Nurse Rose is aware that the statement that
best explains why furosemide (Lasix) is
administered to treat hypertension is:
a. It dilates peripheral blood vessels.
b. It decreases sympathetic
cardioacceleration.
c. It inhibits the angiotensin-coverting
enzymes
d. It inhibits reabsorption of sodium and
water in the loop of Henle.
69. Nurse Nikki knows that laboratory results
supports the diagnosis of systemic lupus
erythematosus (SLE) is:
a. Elavated serum complement level
b. Thrombocytosis, elevated sedimentation
rate
c. Pancytopenia, elevated antinuclear
antibody (ANA) titer
d. Leukocysis, elevated blood urea nitrogen
(BUN) and creatinine levels
70. Arnold, a 19-year-old client with a mild
concussion is discharged from the emergency
department. Before discharge, he complains of a
headache. When offered acetaminophen, his
mother tells the nurse the headache is severe
and she would like her son to have something
stronger. Which of the following responses by
the nurse is appropriate?
a. “Your son had a mild concussion,
acetaminophen is strong enough.”
b. “Aspirin is avoided because of the
danger of Reye’s syndrome in children or
young adults.”
c. “Narcotics are avoided after a head
injury because they may hide a
worsening condition.”
d. Stronger medications may lead to
vomiting, which increases the
intracarnial pressure (ICP).”
71. When evaluating an arterial blood gas from a
male client with a subdural hematoma, the
nurse notes the Paco2 is 30 mm Hg. Which of
the following responses best describes the
result?
a. Appropriate; lowering carbon dioxide
(CO2) reduces intracranial pressure (ICP)
b. Emergent; the client is poorly
oxygenated
c. Normal
d. Significant; the client has alveolar
hypoventilation
72. When prioritizing care, which of the following
clients should the nurse Olivia assess first?
a. A 17-year-old client’s 24-hours
postappendectomy
b. A 33-year-old client with a recent
diagnosis of Guillain-Barre syndrome
c. A 50-year-old client 3 days
postmyocardial infarction
d. A 50-year-old client with diverticulitis
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73. JP has been diagnosed with gout and wants to
know why colchicine is used in the treatment of
gout. Which of the following actions of
colchicines explains why it’s effective for gout?
a. Replaces estrogen
b. Decreases infection
c. Decreases inflammation
d. Decreases bone demineralization
74. Norma asks for information about osteoarthritis.
Which of the following statements about
osteoarthritis is correct?
a. Osteoarthritis is rarely debilitating
b. Osteoarthritis is a rare form of arthritis
c. Osteoarthritis is the most common form
of arthritis
d. Osteoarthritis afflicts people over 60
75. Ruby is receiving thyroid replacement therapy
develops the flu and forgets to take her thyroid
replacement medicine. The nurse understands
that skipping this medication will put the client
at risk for developing which of the following lifethreatening complications?
a. Exophthalmos
b. Thyroid storm
c. Myxedema coma
d. Tibial myxedema
76. Nurse Sugar is assessing a client with Cushing's
syndrome. Which observation should the nurse
report to the physician immediately?
a. Pitting edema of the legs
b. An irregular apical pulse
c. Dry mucous membranes
d. Frequent urination
77. Cyrill with severe head trauma sustained in a car
accident is admitted to the intensive care unit.
Thirty-six hours later, the client's urine output
suddenly rises above 200 ml/hour, leading the
nurse to suspect diabetes insipidus. Which
laboratory findings support the nurse's suspicion
of diabetes insipidus?
a. Above-normal urine and serum
osmolality levels
b. Below-normal urine and serum
osmolality levels
c. Above-normal urine osmolality level,
below-normal serum osmolality level
d. Below-normal urine osmolality level,
above-normal serum osmolality level
119
78. Jomari is diagnosed with hyperosmolar
hyperglycemic nonketotic syndrome (HHNS) is
stabilized and prepared for discharge. When
preparing the client for discharge and home
management, which of the following statements
indicates that the client understands her
condition and how to control it?
a. "I can avoid getting sick by not becoming
dehydrated and by paying attention to
my need to urinate, drink, or eat more
than usual."
b. "If I experience trembling, weakness,
and headache, I should drink a glass of
soda that contains sugar."
c. "I will have to monitor my blood glucose
level closely and notify the physician if
it's constantly elevated."
d. "If I begin to feel especially hungry and
thirsty, I'll eat a snack high in
carbohydrates."
79. A 66-year-old client has been complaining of
sleeping more, increased urination, anorexia,
weakness, irritability, depression, and bone pain
that interferes with her going outdoors. Based
on these assessment findings, the nurse would
suspect which of the following disorders?
a. Diabetes mellitus
b. Diabetes insipidus
c. Hypoparathyroidism
d. Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering
from addisonian crisis about the need to take
fludrocortisone acetate and hydrocortisone at
home. Which statement by the client indicates
an understanding of the instructions?
a. "I'll take my hydrocortisone in the late
afternoon, before dinner."
b. "I'll take all of my hydrocortisone in the
morning, right after I wake up."
c. "I'll take two-thirds of the dose when I
wake up and one-third in the late
afternoon."
d. "I'll take the entire dose at bedtime."
81. Which of the following laboratory test results
would suggest to the nurse Len that a client has
a corticotropin-secreting pituitary adenoma?
a. High corticotropin and low cortisol levels
b. Low corticotropin and high cortisol levels
c. High corticotropin and high cortisol
levels
d. Low corticotropin and low cortisol levels
82. A male client is scheduled for a transsphenoidal
hypophysectomy to remove a pituitary tumor.
Preoperatively, the nurse should assess for
potential complications by doing which of the
following?
a. Testing for ketones in the urine
b. Testing urine specific gravity
c. Checking temperature every 4 hours
d. Performing capillary glucose testing
every 4 hours
83. Capillary glucose monitoring is being performed
every 4 hours for a client diagnosed with
diabetic ketoacidosis. Insulin is administered
using a scale of regular insulin according to
glucose results. At 2 p.m., the client has a
capillary glucose level of 250 mg/dl for which he
receives 8 U of regular insulin. Nurse Mariner
should expect the dose's:
a. onset to be at 2 p.m. and its peak to be
at 3 p.m.
b. onset to be at 2:15 p.m. and its peak to
be at 3 p.m.
c. onset to be at 2:30 p.m. and its peak to
be at 4 p.m.
d. onset to be at 4 p.m. and its peak to be
at 6 p.m.
84. The physician orders laboratory tests to confirm
hyperthyroidism in a female client with classic
signs and symptoms of this disorder. Which test
result would confirm the diagnosis?
a. No increase in the thyroid-stimulating
hormone (TSH) level after 30 minutes
during the TSH stimulation test
b. A decreased TSH level
c. An increase in the TSH level after 30
minutes during the TSH stimulation test
d. Below-normal levels of serum
triiodothyronine (T3) and serum
thyroxine (T4) as detected by
radioimmunoassay
85. Rico with diabetes mellitus must learn how to
self-administer insulin. The physician has
prescribed 10 U of U-100 regular insulin and 35
U of U-100 isophane insulin suspension (NPH) to
be taken before breakfast. When teaching the
client how to select and rotate insulin injection
sites, the nurse should provide which
instruction?
a. "Inject insulin into healthy tissue with
large blood vessels and nerves."
b. "Rotate injection sites within the same
anatomic region, not among different
regions."
c. "Administer insulin into areas of scar
tissue or hypotrophy whenever
possible."
d. "Administer insulin into sites above
muscles that you plan to exercise heavily
later that day."
86. Nurse Sarah expects to note an elevated serum
glucose level in a client with hyperosmolar
hyperglycemic nonketotic syndrome (HHNS).
Which other laboratory finding should the nurse
anticipate?
a. Elevated serum acetone level
b. Serum ketone bodies
c. Serum alkalosis
d. Below-normal serum potassium level
87. For a client with Graves' disease, which nursing
intervention promotes comfort?
a. Restricting intake of oral fluids
b. Placing extra blankets on the client's bed
c. Limiting intake of high-carbohydrate
foods
d. Maintaining room temperature in the
low-normal range
88. Patrick is treated in the emergency department
for a Colles' fracture sustained during a fall.
What is a Colles' fracture?
a. Fracture of the distal radius
b. Fracture of the olecranon
c. Fracture of the humerus
d. Fracture of the carpal scaphoid
89. Cleo is diagnosed with osteoporosis. Which
electrolytes are involved in the development of
this disorder?
a. Calcium and sodium
b. Calcium and phosphorous
c. Phosphorous and potassium
d. Potassium and sodium
90. Johnny a firefighter was involved in
extinguishing a house fire and is being treated to
smoke inhalation. He develops severe hypoxia
48 hours after the incident, requiring intubation
and mechanical ventilation. He most likely has
developed which of the following conditions?
120
a. Adult respiratory distress syndrome
(ARDS)
b. Atelectasis
c. Bronchitis
d. Pneumonia
91. A 67-year-old client develops acute shortness of
breath and progressive hypoxia requiring right
femur. The hypoxia was probably caused by
which of the following conditions?
a. Asthma attack
b. Atelectasis
c. Bronchitis
d. Fat embolism
92. A client with shortness of breath has decreased
to absent breath sounds on the right side, from
the apex to the base. Which of the following
conditions would best explain this?
a. Acute asthma
b. Chronic bronchitis
c. Pneumonia
d. Spontaneous pneumothorax
93. A 62-year-old male client was in a motor vehicle
accident as an unrestrained driver. He’s now in
the emergency department complaining of
difficulty of breathing and chest pain. On
auscultation of his lung field, no breath sounds
are present in the upper lobe. This client may
have which of the following conditions?
a. Bronchitis
b. Pneumonia
c. Pneumothorax
d. Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills
the area of the thoracic cavity?
a. The space remains filled with air only
b. The surgeon fills the space with a gel
c. Serous fluids fills the space and
consolidates the region
d. The tissue from the other lung grows
over to the other side
95. Hemoptysis may be present in the client with a
pulmonary embolism because of which of the
following reasons?
a. Alveolar damage in the infracted area
b. Involvement of major blood vessels in
the occluded area
c. Loss of lung parenchyma
d. Loss of lung tissue
121
96. Aldo with a massive pulmonary embolism will
have an arterial blood gas analysis performed to
determine the extent of hypoxia. The acid-base
disorder that may be present is?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22year-old client is admitted with a pneumothorax.
The surgeon inserts a chest tube and attaches it
to a chest drainage system. Bubbling soon
appears in the water seal chamber. Which of the
following is the most likely cause of the
bubbling?
a. Air leak
b. Adequate suction
c. Inadequate suction
d. Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a
postoperative client. The client receives 3,000 ml
of Ringer’s lactate solution IV to run over 24
hours. The IV infusion set has a drop factor of 10
drops per milliliter. The nurse should regulate
the client’s IV to deliver how many drops per
minute?
a. 18
b. 21
c. 35
d. 40
99. Mickey, a 6-year-old child with a congenital
heart disorder is admitted with congestive heart
failure. Digoxin (lanoxin) 0.12 mg is ordered for
the child. The bottle of Lanoxin contains .05 mg
of Lanoxin in 1 ml of solution. What amount
should the nurse administer to the child?
a. 1.2 ml
b. 2.4 ml
c. 3.5 ml
d. 4.2 ml
100. Nurse Alexandra teaches a client about elastic
stockings. Which of the following statements,
if made by the client, indicates to the nurse
that the teaching was successful?
a. “I will wear the stockings until the
physician tells me to remove them.”
b. “I should wear the stockings even when I
am sleep.”
c. “Every four hours I should remove the
stockings for a half hour.”
d. “I should put on the stockings before
getting out of bed in the morning.”
Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations
1.
2.
3.
4.
5.
6.
7.
8.
9.
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Answer: (C) Hypertension
Rationale: Hypertension, along with fever,
and tenderness over the grafted kidney,
reflects acute rejection.
Answer: (A) Pain
Rationale: Sharp, severe pain (renal colic)
radiating toward the genitalia and thigh is
caused by uretheral distention and
smooth muscle spasm; relief form pain is
the priority.
Answer: (D) Decrease the size and
vascularity of the thyroid gland.
Rationale: Lugol’s solution provides
iodine, which aids in decreasing the
vascularity of the thyroid gland, which
limits the risk of hemorrhage when
surgery is performed.
Answer: (A) Liver Disease
Rationale: The client with liver disease has
a decreased ability to metabolize
carbohydrates because of a decreased
ability to form glycogen (glycogenesis) and
to form glucose from glycogen.
Answer: (C) Leukopenia
Rationale: Leukopenia, a reduction in
WBCs, is a systemic effect of
chemotherapy as a result of
myelosuppression.
Answer: (C) Avoid foods that in the past
caused flatus.
Rationale: Foods that bothered a person
preoperatively will continue to do so after
a colostomy.
Answer: (B) Keep the irrigating container
less than 18 inches above the stoma.”
Rationale: This height permits the solution
to flow slowly with little force so that
excessive peristalsis is not immediately
precipitated.
Answer: (A) Administer Kayexalate
Rationale: Kayexalate,a potassium
exchange resin, permits sodium to be
exchanged for potassium in the intestine,
reducing the serum potassium level.
Answer:(B) 28 gtt/min
Rationale: This is the correct flow rate;
multiply the amount to be infused (2000
ml) by the drop factor (10) and divide the
result by the amount of time in minutes
(12 hours x 60 minutes)
10.
11.
12.
13.
14.
15.
16.
Answer: (D) Upper trunk
Rationale: The percentage designated for
each burned part of the body using the
rule of nines: Head and neck 9%; Right
upper extremity 9%; Left upper extremity
9%; Anterior trunk 18%; Posterior trunk
18%; Right lower extremity 18%; Left
lower extremity 18%; Perineum 1%.
Answer: (C) Bleeding from ears
Rationale: The nurse needs to perform a
thorough assessment that could indicate
alterations in cerebral function, increased
intracranial pressures, fractures and
bleeding. Bleeding from the ears occurs
only with basal skull fractures that can
easily contribute to increased intracranial
pressure and brain herniation.
Answer: (D) may engage in contact sports
Rationale: The client should be advised by
the nurse to avoid contact sports. This will
prevent trauma to the area of the
pacemaker generator.
Answer: (A) Oxygen at 1-2L/min is given to
maintain the hypoxic stimulus for
breathing.
Rationale: COPD causes a chronic CO2
retention that renders the medulla
insensitive to the CO2 stimulation for
breathing. The hypoxic state of the client
then becomes the stimulus for breathing.
Giving the client oxygen in low
concentrations will maintain the client’s
hypoxic drive.
Answer: (B) Facilitate ventilation of the
left lung.
Rationale: Since only a partial
pneumonectomy is done, there is a need
to promote expansion of this remaining
Left lung by positioning the client on the
opposite unoperated side.
Answer: (A) Food and fluids will be
withheld for at least 2 hours.
Rationale: Prior to bronchoscopy, the
doctors sprays the back of the throat with
anesthetic to minimize the gag reflex and
thus facilitate the insertion of the
bronchoscope. Giving the client food and
drink after the procedure without
checking on the return of the gag reflex
can cause the client to aspirate. The gag
reflex usually returns after two hours.
Answer: (C) hyperkalemia.
123
17.
18.
19.
Rationale: Hyperkalemia is a common
complication of acute renal failure. It's
life-threatening if immediate action isn't
taken to reverse it. The administration of
glucose and regular insulin, with sodium
bicarbonate if necessary, can temporarily
prevent cardiac arrest by moving
potassium into the cells and temporarily
reducing serum potassium levels.
Hypernatremia, hypokalemia, and
hypercalcemia don't usually occur with
acute renal failure and aren't treated with
glucose, insulin, or sodium bicarbonate.
Answer: (A) This condition puts her at a
higher risk for cervical cancer; therefore,
she should have a Papanicolaou (Pap)
smear annually.
Rationale: Women with condylomata
acuminata are at risk for cancer of the
cervix and vulva. Yearly Pap smears are
very important for early detection.
Because condylomata acuminata is a
virus, there is no permanent cure.
Because condylomata acuminata can
occur on the vulva, a condom won't
protect sexual partners. HPV can be
transmitted to other parts of the body,
such as the mouth, oropharynx, and
larynx.
Answer: (A) The left kidney usually is
slightly higher than the right one.
Rationale: The left kidney usually is
slightly higher than the right one. An
adrenal gland lies atop each kidney. The
average kidney measures approximately
11 cm (4-3/8") long, 5 to 5.8 cm (2" to
2¼") wide, and 2.5 cm (1") thick. The
kidneys are located retroperitoneally, in
the posterior aspect of the abdomen, on
either side of the vertebral column. They
lie between the 12th thoracic and 3rd
lumbar vertebrae.
Answer: (C) Blood urea nitrogen (BUN)
100 mg/dl and serum creatinine 6.5mg/dl.
Rationale: The normal BUN level ranges 8
to 23 mg/dl; the normal serum creatinine
level ranges from 0.7 to 1.5 mg/dl. The
test results in option C are abnormally
elevated, reflecting CRF and the kidneys'
decreased ability to remove nonprotein
nitrogen waste from the blood. CRF
causes decreased pH and increased
hydrogen ions — not vice versa. CRF also
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increases serum levels of potassium,
magnesium, and phosphorous, and
decreases serum levels of calcium. A uric
acid analysis of 3.5 mg/dl falls within the
normal range of 2.7 to 7.7 mg/dl; PSP
excretion of 75% also falls with the normal
range of 60% to 75%.
Answer: (D) Alteration in the size, shape,
and organization of differentiated cells
Rationale: Dysplasia refers to an alteration
in the size, shape, and organization of
differentiated cells. The presence of
completely undifferentiated tumor cells
that don't resemble cells of the tissues of
their origin is called anaplasia. An increase
in the number of normal cells in a normal
arrangement in a tissue or an organ is
called hyperplasia. Replacement of one
type of fully differentiated cell by another
in tissues where the second type normally
isn't found is called metaplasia.
Answer: (D) Kaposi's sarcoma
Rationale: Kaposi's sarcoma is the most
common cancer associated with AIDS.
Squamous cell carcinoma, multiple
myeloma, and leukemia may occur in
anyone and aren't associated specifically
with AIDS.
Answer: (C) To prevent cerebrospinal fluid
(CSF) leakage
Rationale: The client receiving a
subarachnoid block requires special
positioning to prevent CSF leakage and
headache and to ensure proper anesthetic
distribution. Proper positioning doesn't
help prevent confusion, seizures, or
cardiac arrhythmias.
Answer: (A) Auscultate bowel sounds.
Rationale: If abdominal distention is
accompanied by nausea, the nurse must
first auscultate bowel sounds. If bowel
sounds are absent, the nurse should
suspect gastric or small intestine dilation
and these findings must be reported to
the physician. Palpation should be
avoided postoperatively with abdominal
distention. If peristalsis is absent,
changing positions and inserting a rectal
tube won't relieve the client's discomfort.
Answer: (B) Lying on the left side with
knees bent
Rationale: For a colonoscopy, the nurse
initially should position the client on the
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left side with knees bent. Placing the
client on the right side with legs straight,
prone with the torso elevated, or bent
over with hands touching the floor
wouldn't allow proper visualization of the
large intestine.
Answer: (A) Blood supply to the stoma has
been interrupted
Rationale: An ileostomy stoma forms as
the ileum is brought through the
abdominal wall to the surface skin,
creating an artificial opening for waste
elimination. The stoma should appear
cherry red, indicating adequate arterial
perfusion. A dusky stoma suggests
decreased perfusion, which may result
from interruption of the stoma's blood
supply and may lead to tissue damage or
necrosis. A dusky stoma isn't a normal
finding. Adjusting the ostomy bag
wouldn't affect stoma color, which
depends on blood supply to the area. An
intestinal obstruction also wouldn't
change stoma color.
Answer: (A) Applying knee splints
Rationale: Applying knee splints prevents
leg contractures by holding the joints in a
position of function. Elevating the foot of
the bed can't prevent contractures
because this action doesn't hold the joints
in a position of function. Hyperextending a
body part for an extended time is
inappropriate because it can cause
contractures. Performing shoulder rangeof-motion exercises can prevent
contractures in the shoulders, but not in
the legs.
Answer: (B) Urine output of 20 ml/hour.
Rationale: A urine output of less than 40
ml/hour in a client with burns indicates a
fluid volume deficit. This client's PaO2
value falls within the normal range (80 to
100 mm Hg). White pulmonary secretions
also are normal. The client's rectal
temperature isn't significantly elevated
and probably results from the fluid
volume deficit.
Answer: (A) Turn him frequently.
Rationale: The most important
intervention to prevent pressure ulcers is
frequent position changes, which relieve
pressure on the skin and underlying
tissues. If pressure isn't relieved,
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capillaries become occluded, reducing
circulation and oxygenation of the tissues
and resulting in cell death and ulcer
formation. During passive ROM exercises,
the nurse moves each joint through its
range of movement, which improves joint
mobility and circulation to the affected
area but doesn't prevent pressure ulcers.
Adequate hydration is necessary to
maintain healthy skin and ensure tissue
repair. A footboard prevents plantar
flexion and footdrop by maintaining the
foot in a dorsiflexed position.
Answer: (C) In long, even, outward, and
downward strokes in the direction of hair
growth
Rationale: When applying a topical agent,
the nurse should begin at the midline and
use long, even, outward, and downward
strokes in the direction of hair growth.
This application pattern reduces the risk
of follicle irritation and skin inflammation.
Answer: (A) Beta -adrenergic blockers
Rationale: Beta-adrenergic blockers work
by blocking beta receptors in the
myocardium, reducing the response to
catecholamines and sympathetic nerve
stimulation. They protect the
myocardium, helping to reduce the risk of
another infraction by decreasing
myocardial oxygen demand. Calcium
channel blockers reduce the workload of
the heart by decreasing the heart rate.
Narcotics reduce myocardial oxygen
demand, promote vasodilation, and
decrease anxiety. Nitrates reduce
myocardial oxygen consumption bt
decreasing left ventricular end diastolic
pressure (preload) and systemic vascular
resistance (afterload).
Answer: (C) Raised 30 degrees
Rationale: Jugular venous pressure is
measured with a centimeter ruler to
obtain the vertical distance between the
sternal angle and the point of highest
pulsation with the head of the bed
inclined between 15 to 30 degrees.
Increased pressure can’t be seen when
the client is supine or when the head of
the bed is raised 10 degrees because the
point that marks the pressure level is
above the jaw (therefore, not visible). In
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high Fowler’s position, the veins would be
barely discernible above the clavicle.
Answer: (D) Inotropic agents
Rationale: Inotropic agents are
administered to increase the force of the
heart’s contractions, thereby increasing
ventricular contractility and ultimately
increasing cardiac output. Beta-adrenergic
blockers and calcium channel blockers
decrease the heart rate and ultimately
decreased the workload of the heart.
Diuretics are administered to decrease the
overall vascular volume, also decreasing
the workload of the heart.
Answer: (B) Less than 30% of calories from
fat
Rationale: A client with low serum HDL
and high serum LDL levels should get less
than 30% of daily calories from fat. The
other modifications are appropriate for
this client.
Answer: (C) The emergency department
nurse calls up the latest electrocardiogram
results to check the client’s progress
Rationale: The emergency department
nurse is no longer directly involved with
the client’s care and thus has no legal
right to information about his present
condition. Anyone directly involved in his
care (such as the telemetry nurse and the
on-call physician) has the right to
information about his condition. Because
the client requested that the nurse update
his wife on his condition, doing so doesn’t
breach confidentiality.
Answer: (B) Check endotracheal tube
placement.
Rationale: ET tube placement should be
confirmed as soon as the client arrives in
the emergency department. Once the
airways is secured, oxygenation and
ventilation should be confirmed using an
end-tidal carbon dioxide monitor and
pulse oximetry. Next, the nurse should
make sure L.V. access is established. If the
client experiences symptomatic
bradycardia, atropine is administered as
ordered 0.5 to 1 mg every 3 to 5 minutes
to a total of 3 mg. Then the nurse should
try to find the cause of the client’s arrest
by obtaining an ABG sample. Amiodarone
is indicated for ventricular tachycardia,
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ventricular fibrillation and atrial flutter –
not symptomatic bradycardia.
Answer: (C) 95 mm Hg
Rationale: Use the following formula to
calculate MAP
MAP = systolic + 2 (diastolic)
3
MAP=126 mm Hg + 2 (80 mm Hg)
3
MAP=286 mm HG
3
MAP=95 mm Hg
Answer: (C) Electrocardiogram, complete
blood count, testing for occult blood,
comprehensive serum metabolic panel.
Rationale: An electrocardiogram evaluates
the complaints of chest pain, laboratory
tests determines anemia, and the stool
test for occult blood determines blood in
the stool. Cardiac monitoring, oxygen, and
creatine kinase and lactate
dehydrogenase levels are appropriate for
a cardiac primary problem. A basic
metabolic panel and alkaline phosphatase
and aspartate aminotransferase levels
assess liver function. Prothrombin time,
partial thromboplastin time, fibrinogen
and fibrin split products are measured to
verify bleeding dyscrasias; an
electroencephalogram evaluates brain
electrical activity.
Answer: (D) Heparin-associated
thrombosis and thrombocytopenia (HATT)
Rationale: HATT may occur after CABG
surgery due to heparin use during surgery.
Although DIC and ITP cause platelet
aggregation and bleeding, neither is
common in a client after revascularization
surgery. Pancytopenia is a reduction in all
blood cells.
Answer: (B) Corticosteroids
Rationale: Corticosteroid therapy can
decrease antibody production and
phagocytosis of the antibody-coated
platelets, retaining more functioning
platelets. Methotrexate can cause
thrombocytopenia. Vitamin K is used to
treat an excessive anticoagulate state
from warfarin overload, and ASA
decreases platelet aggregation.
Answer: (D) Xenogeneic
Rationale: An xenogeneic transplant is
between is between human and another
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species. A syngeneic transplant is between
identical twins, allogeneic transplant is
between two humans, and autologous is a
transplant from the same individual.
Answer: (B)
Rationale: Tissue thromboplastin is
released when damaged tissue comes in
contact with clotting factors. Calcium is
released to assist the conversion of
factors X to Xa. Conversion of factors XII to
XIIa and VIII to IIIa are part of the intrinsic
pathway.
Answer: (C) Essential thrombocytopenia
Rationale: Essential thrombocytopenia is
linked to immunologic disorders, such as
SLE and human immunodeficiency virus.
The disorder known as von Willebrand’s
disease is a type of hemophilia and isn’t
linked to SLE. Moderate to severe anemia
is associated with SLE, not polycythemia.
Dressler’s syndrome is pericarditis that
occurs after a myocardial infarction and
isn’t linked to SLE.
Answer: (B) Night sweat
Rationale: In stage 1, symptoms include a
single enlarged lymph node (usually),
unexplained fever, night sweats, malaise,
and generalized pruritis. Although
splenomegaly may be present in some
clients, night sweats are generally more
prevalent. Pericarditis isn’t associated
with Hodgkin’s disease, nor is
hypothermia. Moreover, splenomegaly
and pericarditis aren’t symptoms.
Persistent hypothermia is associated with
Hodgkin’s but isn’t an early sign of the
disease.
Answer: (D) Breath sounds
Rationale: Pneumonia, both viral and
fungal, is a common cause of death in
clients with neutropenia, so frequent
assessment of respiratory rate and breath
sounds is required. Although assessing
blood pressure, bowel sounds, and heart
sounds is important, it won’t help detect
pneumonia.
Answer: (B) Muscle spasm
Rationale: Back pain or paresthesia in the
lower extremities may indicate impending
spinal cord compression from a spinal
tumor. This should be recognized and
treated promptly as progression of the
tumor may result in paraplegia. The other
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options, which reflect parts of the nervous
system, aren’t usually affected by MM.
Answer: (C) 10 years
Rationale: Epidermiologic studies show
the average time from initial contact with
HIV to the development of AIDS is 10
years.
Answer: (A) Low platelet count
Rationale: In DIC, platelets and clotting
factors are consumed, resulting in
microthrombi and excessive bleeding. As
clots form, fibrinogen levels decrease and
the prothrombin time increases. Fibrin
degeneration products increase as
fibrinolysis takes places.
Answer: (D) Hodgkin’s disease
Rationale: Hodgkin’s disease typically
causes fever night sweats, weight loss,
and lymph mode enlargement. Influenza
doesn’t last for months. Clients with sickle
cell anemia manifest signs and symptoms
of chronic anemia with pallor of the
mucous membrane, fatigue, and
decreased tolerance for exercise; they
don’t show fever, night sweats, weight
loss or lymph node enlargement.
Leukemia doesn’t cause lymph node
enlargement.
Answer: (C) A Rh-negative
Rationale: Human blood can sometimes
contain an inherited D antigen. Persons
with the D antigen have Rh-positive blood
type; those lacking the antigen have Rhnegative blood. It’s important that a
person with Rh- negative blood receives
Rh-negative blood. If Rh-positive blood is
administered to an Rh-negative person,
the recipient develops anti-Rh agglutinins,
and sub sequent transfusions with Rhpositive blood may cause serious
reactions with clumping and hemolysis of
red blood cells.
Answer: (B) “I will call my doctor if Stacy
has persistent vomiting and diarrhea”.
Rationale: Persistent (more than 24 hours)
vomiting, anorexia, and diarrhea are signs
of toxicity and the patient should stop the
medication and notify the health care
provider. The other manifestations are
expected side effects of chemotherapy.
Answer: (D) “This is only temporary; Stacy
will re-grow new hair in 3-6 months, but
may be different in texture”.
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Rationale: This is the appropriate
response. The nurse should help the
mother how to cope with her own feelings
regarding the child’s disease so as not to
affect the child negatively. When the hair
grows back, it is still of the same color and
texture.
Answer: (B) Apply viscous Lidocaine to
oral ulcers as needed.
Rationale: Stomatitis can cause pain and
this can be relieved by applying topical
anesthetics such as lidocaine before
mouth care. When the patient is already
comfortable, the nurse can proceed with
providing the patient with oral rinses of
saline solution mixed with equal part of
water or hydrogen peroxide mixed water
in 1:3 concentrations to promote oral
hygiene. Every 2-4 hours.
Answer: (C) Immediately discontinue the
infusion
Rationale: Edema or swelling at the IV site
is a sign that the needle has been
dislodged and the IV solution is leaking
into the tissues causing the edema. The
patient feels pain as the nerves are
irritated by pressure and the IV solution.
The first action of the nurse would be to
discontinue the infusion right away to
prevent further edema and other
complication.
Answer: (C) Chronic obstructive bronchitis
Rationale: Clients with chronic obstructive
bronchitis appear bloated; they have large
barrel chest and peripheral edema,
cyanotic nail beds, and at times,
circumoral cyanosis. Clients with ARDS are
acutely short of breath and frequently
need intubation for mechanical ventilation
and large amount of oxygen. Clients with
asthma don’t exhibit characteristics of
chronic disease, and clients with
emphysema appear pink and cachectic.
Answer: (D) Emphysema
Rationale: Because of the large amount of
energy it takes to breathe, clients with
emphysema are usually cachectic. They’re
pink and usually breathe through pursed
lips, hence the term “puffer.” Clients with
ARDS are usually acutely short of breath.
Clients with asthma don’t have any
particular characteristics, and clients with
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chronic obstructive bronchitis are bloated
and cyanotic in appearance.
Answer: D 80 mm Hg
Rationale: A client about to go into
respiratory arrest will have inefficient
ventilation and will be retaining carbon
dioxide. The value expected would be
around 80 mm Hg. All other values are
lower than expected.
Answer: (C) Respiratory acidosis
Rationale: Because Paco2 is high at 80 mm
Hg and the metabolic measure, HCO3- is
normal, the client has respiratory acidosis.
The pH is less than 7.35, academic, which
eliminates metabolic and respiratory
alkalosis as possibilities. If the HCO3- was
below 22 mEq/L the client would have
metabolic acidosis.
Answer: (C) Respiratory failure
Rationale: The client was reacting to the
drug with respiratory signs of impending
anaphylaxis, which could lead to
eventually respiratory failure. Although
the signs are also related to an asthma
attack or a pulmonary embolism, consider
the new drug first. Rheumatoid arthritis
doesn’t manifest these signs.
Answer: (D) Elevated serum
aminotransferase
Rationale: Hepatic cell death causes
release of liver enzymes alanine
aminotransferase (ALT), aspartate
aminotransferase (AST) and lactate
dehydrogenase (LDH) into the circulation.
Liver cirrhosis is a chronic and irreversible
disease of the liver characterized by
generalized inflammation and fibrosis of
the liver tissues.
Answer: (A) Impaired clotting mechanism
Rationale: Cirrhosis of the liver results in
decreased Vitamin K absorption and
formation of clotting factors resulting in
impaired clotting mechanism.
Answer: (B) Altered level of consciousness
Rationale: Changes in behavior and level
of consciousness are the first sins of
hepatic encephalopathy. Hepatic
encephalopathy is caused by liver failure
and develops when the liver is unable to
convert protein metabolic product
ammonia to urea. This results in
accumulation of ammonia and other toxic
in the blood that damages the cells.
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Answer: (C) “I’ll lower the dosage as
ordered so the drug causes only 2 to 4
stools a day”.
Rationale: Lactulose is given to a patients
with hepatic encephalopathy to reduce
absorption of ammonia in the intestines
by binding with ammonia and promoting
more frequent bowel movements. If the
patient experience diarrhea, it indicates
over dosage and the nurse must reduce
the amount of medication given to the
patient. The stool will be mashy or soft.
Lactulose is also very sweet and may
cause cramping and bloating.
Answer: (B) Severe lower back pain,
decreased blood pressure, decreased RBC
count, increased WBC count.
Rationale: Severe lower back pain
indicates an aneurysm rupture, secondary
to pressure being applied within the
abdominal cavity. When ruptured occurs,
the pain is constant because it can’t be
alleviated until the aneurysm is repaired.
Blood pressure decreases due to the loss
of blood. After the aneurysm ruptures, the
vasculature is interrupted and blood
volume is lost, so blood pressure wouldn’t
increase. For the same reason, the RBC
count is decreased – not increased. The
WBC count increases as cell migrate to the
site of injury.
Answer: (D) Apply gloves and assess the
groin site
Rationale: Observing standard precautions
is the first priority when dealing with any
blood fluid. Assessment of the groin site is
the second priority. This establishes where
the blood is coming from and determines
how much blood has been lost. The goal in
this situation is to stop the bleeding. The
nurse would call for help if it were
warranted after the assessment of the
situation. After determining the extent of
the bleeding, vital signs assessment is
important. The nurse should never move
the client, in case a clot has formed.
Moving can disturb the clot and cause
rebleeding.
Answer: (D) Percutaneous transluminal
coronary angioplasty (PTCA)
Rationale: PTCA can alleviate the blockage
and restore blood flow and oxygenation.
An echocardiogram is a noninvasive
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diagnosis test. Nitroglycerin is an oral
sublingual medication. Cardiac
catheterization is a diagnostic tool – not a
treatment.
Answer: (B) Cardiogenic shock
Rationale: Cardiogenic shock is shock
related to ineffective pumping of the
heart. Anaphylactic shock results from an
allergic reaction. Distributive shock results
from changes in the intravascular volume
distribution and is usually associated with
increased cardiac output. MI isn’t a shock
state, though a severe MI can lead to
shock.
Answer: (C) Kidneys’ excretion of sodium
and water
Rationale: The kidneys respond to rise in
blood pressure by excreting sodium and
excess water. This response ultimately
affects sysmolic blood pressure by
regulating blood volume. Sodium or water
retention would only further increase
blood pressure. Sodium and water travel
together across the membrane in the
kidneys; one can’t travel without the
other.
Answer: (D) It inhibits reabsorption of
sodium and water in the loop of Henle.
Rationale: Furosemide is a loop diuretic
that inhibits sodium and water
reabsorption in the loop Henle, thereby
causing a decrease in blood pressure.
Vasodilators cause dilation of peripheral
blood vessels, directly relaxing vascular
smooth muscle and decreasing blood
pressure. Adrenergic blockers decrease
sympathetic cardioacceleration and
decrease blood pressure. Angiotensinconverting enzyme inhibitors decrease
blood pressure due to their action on
angiotensin.
Answer: (C) Pancytopenia, elevated
antinuclear antibody (ANA) titer
Rationale: Laboratory findings for clients
with SLE usually show pancytopenia,
elevated ANA titer, and decreased serum
complement levels. Clients may have
elevated BUN and creatinine levels from
nephritis, but the increase does not
indicate SLE.
Answer: (C) Narcotics are avoided after a
head injury because they may hide a
worsening condition.
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Rationale: Narcotics may mask changes in
the level of consciousness that indicate
increased ICP and shouldn’t
acetaminophen is strong enough ignores
the mother’s question and therefore isn’t
appropriate. Aspirin is contraindicated in
conditions that may have bleeding, such
as trauma, and for children or young
adults with viral illnesses due to the
danger of Reye’s syndrome. Stronger
medications may not necessarily lead to
vomiting but will sedate the client,
thereby masking changes in his level of
consciousness.
Answer: (A) Appropriate; lowering carbon
dioxide (CO2) reduces intracranial
pressure (ICP)
Rationale: A normal Paco2 value is 35 to
45 mm Hg CO2 has vasodilating
properties; therefore, lowering Paco2
through hyperventilation will lower ICP
caused by dilated cerebral vessels.
Oxygenation is evaluated through Pao2
and oxygen saturation. Alveolar
hypoventilation would be reflected in an
increased Paco2.
Answer: (B) A 33-year-old client with a
recent diagnosis of Guillain-Barre
syndrome
Rationale: Guillain-Barre syndrome is
characterized by ascending paralysis and
potential respiratory failure. The order of
client assessment should follow client
priorities, with disorder of airways,
breathing, and then circulation. There’s no
information to suggest the postmyocardial
infarction client has an arrhythmia or
other complication. There’s no evidence
to suggest hemorrhage or perforation for
the remaining clients as a priority of care.
Answer: (C) Decreases inflammation
Rationale: Then action of colchicines is to
decrease inflammation by reducing the
migration of leukocytes to synovial fluid.
Colchicine doesn’t replace estrogen,
decrease infection, or decrease bone
demineralization.
Answer: (C) Osteoarthritis is the most
common form of arthritis
Rationale: Osteoarthritis is the most
common form of arthritis and can be
extremely debilitating. It can afflict people
of any age, although most are elderly.
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Answer: (C) Myxedema coma
Rationale: Myxedema coma, severe
hypothyroidism, is a life-threatening
condition that may develop if thyroid
replacement medication isn't taken.
Exophthalmos, protrusion of the eyeballs,
is seen with hyperthyroidism. Thyroid
storm is life-threatening but is caused by
severe hyperthyroidism. Tibial myxedema,
peripheral mucinous edema involving the
lower leg, is associated with
hypothyroidism but isn't life-threatening.
Answer: (B) An irregular apical pulse
Rationale: Because Cushing's syndrome
causes aldosterone overproduction, which
increases urinary potassium loss, the
disorder may lead to hypokalemia.
Therefore, the nurse should immediately
report signs and symptoms of
hypokalemia, such as an irregular apical
pulse, to the physician. Edema is an
expected finding because aldosterone
overproduction causes sodium and fluid
retention. Dry mucous membranes and
frequent urination signal dehydration,
which isn't associated with Cushing's
syndrome.
Answer: (D) Below-normal urine
osmolality level, above-normal serum
osmolality level
Rationale: In diabetes insipidus, excessive
polyuria causes dilute urine, resulting in a
below-normal urine osmolality level. At
the same time, polyuria depletes the body
of water, causing dehydration that leads
to an above-normal serum osmolality
level. For the same reasons, diabetes
insipidus doesn't cause above-normal
urine osmolality or below-normal serum
osmolality levels.
Answer: (A) "I can avoid getting sick by not
becoming dehydrated and by paying
attention to my need to urinate, drink, or
eat more than usual."
Rationale: Inadequate fluid intake during
hyperglycemic episodes often leads to
HHNS. By recognizing the signs of
hyperglycemia (polyuria, polydipsia, and
polyphagia) and increasing fluid intake,
the client may prevent HHNS. Drinking a
glass of nondiet soda would be
appropriate for hypoglycemia. A client
whose diabetes is controlled with oral
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antidiabetic agents usually doesn't need
to monitor blood glucose levels. A highcarbohydrate diet would exacerbate the
client's condition, particularly if fluid
intake is low.
Answer: (D) Hyperparathyroidism
Rationale: Hyperparathyroidism is most
common in older women and is
characterized by bone pain and weakness
from excess parathyroid hormone (PTH).
Clients also exhibit hypercaliuria-causing
polyuria. While clients with diabetes
mellitus and diabetes insipidus also have
polyuria, they don't have bone pain and
increased sleeping. Hypoparathyroidism is
characterized by urinary frequency rather
than polyuria.
Answer: (C) "I'll take two-thirds of the
dose when I wake up and one-third in the
late afternoon."
Rationale: Hydrocortisone, a
glucocorticoid, should be administered
according to a schedule that closely
reflects the bodies own secretion of this
hormone; therefore, two-thirds of the
dose of hydrocortisone should be taken in
the morning and one-third in the late
afternoon. This dosage schedule reduces
adverse effects.
Answer: (C) High corticotropin and high
cortisol levels
Rationale: A corticotropin-secreting
pituitary tumor would cause high
corticotropin and high cortisol levels. A
high corticotropin level with a low cortisol
level and a low corticotropin level with a
low cortisol level would be associated
with hypocortisolism. Low corticotropin
and high cortisol levels would be seen if
there was a primary defect in the adrenal
glands.
Answer: (D) Performing capillary glucose
testing every 4 hours
Rationale: The nurse should perform
capillary glucose testing every 4 hours
because excess cortisol may cause insulin
resistance, placing the client at risk for
hyperglycemia. Urine ketone testing isn't
indicated because the client does secrete
insulin and, therefore, isn't at risk for
ketosis. Urine specific gravity isn't
indicated because although fluid balance
can be compromised, it usually isn't
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dangerously imbalanced. Temperature
regulation may be affected by excess
cortisol and isn't an accurate indicator of
infection.
Answer: (C) onset to be at 2:30 p.m. and
its peak to be at 4 p.m.
Rationale: Regular insulin, which is a
short-acting insulin, has an onset of 15 to
30 minutes and a peak of 2 to 4 hours.
Because the nurse gave the insulin at 2
p.m., the expected onset would be from
2:15 p.m. to 2:30 p.m. and the peak from
4 p.m. to 6 p.m.
Answer: (A) No increase in the thyroidstimulating hormone (TSH) level after 30
minutes during the TSH stimulation test
Rationale: In the TSH test, failure of the
TSH level to rise after 30 minutes confirms
hyperthyroidism. A decreased TSH level
indicates a pituitary deficiency of this
hormone. Below-normal levels of T3 and
T4, as detected by radioimmunoassay,
signal hypothyroidism. A below-normal T4
level also occurs in malnutrition and liver
disease and may result from
administration of phenytoin and certain
other drugs.
Answer: (B) "Rotate injection sites within
the same anatomic region, not among
different regions."
Rationale: The nurse should instruct the
client to rotate injection sites within the
same anatomic region. Rotating sites
among different regions may cause
excessive day-to-day variations in the
blood glucose level; also, insulin
absorption differs from one region to the
next. Insulin should be injected only into
healthy tissue lacking large blood vessels,
nerves, or scar tissue or other deviations.
Injecting insulin into areas of hypertrophy
may delay absorption. The client shouldn't
inject insulin into areas of lipodystrophy
(such as hypertrophy or atrophy); to
prevent lipodystrophy, the client should
rotate injection sites systematically.
Exercise speeds drug absorption, so the
client shouldn't inject insulin into sites
above muscles that will be exercised
heavily.
Answer: (D) Below-normal serum
potassium level
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87.
88.
89.
90.
91.
Rationale: A client with HHNS has an
overall body deficit of potassium resulting
from diuresis, which occurs secondary to
the hyperosmolar, hyperglycemic state
caused by the relative insulin deficiency.
An elevated serum acetone level and
serum ketone bodies are characteristic of
diabetic ketoacidosis. Metabolic acidosis,
not serum alkalosis, may occur in HHNS.
Answer: (D) Maintaining room
temperature in the low-normal range
Rationale: Graves' disease causes signs
and symptoms of hypermetabolism, such
as heat intolerance, diaphoresis, excessive
thirst and appetite, and weight loss. To
reduce heat intolerance and diaphoresis,
the nurse should keep the client's room
temperature in the low-normal range. To
replace fluids lost via diaphoresis, the
nurse should encourage, not restrict,
intake of oral fluids. Placing extra blankets
on the bed of a client with heat
intolerance would cause discomfort. To
provide needed energy and calories, the
nurse should encourage the client to eat
high-carbohydrate foods.
Answer: (A) Fracture of the distal radius
Rationale: Colles' fracture is a fracture of
the distal radius, such as from a fall on an
outstretched hand. It's most common in
women. Colles' fracture doesn't refer to a
fracture of the olecranon, humerus, or
carpal scaphoid.
Answer: (B) Calcium and phosphorous
Rationale: In osteoporosis, bones lose
calcium and phosphate salts, becoming
porous, brittle, and abnormally vulnerable
to fracture. Sodium and potassium aren't
involved in the development of
steoporosis.
Answer: (A) Adult respiratory distress
syndrome (ARDS)
Rationale: Severe hypoxia after smoke
inhalation is typically related to ARDS. The
other conditions listed aren’t typically
associated with smoke inhalation and
severe hypoxia.
Answer: (D) Fat embolism
Rationale: Long bone fractures are
correlated with fat emboli, which cause
shortness of breath and hypoxia. It’s
unlikely the client has developed asthma
or bronchitis without a previous history.
92.
93.
94.
95.
96.
97.
He could develop atelectasis but it
typically doesn’t produce progressive
hypoxia.
Answer: (D) Spontaneous pneumothorax
Rationale: A spontaneous pneumothorax
occurs when the client’s lung collapses,
causing an acute decreased in the amount
of functional lung used in oxygenation.
The sudden collapse was the cause of his
chest pain and shortness of breath. An
asthma attack would show wheezing
breath sounds, and bronchitis would have
rhonchi. Pneumonia would have bronchial
breath sounds over the area of
consolidation.
Answer: (C) Pneumothorax
Rationale: From the trauma the client
experienced, it’s unlikely he has
bronchitis, pneumonia, or TB; rhonchi
with bronchitis, bronchial breath sounds
with TB would be heard.
Answer: (C) Serous fluids fills the space
and consolidates the region
Rationale: Serous fluid fills the space and
eventually consolidates, preventing
extensive mediastinal shift of the heart
and remaining lung. Air can’t be left in the
space. There’s no gel that can be placed in
the pleural space. The tissue from the
other lung can’t cross the mediastinum,
although a temporary mediastinal shift
exits until the space is filled.
Answer: (A) Alveolar damage in the
infracted area
Rationale: The infracted area produces
alveolar damage that can lead to the
production of bloody sputum, sometimes
in massive amounts. Clot formation
usually occurs in the legs. There’s a loss of
lung parenchyma and subsequent scar
tissue formation.
Answer: (D) Respiratory alkalosis
Rationale: A client with massive
pulmonary embolism will have a large
region and blow off large amount of
carbon dioxide, which crosses the
unaffected alveolar-capillary membrane
more readily than does oxygen and results
in respiratory alkalosis.
Answer: (A) Air leak
Rationale: Bubbling in the water seal
chamber of a chest drainage system stems
from an air leak. In pneumothorax an air
98.
99.
100.
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leak can occur as air is pulled from the
pleural space. Bubbling doesn’t normally
occur with either adequate or inadequate
suction or any preexisting bubbling in the
water seal chamber.
Answer: (B) 21
Rationale: 3000 x 10 divided by 24 x 60.
Answer: (B) 2.4 ml
Rationale: .05 mg/ 1 ml = .12mg/ x ml,
.05x = .12, x = 2.4 ml.
Answer: (D) “I should put on the stockings
before getting out of bed in the morning.
Rationale: Promote venous return by
applying external pressure on veins.
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TEST V - Care of Clients with Physiologic and
Psychosocial Alterations
1. Mr. Marquez reports of losing his job, not being
able to sleep at night, and feeling upset with his
wife. Nurse John responds to the client, “You
may want to talk about your employment
situation in group today.” The Nurse is using
which therapeutic technique?
a. Observations
b. Restating
c. Exploring
d. Focusing
2. Tony refuses his evening dose of Haloperidol
(Haldol), then becomes extremely agitated in the
dayroom while other clients are watching
television. He begins cursing and throwing
furniture. Nurse Oliver first action is to:
a. Check the client’s medical record for an
order for an as-needed I.M. dose of
medication for agitation.
b. Place the client in full leather restraints.
c. Call the attending physician and report
the behavior.
d. Remove all other clients from the
dayroom.
3. Tina who is manic, but not yet on medication,
comes to the drug treatment center. The nurse
would not let this client join the group session
because:
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 medication
first.
4. Dervid, an adolescent boy was admitted for
substance abuse and hallucinations. The client’s
mother asks Nurse Armando to talk with his
husband when he arrives at the hospital. The
mother says that she is afraid of what the father
might say to the boy. The most appropriate
nursing intervention would be to:
a. Inform the mother that she and the
father can work through this problem
themselves.
b. Refer the mother to the hospital social
worker.
c. Agree to talk with the mother and the
father together.
d. Suggest that the father and son work
things out.
5. What is Nurse John likely to note in a male client
being 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 3
days, but now complains that it “doesn’t help”
and refuses to take it. What should the nurse say
or 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 before
seeing the results.
7. Dervid, an adolescent has a history of truancy
from school, running away from home and
“barrowing” other people’s things without their
permission. The adolescent denies stealing,
rationalizing instead that as long as no one was
using the items, it was all right to borrow them.
It is important for the nurse to understand the
psychodynamically, this behavior may be largely
attributed to a developmental defect related to
the:
a. Id
b. Ego
c. Superego
d. Oedipal complex
8. In preparing a female client for electroconvulsive
therapy (ECT), Nurse Michelle knows that
succinylcoline (Anectine) will be administered
for which therapeutic effect?
a. Short-acting anesthesia
b. Decreased oral and respiratory
secretions.
c. Skeletal muscle paralysis.
d. Analgesia.
9. Nurse Gina is aware that the dietary implications
for a client in manic phase of bipolar disorder is:
a. Serve the client a bowl of soup, buttered
French bread, and apple slices.
b. Increase calories, decrease fat, and
decrease protein.
c. Give the client pieces of cut-up steak,
carrots, and an apple.
d. Increase calories, carbohydrates, and
protein.
10. What parental behavior toward a child during an
admission procedure should cause Nurse Ron to
suspect child abuse?
a. Flat affect
b. Expressing guilt
c. Acting overly solicitous toward the child.
d. Ignoring the child.
11. Nurse Lynnette notices that a female client with
obsessive-compulsive disorder washes her hands
for long periods each day. How should the nurse
respond to this compulsive behavior?
a. By designating times during which the
client can focus on the behavior.
b. By urging the client to reduce the
frequency of the behavior as rapidly as
possible.
c. By calling attention to or attempting to
prevent the behavior.
d. By discouraging the client from
verbalizing anxieties.
12. After seeking help at an outpatient mental
health clinic, Ruby who was raped while walking
her dog is diagnosed with posttraumatic stress
disorder (PTSD). Three months later, Ruby
returns to the clinic, complaining of fear, loss of
control, and helpless feelings. Which nursing
intervention is most appropriate for Ruby?
a. Recommending a high-protein, low-fat
diet.
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 traumatic
event with the client.
13. Meryl, age 19, is highly dependent on her
parents and fears leaving home to go away to
college. Shortly before the semester starts, she
complains that her legs are paralyzed and is
rushed to the emergency department. When
physical examination rules out a physical cause
for her paralysis, the physician admits her to the
psychiatric unit where she is diagnosed with
conversion disorder. Meryl asks the nurse, "Why
has this happened to me?" What is the nurse's
best response?
a. "You've developed this paralysis so you
can stay with your parents. You must
134
deal with this conflict if you want to walk
again."
b. "It must be awful not to be able to move
your legs. You may feel better if you
realize the problem is psychological, not
physical."
c. "Your problem is real but there is no
physical basis for it. We'll work on what
is going on in your life to find out why
it's happened."
d. "It isn't uncommon for someone with
your personality to develop a conversion
disorder during times of stress."
14. Nurse Krina knows that the following drugs have
been known to be effective in treating
obsessive-compulsive disorder (OCD):
a. benztropine (Cogentin) and
diphenhydramine (Benadryl).
b. chlordiazepoxide (Librium) and
diazepam (Valium)
c. fluvoxamine (Luvox) and clomipramine
(Anafranil)
d. divalproex (Depakote) and lithium
(Lithobid)
15. Alfred was newly diagnosed with anxiety
disorder. The physician prescribed buspirone
(BuSpar). The nurse is aware that the teaching
instructions for newly prescribed buspirone
should include which of the following?
a. A warning about the drugs delayed
therapeutic effect, which is from 14 to
30 days.
b. A warning about the incidence of
neuroleptic malignant syndrome (NMS).
c. A reminder of the need to schedule
blood work in 1 week to check blood
levels of the drug.
d. A warning that immediate sedation can
occur with a resultant drop in pulse.
16. Richard with agoraphobia has been symptomfree for 4 months. Classic signs and symptoms of
phobias include:
a. Insomnia and an inability to concentrate.
b. Severe anxiety and fear.
c. Depression and weight loss.
d. Withdrawal and failure to distinguish
reality from fantasy.
17. Which medications have been found to help
reduce or eliminate panic attacks?
135
a.
b.
c.
d.
Antidepressants
Anticholinergics
Antipsychotics
Mood stabilizers
18. A client seeks care because she feels depressed
and has gained weight. To treat her atypical
depression, the physician prescribes
tranylcypromine sulfate (Parnate), 10 mg by
mouth twice per day. When this drug is used to
treat atypical depression, what is its onset of
action?
a. 1 to 2 days
b. 3 to 5 days
c. 6 to 8 days
d. 10 to 14 days
19. A 65 years old client is in the first stage of
Alzheimer's disease. Nurse Patricia should plan
to focus this client's care on:
a. Offering nourishing finger foods to help
maintain the client's nutritional status.
b. Providing emotional support and
individual counseling.
c. Monitoring the client to prevent minor
illnesses from turning into major
problems.
d. Suggesting new activities for the client
and family to do together.
20. The nurse is assessing a client who has just been
admitted to the emergency department. Which
signs would suggest an overdose of an
antianxiety agent?
a. Combativeness, sweating, and confusion
b. Agitation, hyperactivity, and grandiose
ideation
c. Emotional lability, euphoria, and
impaired memory
d. Suspiciousness, dilated pupils, and
increased blood pressure
21. The nurse is caring for a client diagnosed with
antisocial personality disorder. The client has a
history of fighting, cruelty to animals, and
stealing. Which of the following traits would the
nurse be most likely to uncover during
assessment?
a. History of gainful employment
b. Frequent expression of guilt regarding
antisocial behavior
c. Demonstrated ability to maintain close,
stable relationships
d. A low tolerance for frustration
22. Nurse Amy is providing care for a male client
undergoing opiate withdrawal. Opiate
withdrawal causes severe physical discomfort
and can be life-threatening. To minimize these
effects, opiate users are commonly detoxified
with:
a. Barbiturates
b. Amphetamines
c. Methadone
d. Benzodiazepines
23. Nurse Cristina is caring for a client who
experiences false sensory perceptions with no
basis in reality. These perceptions are known as:
a. Delusions
b. Hallucinations
c. Loose associations
d. Neologisms
24. Nurse Marco is developing a plan of care for a
client with anorexia nervosa. Which action
should the nurse include in the plan?
a. Restricts visits with the family and
friends 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, which
will reduce her anxiety.
25. Tim is admitted with a diagnosis of delusions of
grandeur. The nurse is aware that this diagnosis
reflects a belief that one is:
a. Highly important or famous.
b. Being persecuted
c. Connected to events unrelated to
oneself
d. Responsible for the evil in the world.
26. Nurse Jen is caring for a male client with manic
depression. The plan of care for a client in a
manic state would include:
a. Offering a high-calorie meals and
strongly encouraging the client to finish
all food.
b. Insisting that the client remain active
through the day so that he’ll sleep at
night.
c. Allowing the client to exhibit
hyperactive, demanding, manipulative
behavior without setting limits.
d. Listening attentively with a neutral
attitude and avoiding power struggles.
27. Ramon is admitted for detoxification after a
cocaine overdose. The client tells the nurse that
he frequently uses cocaine but that he can
control his use if he chooses. Which coping
mechanism is he using?
a. Withdrawal
b. Logical thinking
c. Repression
d. Denial
28. Richard is admitted with a diagnosis of
schizotypal personality disorder. hich signs
would this client exhibit during social situations?
a. Aggressive behavior
b. Paranoid thoughts
c. Emotional affect
d. Independence needs
29. Nurse Mickey is caring for a client diagnosed
with bulimia. The most appropriate initial goal
for a client diagnosed with bulimia is to:
a. Avoid shopping for large amounts of
food.
b. Control eating impulses.
c. Identify anxiety-causing situations
d. Eat only three meals per day.
30. Rudolf is admitted for an overdose of
amphetamines. When assessing the client, the
nurse should expect to see:
a. Tension and irritability
b. Slow pulse
c. Hypotension
d. Constipation
31. Nicolas is experiencing hallucinations tells the
nurse, “The voices are telling me I’m no good.”
The client asks if the nurse hears the voices. The
most appropriate response by the nurse would
be:
a. “It is the voice of your conscience, which
only you can control.”
b. “No, I do not hear your voices, but I
believe you can hear them”.
c. “The voices are coming from within you
and only you can hear them.”
d. “Oh, the voices are a symptom of your
illness; don’t pay any attention to them.”
136
32. The nurse is aware that the side effect of
electroconvulsive therapy that a client may
experience:
a. Loss of appetite
b. Postural hypotension
c. Confusion for a time after treatment
d. Complete loss of memory for a time
33. A dying male client gradually moves toward
resolution of feelings regarding impending
death. Basing care on the theory of Kubler-Ross,
Nurse Trish plans to use nonverbal interventions
when assessment reveals that the client is in the:
a. Anger stage
b. Denial stage
c. Bargaining stage
d. Acceptance stage
34. The outcome that is unrelated to a crisis state is:
a. Learning more constructive coping skills
b. Decompensation to a lower level of
functioning.
c. Adaptation and a return to a prior level
of functioning.
d. A higher level of anxiety continuing for
more than 3 months.
35. Miranda a psychiatric client is to be discharged
with orders for haloperidol (haldol) therapy.
When developing a teaching plan for discharge,
the nurse should include cautioning the client
against:
a. Driving at night
b. Staying in the sun
c. Ingesting wines and cheeses
d. Taking medications containing aspirin
36. Jen a nursing student is anxious about the
upcoming board examination but is able to study
intently and does not become distracted by a
roommate’s talking and loud music. The
student’s ability to ignore distractions and to
focus on studying demonstrates:
a. Mild-level anxiety
b. Panic-level anxiety
c. Severe-level anxiety
d. Moderate-level anxiety
37. When assessing a premorbid personality
characteristic of a client with a major
depression, it would be unusual for the nurse to
find that this client demonstrated:
a. Rigidity
b. Stubbornness
137
c. Diverse interest
d. Over meticulousness
38. Nurse Krina recognizes that the suicidal risk for
depressed client is greatest:
a. As their depression begins to improve
b. When their depression is most severe
c. Before any type of treatment is started
d. As they lose interest in the environment
39. Nurse Kate would expect that a client with
vascular dementis would experience:
a. Loss of remote memory related to
anoxia
b. Loss of abstract thinking related to
emotional state
c. Inability to concentrate related to
decreased stimuli
d. Disturbance in recalling recent events
related to cerebral hypoxia.
40. Josefina is to be discharged on a regimen of
lithium carbonate. In the teaching plan for
discharge the nurse should include:
a. Advising the client to watch the diet
carefully
b. Suggesting that the client take the pills
with milk
c. Reminding the client that a CBC must be
done once a month.
d. Encouraging the client to have blood
levels checked as ordered.
41. The psychiatrist orders lithium carbonate 600
mg p.o t.i.d for a female client. Nurse Katrina
would be aware that the teachings about the
side effects of this drug were understood when
the client state, “I will call my doctor
immediately if I notice any:
a. Sensitivity to bright light or sun
b. Fine hand tremors or slurred speech
c. Sexual dysfunction or breast
enlargement
d. Inability to urinate or difficulty when
urinating
42. Nurse Mylene recognizes that the most
important factor necessary for the establishment
of trust in a critical care area is:
a. Privacy
b. Respect
c. Empathy
d. Presence
43. When establishing an initial nurse-client
relationship, Nurse Hazel should explore with
the client the:
a. Client’s perception of the presenting
problem.
b. Occurrence of fantasies the client may
experience.
c. Details of any ritualistic acts carried out
by the client
d. Client’s feelings when external; controls
are instituted.
44. Tranylcypromine sulfate (Parnate) is prescribed
for a depressed client who has not responded to
the tricyclic antidepressants. After teaching the
client about the medication, Nurse Marian
evaluates that learning has occurred when the
client states, “I will avoid:
a. Citrus fruit, tuna, and yellow
vegetables.”
b. Chocolate milk, aged cheese, and
yogurt’”
c. Green leafy vegetables, chicken, and
milk.”
d. Whole grains, red meats, and
carbonated soda.”
45. Nurse John is a aware that most crisis situations
should resolve in about:
a. 1 to 2 weeks
b. 4 to 6 weeks
c. 4 to 6 months
d. 6 to 12 months
46. Nurse Judy knows that statistics show that in
adolescent suicide behavior:
a. Females use more dramatic methods
than males
b. Males account for more attempts than
do females
c. Females talk more about suicide before
attempting it
d. Males are more likely to use lethal
methods than are females
47. Dervid with paranoid schizophrenia repeatedly
uses profanity during an activity therapy session.
Which response by the nurse would be most
appropriate?
a. "Your behavior won't be tolerated. Go to
your room immediately."
b. "You're just doing this to get back at me
for making you come to therapy."
c. "Your cursing is interrupting the activity.
Take time out in your room for 10
minutes."
d. "I'm disappointed in you. You can't
control yourself even for a few minutes."
48. Nurse Maureen knows that the nonantipsychotic
medication used to treat some clients with
schizoaffective disorder is:
a. phenelzine (Nardil)
b. chlordiazepoxide (Librium)
c. lithium carbonate (Lithane)
d. imipramine (Tofranil)
49. Which information is most important for the
nurse Trinity to include in a teaching plan for a
male schizophrenic client taking clozapine
(Clozaril)?
a. Monthly blood tests will be necessary.
b. Report a sore throat or fever to the
physician immediately.
c. Blood pressure must be monitored for
hypertension.
d. Stop the medication when symptoms
subside.
50. Ricky with chronic schizophrenia takes
neuroleptic medication is admitted to the
psychiatric unit. Nursing assessment reveals
rigidity, fever, hypertension, and diaphoresis.
These findings suggest which life- threatening
reaction:
a. Tardive dyskinesia.
b. Dystonia.
c. Neuroleptic malignant syndrome.
d. Akathisia.
51. Which nursing intervention would be most
appropriate if a male client develop orthostatic
hypotension while taking amitriptyline (Elavil)?
a. Consulting with the physician about
substituting a different type of
antidepressant.
b. Advising the client to sit up for 1 minute
before getting out of bed.
c. Instructing the client to double the
dosage until the problem resolves.
d. Informing the client that this adverse
reaction should disappear within 1
week.
138
52. Mr. Cruz visits the physician's office to seek
treatment for depression, feelings of
hopelessness, poor appetite, insomnia, fatigue,
low self- esteem, poor concentration, and
difficulty making decisions. The client states that
these 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 emergency
department. Dr. Trinidad prescribes activated
charcoal (Charcocaps) to be administered by
mouth immediately. Before administering the
dose, the nurse verifies the dosage ordered.
What is the usual minimum dose of activated
charcoal?
a. 5 g mixed in 250 ml of water
b. 15 g mixed in 500 ml of water
c. 30 g mixed in 250 ml of water
d. 60 g mixed in 500 ml of water
54. What herbal medication for depression, widely
used in Europe, is now being prescribed in the
United States?
a. Ginkgo biloba
b. Echinacea
c. St. John's wort
d. Ephedra
55. Cely with manic episodes is taking lithium.
Which electrolyte level should the nurse check
before administering this medication?
a. Clcium
b. Sodium
c. Chloride
d. Potassium
56. Nurse Josefina is caring for a client who has been
diagnosed with delirium. Which statement about
delirium is true?
a. It's characterized by an acute onset and
lasts about 1 month.
b. It's characterized by a slowly evolving
onset and lasts about 1 week.
c. It's characterized by a slowly evolving
onset and lasts about 1 month.
d. It's characterized by an acute onset and
lasts hours to a number of days.
139
57. Edward, a 66 year old client with slight memory
impairment and poor concentration is diagnosed
with primary degenerative dementia of the
Alzheimer's type. Early signs of this dementia
include subtle personality changes and
withdrawal from social interactions. To assess
for progression to the middle stage of
Alzheimer's disease, the nurse should observe
the 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 started
on imipramine (Tofranil), 75 mg by mouth at
bedtime. The nurse should tell the client that:
a. This medication may be habit forming
and will be discontinued as soon as the
client feels better.
b. This medication has no serious adverse
effects.
c. The client should avoid eating such
foods as aged cheeses, yogurt, and
chicken livers while taking the
medication.
d. This medication may initially cause
tiredness, which should become less
bothersome over time.
59. Kathleen is admitted to the psychiatric clinic for
treatment of anorexia nervosa. To promote the
client's physical health, the nurse should plan to:
a. Severely restrict the client's physical
activities.
b. Weigh the client daily, after the evening
meal.
c. Monitor vital signs, serum electrolyte
levels, and acid-base balance.
d. Instruct the client to keep an accurate
record of food and fluid intake.
60. Celia with a history of polysubstance abuse is
admitted to the facility. She complains of nausea
and vomiting 24 hours after admission. The
nurse assesses the client and notes piloerection,
pupillary dilation, and lacrimation. The nurse
suspects that the client is going through which of
the following withdrawals?
a. Alcohol withdrawal
b. Cannibis withdrawal
c. Cocaine withdrawal
d. Opioid withdrawal
61. Mr. Garcia, an attorney who throws books and
furniture around the office after losing a case is
referred to the psychiatric nurse in the law firm's
employee assistance program. Nurse Beatriz
knows that the client's behavior most likely
represents the use of which defense
mechanism?
a. Regression
b. Projection
c. Reaction-formation
d. Intellectualization
62. Nurse Anne is caring for a client who has been
treated long term with antipsychotic medication.
During the assessment, Nurse Anne checks the
client for tardive dyskinesia. If tardive dyskinesia
is present, Nurse Anne would most likely
observe:
a. Abnormal movements and involuntary
movements of the mouth, tongue, and
face.
b. Abnormal breathing through the nostrils
accompanied by a “thrill.”
c. Severe headache, flushing, tremors, and
ataxia.
d. Severe hypertension, migraine
headache,
63. Dennis has a lithium level of 2.4 mEq/L. The
nurse immediately would assess the client for
which of the following signs or symptoms?
a. Weakness
b. Diarrhea
c. Blurred vision
d. Fecal incontinence
64. Nurse Jannah is monitoring a male client who
has been placed inrestraints because of violent
behavior. Nurse determines that it will be safe to
remove the restraints when:
a. The client verbalizes the reasons for the
violent behavior.
b. The client apologizes and tells the nurse
that it will never happen again.
c. No acts of aggression have been
observed within 1 hour after the release
of two of the extremity restraints.
d. The administered medication has taken
effect.
65. Nurse Irish is aware that Ritalin is the drug of
choice for a child with ADHD. The side effects of
the following may be noted by the nurse:
a. Increased attention span and
concentration
b. Increase in appetite
c. Sleepiness and lethargy
d. Bradycardia and diarrhea
a. Revealing personal information to the
client
b. Focusing on the feelings of the client.
c. Confronting the client about
discrepancies in verbal or non-verbal
behavior
d. The client feels angry towards the nurse
who resembles his mother.
66. Kitty, a 9 year old child has very limited
vocabulary and interaction skills. She has an I.Q.
of 45. She is diagnosed to have Mental
retardation of this classification:
a. Profound
b. Mild
c. Moderate
d. Severe
72. Tristan is on Lithium has suffered from diarrhea
and vomiting. What should the nurse in-charge
do first:
a. Recognize this as a drug interaction
b. Give the client Cogentin
c. Reassure the client that these are
common side effects of lithium therapy
d. Hold the next dose and obtain an order
for a stat serum lithium level
67. The therapeutic approach in the care of Armand
an autistic child include the following EXCEPT:
a. Engage in diversionary activities when
acting -out
b. Provide an atmosphere of acceptance
c. Provide safety measures
d. Rearrange the environment to activate
the child
68. Jeremy is brought to the emergency room by
friends who state that he took something an
hour ago. He is actively hallucinating, agitated,
with irritated nasal septum.
a. Heroin
b. Cocaine
c. LSD
d. Marijuana
69. Nurse Pauline is aware that Dementia unlike
delirium is characterized by:
a. Slurred speech
b. Insidious onset
c. Clouding of consciousness
d. Sensory perceptual change
70. A 35 year old female has intense fear of riding an
elevator. She claims “ As if I will die inside.” The
client is suffering from:
a. Agoraphobia
b. Social phobia
c. Claustrophobia
d. Xenophobia
71. Nurse Myrna develops a counter-transference
reaction. This is evidenced by:
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73. Nurse Sarah ensures a therapeutic environment
for all the client. Which of the following best
describes a therapeutic milieu?
a. A therapy that rewards adaptive
behavior
b. A cognitive approach to change behavior
c. A living, learning or working
environment.
d. A permissive and congenial environment
74. Anthony is very hostile toward one of the staff
for no apparent reason. He is manifesting:
a. Splitting
b. Transference
c. Countertransference
d. Resistance
75. Marielle, 17 years old was sexually attacked
while on her way home from school. She is
brought to the hospital by her mother. Rape is
an example of which type of crisis:
a. Situational
b. Adventitious
c. Developmental
d. Internal
76. Nurse Greta is aware that the following is
classified as an Axis I disorder by the Diagnosis
and Statistical Manual of Mental Disorders, Text
Revision (DSM-IV-TR) is:
a. Obesity
b. Borderline personality disorder
c. Major depression
d. Hypertension
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77. Katrina, a newly admitted is extremely hostile
toward a staff member she has just met, without
apparent reason. According to Freudian theory,
the nurse should suspect that the client is
experiencing which of the following
phenomena?
a. Intellectualization
b. Transference
c. Triangulation
d. Splitting
78. An 83year-old male client is in extended care
facility is anxious most of the time and
frequently complains of a number of vague
symptoms that interfere with his ability to eat.
These symptoms indicate which of the following
disorders?
a. Conversion disorder
b. Hypochondriasis
c. Severe anxiety
d. Sublimation
79. Charina, a college student who frequently visited
the health center during the past year with
multiple vague complaints of GI symptoms
before course examinations. Although physical
causes have been eliminated, the student
continues to express her belief that she has a
serious illness. These symptoms are typically of
which of the following disorders?
a. Conversion disorder
b. Depersonalization
c. Hypochondriasis
d. Somatization disorder
80. Nurse Daisy is aware that the following
pharmacologic agents are sedative- hypnotic
medication is used to induce sleep for a client
experiencing a sleep disorder is:
a. Triazolam (Halcion)
b. Paroxetine (Paxil)\
c. Fluoxetine (Prozac)
d. Risperidone (Risperdal)
81. Aldo, with a somatoform pain disorder may
obtain secondary gain. Which of the following
statement refers to a secondary gain?
a. It brings some stability to the family
b. It decreases the preoccupation with the
physical illness
c. It enables the client to avoid some
unpleasant activity
d. It promotes emotional support or
attention for the client
82. Dervid is diagnosed with panic disorder with
agoraphobia is talking with the nurse in-charge
about the progress made in treatment. Which of
the following statements indicates a positive
client response?
a. “I went to the mall with my friends last
Saturday”
b. “I’m hyperventilating only when I have a
panic attack”
c. “Today I decided that I can stop taking
my medication”
d. “Last night I decided to eat more than a
bowl of cereal”
83. The effectiveness of monoamine oxidase (MAO)
inhibitor drug therapy in a client with
posttraumatic stress disorder can be
demonstrated by which of the following client
self –reports?
a. “I’m sleeping better and don’t have
nightmares”
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 anxiety
disorder wants to stop taking his lorazepam
(Ativan). Which of the following important facts
should nurse Betty discuss with the client about
discontinuing the medication?
a. Stopping the drug may cause depression
b. Stopping the drug increases cognitive
abilities
c. Stopping the drug decreases sleeping
difficulties
d. Stopping the drug can cause withdrawal
symptoms
85. Jennifer, an adolescent who is depressed and
reported by his parents as having difficulty in
school is brought to the community mental
health center to be evaluated. Which of the
following other health problems would the nurse
suspect?
a. Anxiety disorder
b. Behavioral difficulties
c. Cognitive impairment
d. Labile moods
86. Ricardo, an outpatient in psychiatric facility is
diagnosed with dysthymic disorder. Which of the
following statement about dysthymic disorder is
true?
a. It involves a mood range from moderate
depression to hypomania
b. It involves a single manic depression
c. It’s a form of depression that occurs in
the fall and winter
d. It’s a mood disorder similar to major
depression but of mild to moderate
severity
87. The nurse is aware that the following ways in
vascular dementia different from Alzheimer’s
disease is:
a. Vascular dementia has more abrupt
onset
b. The duration of vascular dementia is
usually brief
c. Personality change is common in
vascular dementia
d. The inability to perform motor activities
occurs in vascular dementia
88. Loretta, a newly admitted client was diagnosed
with delirium and has history of hypertension
and anxiety. She had been taking digoxin,
furosemide (Lasix), and diazepam (Valium) for
anxiety. This client’s impairment may be related
to which of the following conditions?
a. Infection
b. Metabolic acidosis
c. Drug intoxication
d. Hepatic encephalopathy
89. Nurse Ron enters a client’s room, the client says,
“They’re crawling on my sheets! Get them off
my bed!” Which of the following assessment is
the most accurate?
a. The client is experiencing aphasia
b. The client is experiencing dysarthria
c. The client is experiencing a flight of ideas
d. The client is experiencing visual
hallucination
90. Which of the following descriptions of a client’s
experience and behavior can be assessed as an
illusion?
a. The client tries to hit the nurse when
vital signs must be taken
b. The client says, “I keep hearing a voice
telling me to run away”
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c. The client becomes anxious whenever
the nurse leaves the bedside
d. The client looks at the shadow on a wall
and tells the nurse she sees frightening
faces on the wall.
91. During conversation of Nurse John with a client,
he observes that the client shift from one topic
to the next on a regular basis. Which of the
following terms describes this disorder?
a. Flight of ideas
b. Concrete thinking
c. Ideas of reference
d. Loose association
92. Francis tells the nurse that her coworkers are
sabotaging the computer. When the nurse asks
questions, the client becomes argumentative.
This behavior shows personality traits associated
with which of the following personality disorder?
a. Antisocial
b. Histrionic
c. Paranoid
d. Schizotypal
93. Which of the following interventions is
important for a Cely experiencing with paranoid
personality disorder taking olanzapine
(Zyprexa)?
a. Explain effects of serotonin syndrome
b. Teach the client to watch for
extrapyramidal adverse reaction
c. Explain that the drug is less affective if
the client smokes
d. Discuss the need to report paradoxical
effects such as euphoria
94. Nurse Alexandra notices other clients on the unit
avoiding a client diagnosed with antisocial
personality disorder. When discussing
appropriate behavior in group therapy, which of
the following comments is expected about this
client by his peers?
a. Lack of honesty
b. Belief in superstition
c. Show of temper tantrums
d. Constant need for attention
95. Tommy, with dependent personality disorder is
working to increase his self- esteem. Which of
the following statements by the Tommy shows
teaching was successful?
143
a. “I’m not going to look just at the
negative things about myself”
b. “I’m most concerned about my level of
competence and progress”
c. “I’m not as envious of the things other
people have as I used to be”
d. “I find I can’t stop myself from taking
over things other should be doing”
96. Norma, a 42-year-old client with a diagnosis of
chronic undifferentiated schizophrenia lives in a
rooming house that has a weekly nursing clinic.
She scratches while she tells the nurse she feels
creatures eating away at her skin. Which of the
following interventions should be done first?
a. Talk about his hallucinations and fears
b. Refer him for anticholinergic adverse
reactions
c. Assess for possible physical problems
such as rash
d. Call his physician to get his medication
increased to control his psychosis
97. Ivy, who is on the psychiatric unit is copying and
imitating the movements of her primary nurse.
During recovery, she says, “I thought the nurse
was my mirror. I felt connected only when I saw
my nurse.” This behavior is known by which of
the following terms?
a. Modeling
b. Echopraxia
c. Ego-syntonicity
d. Ritualism
98. Jun approaches the nurse and tells that he hears
a voice telling him that he’s evil and deserves to
die. Which of the following terms describes the
client’s perception?
a. Delusion
b. Disorganized speech
c. Hallucination
d. Idea of reference
99. Mike is admitted to a psychiatric unit with a
diagnosis of undifferentiated schizophrenia.
Which of the following defense mechanisms is
probably used by mike?
a. Projection
b. Rationalization
c. Regression
d. Repression
100. Rocky has started taking haloperidol (Haldol).
Which of the following instructions is most
appropriate for Ricky before taking
haloperidol?
a. Should report feelings of restlessness or
agitation at once
b. Use a sunscreen outdoors on a yearround basis
c. Be aware you’ll feel increased energy
taking this drug
d. This drug will indirectly control essential
hypertension
Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations
1. Answer: (D) Focusing
Rationale: The nurse is using focusing by
suggesting that the client discuss a specific issue.
The nurse didn’t restate the question, make
observation, or ask further question (exploring).
2. Answer: (D) Remove all other clients from the
dayroom.
Rationale: The nurse’s first priority is to consider
the safety of the clients in the therapeutic
setting. The other actions are appropriate
responses after ensuring the safety of other
clients.
3. Answer: (A) The client is disruptive.
Rationale: Group activity provides too much
stimulation, which the client will not be able to
handle (harmful to self) and as a result will be
disruptive to others.
4. Answer: (C) Agree to talk with the mother and
the father together.
Rationale: By agreeing to talk with both parents,
the nurse can provide emotional support and
further assess and validate the family’s needs.
5. Answer: (A) Perceptual disorders.
Rationale: Frightening visual hallucinations are
especially common in clients experiencing
alcohol withdrawal.
6. Answer: (D) Suggest that it takes a while before
seeing the results.
Rationale: The client needs a specific response;
that it takes 2 to 3 weeks (a delayed effect) until
the therapeutic blood level is reached.
7. Answer: (C) Superego
Rationale: This behavior shows a weak sense of
moral consciousness. According to Freudian
theory, personality disorders stem from a weak
superego.
8. Answer: (C) Skeletal muscle paralysis.
Rationale: Anectine is a depolarizing muscle
relaxant causing paralysis. It is used to reduce
the intensity of muscle contractions during the
convulsive stage, thereby reducing the risk of
bone fractures or dislocation.
9. Answer: (D) Increase calories, carbohydrates,
and protein.
Rationale: This client increased protein for tissue
building and increased calories to replace what is
burned up (usually via carbohydrates).
10. Answer: (C) Acting overly solicitous toward the
child.
144
Rationale: This behavior is an example of
reaction formation, a coping mechanism.
11. Answer: (A) By designating times during which
the client can focus on the behavior.
Rationale: The nurse should designate times
during which the client can focus on the
compulsive behavior or obsessive thoughts. The
nurse should urge the client to reduce the
frequency of the compulsive behavior gradually,
not rapidly. She shouldn't call attention to or try
to prevent the behavior. Trying to prevent the
behavior may cause pain and terror in the client.
The nurse should encourage the client to
verbalize anxieties to help distract attention
from the compulsive behavior.
12. Answer: (D) Exploring the meaning of the
traumatic event with the client.
Rationale: The client with PTSD needs
encouragement to examine and understand the
meaning of the traumatic event and consequent
losses. Otherwise, symptoms may worsen and
the client may become depressed or engage in
self-destructive behavior such as substance
abuse. The client must explore the meaning of
the event and won't heal without this, no matter
how much time passes. Behavioral techniques,
such as relaxation therapy, may help decrease
the client's anxiety and induce sleep. The
physician may prescribe antianxiety agents or
antidepressants cautiously to avoid dependence;
sleep medication is rarely appropriate. A special
diet isn't indicated unless the client also has an
eating disorder or a nutritional problem.
13. Answer: (C) "Your problem is real but there is no
physical basis for it. We'll work on what is going
on in your life to find out why it's happened."
Rationale: The nurse must be honest with the
client by telling her that the paralysis has no
physiologic cause while also conveying empathy
and acknowledging that her symptoms are real.
The client will benefit from psychiatric
treatment, which will help her understand the
underlying cause of her symptoms. After the
psychological conflict is resolved, her symptoms
will disappear. Saying that it must be awful not
to be able to move her legs wouldn't answer the
client's question; knowing that the cause is
psychological wouldn't necessarily make her feel
better. Telling her that she has developed
paralysis to avoid leaving her parents or that her
personality caused her disorder wouldn't help
her understand and resolve the underlying
conflict.
145
14. Answer: (C) fluvoxamine (Luvox) and
clomipramine (Anafranil)
Rationale: The antidepressants fluvoxamine and
clomipramine have been effective in the
treatment of OCD. Librium and Valium may be
helpful in treating anxiety related to OCD but
aren't drugs of choice to treat the illness. The
other medications mentioned aren't effective in
the treatment of OCD.
15. Answer: (A) A warning about the drugs delayed
therapeutic effect, which is from 14 to 30 days.
Rationale: The client should be informed that
the drug's therapeutic effect might not be
reached for 14 to 30 days. The client must be
instructed to continue taking the drug as
directed. Blood level checks aren't necessary.
NMS hasn't been reported with this drug, but
tachycardia is frequently reported.
16. Answer: (B) Severe anxiety and fear.
Rationale: Phobias cause severe anxiety (such as
a panic attack) that is out of proportion to the
threat of the feared object or situation. Physical
signs and symptoms of phobias include profuse
sweating, poor motor control, tachycardia, and
elevated blood pressure. Insomnia, an inability
to concentrate, and weight loss are common in
depression. Withdrawal and failure to
distinguish reality from fantasy occur in
schizophrenia.
17. Answer: (A) Antidepressants
Rationale: Tricyclic and monoamine oxidase
(MAO) inhibitor antidepressants have been
found to be effective in treating clients with
panic attacks. Why these drugs help control
panic attacks isn't clearly understood.
Anticholinergic agents, which are smoothmuscle relaxants, relieve physical symptoms of
anxiety but don't relieve the anxiety itself.
Antipsychotic drugs are inappropriate because
clients who experience panic attacks aren't
psychotic. Mood stabilizers aren't indicated
because panic attacks are rarely associated with
mood changes.
18. Answer: (B) 3 to 5 days
Rationale: Monoamine oxidase inhibitors, such
as tranylcypromine, have an onset of action of
approximately 3 to 5 days. A full clinical
response may be delayed for 3 to 4 weeks. The
therapeutic effects may continue for 1 to 2
weeks after discontinuation.
19. Answer: (B) Providing emotional support and
individual counseling.
20.
21.
22.
23.
Rationale: Clients in the first stage of Alzheimer's
disease are aware that something is happening
to them and may become overwhelmed and
frightened. Therefore, nursing care typically
focuses on providing emotional support and
individual counseling. The other options are
appropriate during the second stage of
Alzheimer's disease, when the client needs
continuous monitoring to prevent minor
illnesses from progressing into major problems
and when maintaining adequate nutrition may
become a challenge. During this stage, offering
nourishing finger foods helps clients to feed
themselves and maintain adequate nutrition.
Answer: (C) Emotional lability, euphoria, and
impaired memory
Rationale: Signs of antianxiety agent overdose
include emotional lability, euphoria, and
impaired memory. Phencyclidine overdose can
cause combativeness, sweating, and confusion.
Amphetamine overdose can result in agitation,
hyperactivity, and grandiose ideation.
Hallucinogen overdose can produce
suspiciousness, dilated pupils, and increased
blood pressure.
Answer: (D) A low tolerance for frustration
Rationale: Clients with an antisocial personality
disorder exhibit a low tolerance for frustration,
emotional immaturity, and a lack of impulse
control. They commonly have a history of
unemployment, miss work repeatedly, and quit
work without other plans for employment. They
don't feel guilt about their behavior and
commonly perceive themselves as victims. They
also display a lack of responsibility for the
outcome of their actions. Because of a lack of
trust in others, clients with antisocial personality
disorder commonly have difficulty developing
stable, close relationships.
Answer: (C) Methadone
Rationale: Methadone is used to detoxify opiate
users because it binds with opioid receptors at
many sites in the central nervous system but
doesn’t have the same deterious effects as other
opiates, such as cocaine, heroin, and morphine.
Barbiturates, amphetamines, and
benzodiazepines are highly addictive and would
require detoxification treatment.
Answer: (B) Hallucinations
Rationale: Hallucinations are visual, auditory,
gustatory, tactile, or olfactory perceptions that
have no basis in reality. Delusions are false
beliefs, rather than perceptions, that the client
24.
25.
26.
27.
28.
146
accepts as real. Loose associations are rapid
shifts among unrelated ideas. Neologisms are
bizarre words that have meaning only to the
client.
Answer: (C) Set up a strict eating plan for the
client.
Rationale: Establishing a consistent eating plan
and monitoring the client’s weight are very
important in this disorder. The family and friends
should be included in the client’s care. The client
should be monitored during meals-not given
privacy. Exercise must be limited and supervised.
Answer: (A) Highly important or famous.
Rationale: A delusion of grandeur is a false belief
that one is highly important or famous. A
delusion of persecution is a false belief that one
is being persecuted. A delusion of reference is a
false belief that one is connected to events
unrelated to oneself or a belief that one is
responsible for the evil in the world.
Answer: (D) Listening attentively with a neutral
attitude and avoiding power struggles.
Rationale: The nurse should listen to the client’s
requests, express willingness to seriously
consider the request, and respond later. The
nurse should encourage the client to take short
daytime naps because he expends so much
energy. The nurse shouldn’t try to restrain the
client when he feels the need to move around as
long as his activity isn’t harmful. High calorie
finger foods should be offered to supplement
the client’s diet, if he can’t remain seated long
enough to eat a complete meal. The nurse
shouldn’t be forced to stay seated at the table to
finid=sh a meal. The nurse should set limits in a
calm, clear, and self-confident tone of voice.
Answer: (D) Denial
Rationale: Denial is unconscious defense
mechanism in which emotional conflict and
anxiety is avoided by refusing to acknowledge
feelings, desires, impulses, or external facts that
are consciously intolerable. Withdrawal is a
common response to stress, characterized by
apathy. Logical thinking is the ability to think
rationally and make responsible decisions, which
would lead the client admitting the problem and
seeking help. Repression is suppressing past
events from the consciousness because of guilty
association.
Answer: (B) Paranoid thoughts
Rationale: Clients with schizotypal personality
disorder experience excessive social anxiety that
can lead to paranoid thoughts. Aggressive
29.
30.
31.
32.
33.
34.
35.
36.
37.
behavior is uncommon, although these clients
may experience agitation with anxiety. Their
behavior is emotionally cold with a flattened
affect, regardless of the situation. These clients
demonstrate a reduced capacity for close or
dependent relationships.
Answer: (C) Identify anxiety-causing situations
Rationale: Bulimic behavior is generally a
maladaptive coping response to stress and
underlying issues. The client must identify
anxiety-causing situations that stimulate the
bulimic behavior and then learn new ways of
coping with the anxiety.
Answer: (A) Tension and irritability
Rationale: An amphetamine is a nervous system
stimulant that is subject to abuse because of its
ability to produce wakefulness and euphoria. An
overdose increases tension and irritability.
Options B and C are incorrect because
amphetamines stimulate norepinephrine, which
increase the heart rate and blood flow. Diarrhea
is a common adverse effect so option D is
incorrect.
Answer: (B) “No, I do not hear your voices, but I
believe you can hear them”.
Rationale: The nurse, demonstrating knowledge
and understanding, accepts the client’s
perceptions even though they are hallucinatory.
Answer: (C) Confusion for a time after treatment
Rationale: The electrical energy passing through
the cerebral cortex during ECT results in a
temporary state of confusion after treatment.
Answer: (D) Acceptance stage
Rationale: Communication and intervention
during this stage are mainly nonverbal, as when
the client gestures to hold the nurse’s hand.
Answer: (D) A higher level of anxiety continuing
for more than 3 months.
Rationale: This is not an expected outcome of a
crisis because by definition a crisis would be
resolved in 6 weeks.
Answer: (B) Staying in the sun
Rationale: Haldol causes photosensitivity. Severe
sunburn can occur on exposure to the sun.
Answer: (D) Moderate-level anxiety
Rationale: A moderately anxious person can
ignore peripheral events and focuses on central
concerns.
Answer: (C) Diverse interest
Rationale: Before onset of depression, these
clients usually have very narrow, limited
interest.
147
38. Answer: (A) As their depression begins to
improve
Rationale: At this point the client may have
enough energy to plan and execute an attempt.
39. Answer: (D) Disturbance in recalling recent
events related to cerebral hypoxia.
Rationale: Cell damage seems to interfere with
registering input stimuli, which affects the ability
to register and recall recent events; vascular
dementia is related to multiple vascular lesions
of the cerebral cortex and subcortical structure.
40. Answer: (D) Encouraging the client to have blood
levels checked as ordered.
Rationale: Blood levels must be checked monthly
or bimonthly when the client is on maintenance
therapy because there is only a small range
between therapeutic and toxic levels.
41. Answer: (B) Fine hand tremors or slurred speech
Rationale: These are common side effects of
lithium carbonate.
42. Answer: (D) Presence
Rationale: The constant presence of a nurse
provides emotional support because the client
knows that someone is attentive and available in
case of an emergency.
43. Answer: (A) Client’s perception of the presenting
problem.
Rationale: The nurse can be most therapeutic by
starting where the client is, because it is the
client’s concept of the problem that serves as
the starting point of the relationship.
44. Answer: (B) Chocolate milk, aged cheese, and
yogurt’”
Rationale: These high-tyramine foods, when
ingested in the presence of an MAO inhibitor,
cause a severe hypertensive response.
45. Answer: (B) 4 to 6 weeks
Rationale: Crisis is self-limiting and lasts from 4
to 6 weeks.
46. Answer: (D) Males are more likely to use lethal
methods than are females
Rationale: This finding is supported by research;
females account for 90% of suicide attempts but
males are three times more successful because
of methods used.
47. Answer: (C) "Your cursing is interrupting the
activity. Take time out in your room for 10
minutes."
Rationale: The nurse should set limits on client
behavior to ensure a comfortable environment
for all clients. The nurse should accept hostile or
quarrelsome client outbursts within limits
without becoming personally offended, as in
48.
49.
50.
51.
option A. Option B is incorrect because it implies
that the client’s actions reflect feelings toward
the staff instead of the client's own misery.
Judgmental remarks, such as option D, may
decrease the client's self-esteem.
Answer: (C) lithium carbonate (Lithane)
Rationale: Lithium carbonate, an antimania drug,
is used to treat clients with cyclical
schizoaffective disorder, a psychotic disorder
once classified under schizophrenia that causes
affective symptoms, including maniclike activity.
Lithium helps control the affective component of
this disorder. Phenelzine is a monoamine
oxidase inhibitor prescribed for clients who don't
respond to other antidepressant drugs such as
imipramine. Chlordiazepoxide, an antianxiety
agent, generally is contraindicated in psychotic
clients. Imipramine, primarily considered an
antidepressant agent, is also used to treat clients
with agoraphobia and that undergoing cocaine
detoxification.
Answer: (B) Report a sore throat or fever to the
physician immediately.
Rationale: A sore throat and fever are
indications of an infection caused by
agranulocytosis, a potentially life-threatening
complication of clozapine. Because of the risk of
agranulocytosis, white blood cell (WBC) counts
are necessary weekly, not monthly. If the WBC
count drops below 3,000/μl, the medication
must be stopped. Hypotension may occur in
clients taking this medication. Warn the client to
stand up slowly to avoid dizziness from
orthostatic hypotension. The medication should
be continued, even when symptoms have been
controlled. If the medication must be stopped, it
should be slowly tapered over 1 to 2 weeks and
only under the supervision of a physician.
Answer: (C) Neuroleptic malignant syndrome.
Rationale: The client's signs and symptoms
suggest neuroleptic malignant syndrome, a lifethreatening reaction to neuroleptic medication
that requires immediate treatment. Tardive
dyskinesia causes involuntary movements of the
tongue, mouth, facial muscles, and arm and leg
muscles. Dystonia is characterized by cramps
and rigidity of the tongue, face, neck, and back
muscles. Akathisia causes restlessness, anxiety,
and jitteriness.
Answer: (B) Advising the client to sit up for 1
minute before getting out of bed.
Rationale: To minimize the effects of
amitriptyline-induced orthostatic hypotension,
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the nurse should advise the client to sit up for 1
minute before getting out of bed. Orthostatic
hypotension commonly occurs with tricyclic
antidepressant therapy. In these cases, the
dosage may be reduced or the physician may
prescribe nortriptyline, another tricyclic
antidepressant. Orthostatic hypotension
disappears only when the drug is discontinued.
Answer: (D) Dysthymic disorder.
Rationale: Dysthymic disorder is marked by
feelings of depression lasting at least 2 years,
accompanied by at least two of the following
symptoms: sleep disturbance, appetite
disturbance, low energy or fatigue, low selfesteem, poor concentration, difficulty making
decisions, and hopelessness. These symptoms
may be relatively continuous or separated by
intervening periods of normal mood that last a
few days to a few weeks. Cyclothymic disorder is
a chronic mood disturbance of at least 2 years'
duration marked by numerous periods of
depression and hypomania. Atypical affective
disorder is characterized by manic signs and
symptoms. Major depression is a recurring,
persistent sadness or loss of interest or pleasure
in almost all activities, with signs and symptoms
recurring for at least 2 weeks.
Answer: (C) 30 g mixed in 250 ml of water
Rationale: The usual adult dosage of activated
charcoal is 5 to 10 times the estimated weight of
the drug or chemical ingested, or a minimum
dose of 30 g, mixed in 250 ml of water. Doses
less than this will be ineffective; doses greater
than this can increase the risk of adverse
reactions, although toxicity doesn't occur with
activated charcoal, even at the maximum dose.
Answer: (C) St. John's wort
Rationale: St. John's wort has been found to
have serotonin-elevating properties, similar to
prescription antidepressants. Ginkgo biloba is
prescribed to enhance mental acuity. Echinacea
has immune-stimulating properties. Ephedra is a
naturally occurring stimulant that is similar to
ephedrine.
Answer: (B) Sodium
Rationale: Lithium is chemically similar to
sodium. If sodium levels are reduced, such as
from sweating or diuresis, lithium will be
reabsorbed by the kidneys, increasing the risk of
toxicity. Clients taking lithium shouldn't restrict
their intake of sodium and should drink
adequate amounts of fluid each day. The other
electrolytes are important for normal body
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functions but sodium is most important to the
absorption of lithium.
Answer: (D) It's characterized by an acute onset
and lasts hours to a number of days
Rationale: Delirium has an acute onset and
typically can last from several hours to several
days.
Answer: (B) Impaired communication.
Rationale: Initially, memory impairment may be
the only cognitive deficit in a client with
Alzheimer's disease. During the early stage of
this disease, subtle personality changes may also
be present. However, other than occasional
irritable outbursts and lack of spontaneity, the
client is usually cooperative and exhibits socially
appropriate behavior. Signs of advancement to
the middle stage of Alzheimer's disease include
exacerbated cognitive impairment with obvious
personality changes and impaired
communication, such as inappropriate
conversation, actions, and responses. During the
late stage, the client can't perform self-care
activities and may become mute.
Answer: (D) This medication may initially cause
tiredness, which should become less
bothersome over time.
Rationale: Sedation is a common early adverse
effect of imipramine, a tricyclic antidepressant,
and usually decreases as tolerance develops.
Antidepressants aren't habit forming and don't
cause physical or psychological dependence.
However, after a long course of high-dose
therapy, the dosage should be decreased
gradually to avoid mild withdrawal symptoms.
Serious adverse effects, although rare, include
myocardial infarction, heart failure, and
tachycardia. Dietary restrictions, such as
avoiding aged cheeses, yogurt, and chicken
livers, are necessary for a client taking a
monoamine oxidase inhibitor, not a tricyclic
antidepressant.
Answer: (C) Monitor vital signs, serum
electrolyte levels, and acid-base balance.
Rationale: An anorexic client who requires
hospitalization is in poor physical condition from
starvation and may die as a result of
arrhythmias, hypothermia, malnutrition,
infection, or cardiac abnormalities secondary to
electrolyte imbalances. Therefore, monitoring
the client's vital signs, serum electrolyte level,
and acid base balance is crucial. Option A may
worsen anxiety. Option B is incorrect because a
weight obtained after breakfast is more accurate
149
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than one obtained after the evening meal.
Option D would reward the client with attention
for not eating and reinforce the control issues
that are central to the underlying psychological
problem; also, the client may record food and
fluid intake inaccurately.
Answer: (D) Opioid withdrawal
Rationale: The symptoms listed are specific to
opioid withdrawal. Alcohol withdrawal would
show elevated vital signs. There is no real
withdrawal from cannibis. Symptoms of cocaine
withdrawal include depression, anxiety, and
agitation.
Answer: (A) Regression
Rationale: An adult who throws temper
tantrums, such as this one, is displaying
regressive behavior, or behavior that is
appropriate at a younger age. In projection, the
client blames someone or something other than
the source. In reaction formation, the client acts
in opposition to his feelings. In
intellectualization, the client overuses rational
explanations or abstract thinking to decrease the
significance of a feeling or event.
Answer: (A) Abnormal movements and
involuntary movements of the mouth, tongue,
and face.
Rationale: Tardive dyskinesia is a severe reaction
associated with long term use of antipsychotic
medication. The clinical manifestations include
abnormal movements (dyskinesia) and
involuntary movements of the mouth, tongue
(fly catcher tongue), and face.
Answer: (C) Blurred vision
Rationale: At lithium levels of 2 to 2.5 mEq/L the
client will experienced blurred vision, muscle
twitching, severe hypotension, and persistent
nausea and vomiting. With levels between 1.5
and 2 mEq/L the client experiencing vomiting,
diarrhea, muscle weakness, ataxia, dizziness,
slurred speech, and confusion. At lithium levels
of 2.5 to 3 mEq/L or higher, urinary and fecal
incontinence occurs, as well as seizures, cardiac
dysrythmias, peripheral vascular collapse, and
death.
Answer: (C) No acts of aggression have been
observed within 1 hour after the release of two
of the extremity restraints.
Rationale: The best indicator that the behavior is
controlled, if the client exhibits no signs of
aggression after partial release of restraints.
Options , B, and D do not ensure that the client
has controlled the behavior.
65. Answer: (A) increased attention span and
concentration
Rationale: The medication has a paradoxic effect
that decreases hyperactivity and impulsivity
among children with ADHD. B, C, D. Side effects
of Ritalin include anorexia, insomnia, diarrhea
and irritability.
66. Answer: (C) Moderate
Rationale: The child with moderate mental
retardation has an I.Q. of 35- 50 Profound
Mental retardation has an I.Q. of below 20; Mild
mental retardation 50-70 and Severe mental
retardation has an I.Q. of 20-35.
67. Answer: (D) Rearrange the environment to
activate the child
Rationale: The child with autistic disorder does
not want change. Maintaining a consistent
environment is therapeutic. A. Angry outburst
can be re-channeling through safe activities. B.
Acceptance enhances a trusting relationship. C.
Ensure safety from self-destructive behaviors
like head banging and hair pulling.
68. Answer: (B) cocaine
Rationale: The manifestations indicate
intoxication with cocaine, a CNS stimulant. A.
Intoxication with heroine is manifested by
euphoria then impairment in judgment,
attention and the presence of papillary
constriction. C. Intoxication with hallucinogen
like LSD is manifested by grandiosity,
hallucinations, synesthesia and increase in vital
signs D. Intoxication with Marijuana, a
cannabinoid is manifested by sensation of
slowed time, conjunctival redness, social
withdrawal, impaired judgment and
hallucinations.
69. Answer: (B) insidious onset
Rationale: Dementia has a gradual onset and
progressive deterioration. It causes pronounced
memory and cognitive disturbances. A,C and D
are all characteristics of delirium.
70. Answer: (C) Claustrophobia
Rationale: Claustrophobia is fear of closed space.
A. Agoraphobia is fear of open space or being a
situation where escape is difficult. B. Social
phobia is fear of performing in the presence of
others in a way that will be humiliating or
embarrassing. D. Xenophobia is fear of
strangers.
71. Answer: (A) Revealing personal information to
the client
Rationale: Counter-transference is an emotional
reaction of the nurse on the client based on her
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unconscious needs and conflicts. B and C. These
are therapeutic approaches. D. This is
transference reaction where a client has an
emotional reaction towards the nurse based on
her past.
Answer: (D) Hold the next dose and obtain an
order for a stat serum lithium level
Rationale: Diarrhea and vomiting are
manifestations of Lithium toxicity. The next dose
of lithium should be withheld and test is done to
validate the observation. A. The manifestations
are not due to drug interaction. B. Cogentin is
used to manage the extra pyramidal symptom
side effects of antipsychotics. C. The common
side effects of Lithium are fine hand tremors,
nausea, polyuria and polydipsia.
Answer: (C) A living, learning or working
environment.
Rationale: A therapeutic milieu refers to a broad
conceptual approach in which all aspects of the
environment are channeled to provide a
therapeutic environment for the client. The six
environmental elements include structure,
safety, norms; limit setting, balance and unit
modification. A. Behavioral approach in
psychiatric care is based on the premise that
behavior can be learned or unlearned through
the use of reward and punishment. B. Cognitive
approach to change behavior is done by
correcting distorted perceptions and irrational
beliefs to correct maladaptive behaviors. D. This
is not congruent with therapeutic milieu.
Answer: (B) Transference
Rationale: Transference is a positive or negative
feeling associated with a significant person in
the client’s past that are unconsciously assigned
to another A. Splitting is a defense mechanism
commonly seen in a client with personality
disorder in which the world is perceived as all
good or all bad C. Countert-transference is a
phenomenon where the nurse shifts feelings
assigned to someone in her past to the patient
D. Resistance is the client’s refusal to submit
himself to the care of the nurse
Answer: (B) Adventitious
Rationale: Adventitious crisis is a crisis involving
a traumatic event. It is not part of everyday life.
A. Situational crisis is from an external source
that upset ones psychological equilibrium C and
D. are the same. They are transitional or
developmental periods in life
Answer: (C) Major depression
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Rationale: The DSM-IV-TR classifies major
depression as an Axis I disorder. Borderline
personality disorder as an Axis II; obesity and
hypertension, Axis III.
Answer: (B) Transference
Rationale: Transference is the unconscious
assignment of negative or positive feelings
evoked by a significant person in the client’s past
to another person. Intellectualization is a
defense mechanism in which the client avoids
dealing with emotions by focusing on facts.
Triangulation refers to conflicts involving three
family members. Splitting is a defense
mechanism commonly seen in clients with
personality disorder in which the world is
perceived as all good or all bad.
Answer: (B) Hypochondriasis
Rationale: Complains of vague physical
symptoms that have no apparent medical causes
are characteristic of clients with
hypochondriasis. In many cases, the GI system is
affected. Conversion disorders are characterized
by one or more neurologic symptoms. The
client’s symptoms don’t suggest severe anxiety.
A client experiencing sublimation channels
maladaptive feelings or impulses into socially
acceptable behavior
Answer: (C) Hypochondriasis
Rationale: Hypochodriasis in this case is shown
by the client’s belief that she has a serious
illness, although pathologic causes have been
eliminated. The disturbance usually lasts at least
6 with identifiable life stressor such as, in this
case, course examinations. Conversion disorders
are characterized by one or more neurologic
symptoms. Depersonalization refers to
persistent recurrent episodes of feeling
detached from one’s self or body. Somatoform
disorders generally have a chronic course with
few remissions.
Answer: (A) Triazolam (Halcion)
Rationale: Triazolam is one of a group of
sedative hypnotic medication that can be used
for a limited time because of the risk of
dependence. Paroxetine is a scrotonin-specific
reutake inhibitor used for treatment of
depression panic disorder, and obsessivecompulsive disorder. Fluoxetine is a scrotoninspecific reuptake inhibitor used for depressive
disorders and obsessive-compulsive disorders.
Risperidome is indicated for psychotic disorders.
Answer: (D) It promotes emotional support or
attention for the client
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Rationale: Secondary gain refers to the benefits
of the illness that allow the client to receive
emotional support or attention. Primary gain
enables the client to avoid some unpleasant
activity. A dysfunctional family may disregard
the real issue, although some conflict is relieved.
Somatoform pain disorder is a preoccupation
with pain in the absence of physical disease.
Answer: (A) “I went to the mall with my friends
last Saturday”
Rationale: Clients with panic disorder tent to be
socially withdrawn. Going to the mall is a sign of
working on avoidance behaviors.
Hyperventilating is a key symptom of panic
disorder. Teaching breathing control is a major
intervention for clients with panic disorder. The
client taking medications for panic disorder; such
as tricylic antidepressants and benzodiazepines
must be weaned off these drugs. Most clients
with panic disorder with agoraphobia don’t have
nutritional problems.
Answer: (A) “I’m sleeping better and don’t have
nightmares”
Rationale: MAO inhibitors are used to treat sleep
problems, nightmares, and intrusive daytime
thoughts in individual with posttraumatic stress
disorder. MAO inhibitors aren’t used to help
control flashbacks or phobias or to decrease the
craving for alcohol.
Answer: (D) Stopping the drug can cause
withdrawal symptoms
Rationale: Stopping antianxiety drugs such as
benzodiazepines can cause the client to have
withdrawal symptoms. Stopping a
benzodiazepine doesn’t tend to cause
depression, increase cognitive abilities, or
decrease sleeping difficulties.
Answer: (B) Behavioral difficulties
Rationale: Adolescents tend to demonstrate
severe irritability and behavioral problems
rather than simply a depressed mood. Anxiety
disorder is more commonly associated with
small children rather than with adolescents.
Cognitive impairment is typically associated with
delirium or dementia. Labile mood is more
characteristic of a client with cognitive
impairment or bipolar disorder.
Answer: (D) It’s a mood disorder similar to major
depression but of mild to moderate severity
Rationale: Dysthymic disorder is a mood disorder
similar to major depression but it remains mild
to moderate in severity. Cyclothymic disorder is
a mood disorder characterized by a mood range
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from moderate depression to hypomania.
Bipolar I disorder is characterized by a single
manic episode with no past major depressive
episodes. Seasonal- affective disorder is a form
of depression occurring in the fall and winter.
Answer: (A) Vascular dementia has more abrupt
onset
Rationale: Vascular dementia differs from
Alzheimer’s disease in that it has a more abrupt
onset and runs a highly variable course.
Personally change is common in Alzheimer’s
disease. The duration of delirium is usually brief.
The inability to carry out motor activities is
common in Alzheimer’s disease.
Answer: (C) Drug intoxication
Rationale: This client was taking several
medications that have a propensity for
producing delirium; digoxin (a digitalis
glycoxide), furosemide (a thiazide diuretic), and
diazepam (a benzodiazepine). Sufficient
supporting data don’t exist to suspect the other
options as causes.
Answer: (D) The client is experiencing visual
hallucination
Rationale: The presence of a sensory stimulus
correlates with the definition of a hallucination,
which is a false sensory perception. Aphasia
refers to a communication problem. Dysarthria is
difficulty in speech production. Flight of ideas is
rapid shifting from one topic to another.
Answer: (D) The client looks at the shadow on a
wall and tells the nurse she sees frightening
faces on the wall.
Rationale: Minor memory problems are
distinguished from dementia by their minor
severity and their lack of significant interference
with the client’s social or occupational lifestyle.
Other options would be included in the history
data but don’t directly correlate with the client’s
lifestyle.
Answer: (D) Loose association
Rationale: Loose associations are conversations
that constantly shift in topic. Concrete thinking
implies highly definitive thought processes.
Flight of ideas is characterized by conversation
that’s disorganized from the onset. Loose
associations don’t necessarily start in a cogently,
then becomes loose.
Answer: (C) Paranoid
Rationale: Because of their suspiciousness,
paranoid personalities ascribe malevolent
activities to others and tent to be defensive,
becoming quarrelsome and argumentative.
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Clients with antisocial personality disorder can
also be antagonistic and argumentative but are
less suspicious than paranoid personalities.
Clients with histrionic personality disorder are
dramatic, not suspicious and argumentative.
Clients with schizoid personality disorder are
usually detached from other and tend to have
eccentric behavior.
Answer: (C) Explain that the drug is less affective
if the client smokes
Rationale: Olanzapine (Zyprexa) is less effective
for clients who smoke cigarettes. Serotonin
syndrome occurs with clients who take a
combination of antidepressant medications.
Olanzapine doesn’t cause euphoria, and
extrapyramidal adverse reactions aren’t a
problem. However, the client should be aware of
adverse effects such as tardive dyskinesia.
Answer: (A) Lack of honesty
Rationale: Clients with antisocial personality
disorder tent to engage in acts of dishonesty,
shown by lying. Clients with schizotypal
personality disorder tend to be superstitious.
Clients with histrionic personality disorders tend
to overreact to frustrations and
disappointments, have temper tantrums, and
seek attention.
Answer: (A) “I’m not going to look just at the
negative things about myself”
Rationale: As the client makes progress on
improving self-esteem, self- blame and negative
self-evaluation will decrease. Clients with
dependent personality disorder tend to feel
fragile and inadequate and would be extremely
unlikely to discuss their level of competence and
progress. These clients focus on self and aren’t
envious or jealous. Individuals with dependent
personality disorders don’t take over situations
because they see themselves as inept and
inadequate.
Answer: (C) Assess for possible physical
problems such as rash
Rationale: Clients with schizophrenia generally
have poor visceral recognition because they live
so fully in their fantasy world. They need to have
as in-depth assessment of physical complaints
that may spill over into their delusional
symptoms. Talking with the client won’t provide
as assessment of his itching, and itching isn’t as
adverse reaction of antipsychotic drugs, calling
the physician to get the client’s medication
increased doesn’t address his physical
complaints.
97. Answer: (B) Echopraxia
Rationale: Echopraxia is the copying of another’s
behaviors and is the result of the loss of ego
boundaries. Modeling is the conscious copying
of someone’s behaviors. Ego-syntonicity refers
to behaviors that correspond with the
individual’s sense of self. Ritualism behaviors are
repetitive and compulsive.
98. Answer: (C) Hallucination
Rationale: Hallucinations are sensory
experiences that are misrepresentations of
reality or have no basis in reality. Delusions are
beliefs not based in reality. Disorganized speech
is characterized by jumping from one topic to
the next or using unrelated words. An idea of
reference is a belief that an unrelated situation
holds special meaning for the client.
99. Answer: (C) Regression
Rationale: Regression, a return to earlier
behavior to reduce anxiety, is the basic defense
mechanism in schizophrenia. Projection is a
defense mechanism in which one blames others
and attempts to justify actions; it’s used
primarily by people with paranoid schizophrenia
and delusional disorder. Rationalization is a
defense mechanism used to justify one’s action.
Repression is the basic defense mechanism in
the neuroses; it’s an involuntary exclusion of
painful thoughts, feelings, or experiences from
awareness.
100. Answer: (A) Should report feelings of
restlessness or agitation at once
Rationale: Agitation and restlessness are adverse
effect of haloperidol and can be treated with
antocholinergic drugs. Haloperidol isn’t likely to
cause photosensitivity or control essential
hypertension. Although the client may
experience increased concentration and activity,
these effects are due to a decreased in
symptoms, not the drug itself.
153
PART III PRACTICE TEST I FOUNDATION OF
NURSING
1. Which element in the circular chain of infection
can be eliminated by preserving skin integrity?
a. Host
b. Reservoir
c. Mode of transmission
d. Portal of entry
2. Which of the following will probably result in a
break in sterile technique for respiratory
isolation?
a. Opening the patient’s window to the
outside environment
b. Turning on the patient’s room ventilator
c. Opening the door of the patient’s room
leading into the hospital corridor
d. Failing to wear gloves when
administering a bed bath
3. Which of the following patients is at greater risk
for contracting an infection?
a. A patient with leukopenia
b. A patient receiving broad-spectrum
antibiotics
c. A postoperative patient who has
undergone orthopedic surgery
d. A newly diagnosed diabetic patient
4. Effective hand washing requires the use of:
a. Soap or detergent to promote
emulsification
b. Hot water to destroy bacteria
c. A disinfectant to increase surface
tension
d. All of the above
5. After routine patient contact, hand washing
should last at least:
a. 30 seconds
b. 1 minute
c. 2 minute
d. 3 minutes
6. Which of the following procedures always
requires surgical asepsis?
a. Vaginal instillation of conjugated
estrogen
b. Urinary catheterization
c. Nasogastric tube insertion
d. Colostomy irrigation
7. Sterile technique is used whenever:
a. Strict isolation is required
b. Terminal disinfection is performed
c. Invasive procedures are performed
d. Protective isolation is necessary
8. Which of the following constitutes a break in
sterile technique while preparing a sterile field
for a dressing change?
a. Using sterile forceps, rather than sterile
gloves, to handle a sterile item
b. Touching the outside wrapper of
sterilized material without sterile gloves
c. Placing a sterile object on the edge of
the sterile field
d. Pouring out a small amount of solution
(15 to 30 ml) before pouring the solution
into a sterile container
9. A natural body defense that plays an active role
in preventing infection is:
a. Yawning
b. Body hair
c. Hiccupping
d. Rapid eye movements
10. All of the following statement are true about
donning sterile gloves except:
a. The first glove should be picked up by
grasping the inside of the cuff.
b. The second glove should be picked up by
inserting the gloved fingers under the
cuff outside the glove.
c. The gloves should be adjusted by sliding
the gloved fingers under the sterile cuff
and pulling the glove over the wrist
d. The inside of the glove is considered
sterile
11. When removing a contaminated gown, the nurse
should be careful that the first thing she touches
is the:
a. Waist tie and neck tie at the back of the
gown
b. Waist tie in front of the gown
c. Cuffs of the gown
d. Inside of the gown
12. Which of the following nursing interventions is
considered the most effective form or universal
precautions?
a. Cap all used needles before removing
them from their syringes
b. Discard all used uncapped needles and
syringes in an impenetrable protective
container
c. Wear gloves when administering IM
injections
d. Follow enteric precautions
13. All of the following measures are recommended
to prevent pressure ulcers except:
a. Massaging the reddened are with lotion
b. Using a water or air mattress
c. Adhering to a schedule for positioning
and turning
d. Providing meticulous skin care
14. Which of the following blood tests should be
performed before a blood transfusion?
a. Prothrombin and coagulation time
b. Blood typing and cross-matching
c. Bleeding and clotting time
d. Complete blood count (CBC) and
electrolyte levels.
15. The primary purpose of a platelet count is to
evaluate the:
a. Potential for clot formation
b. Potential for bleeding
c. Presence of an antigen-antibody
response
d. Presence of cardiac enzymes
16. Which of the following white blood cell (WBC)
counts clearly indicates leukocytosis?
a. 4,500/mm³
b. 7,000/mm³
c. 10,000/mm³
d. 25,000/mm³
17. After 5 days of diuretic therapy with 20mg of
furosemide (Lasix) daily, a patient begins to
exhibit fatigue, muscle cramping and muscle
weakness. These symptoms probably indicate
that the patient is experiencing:
a. Hypokalemia
b. Hyperkalemia
c. Anorexia
d. Dysphagia
18. Which of the following statements about chest
X-ray is false?
a. No contradictions exist for this test
154
b. Before the procedure, the patient should
remove all jewelry, metallic objects, and
buttons above the waist
c. A signed consent is not required
d. Eating, drinking, and medications are
allowed before this test
19. The most appropriate time for the nurse to
obtain a sputum specimen for culture is:
a. Early in the morning
b. After the patient eats a light breakfast
c. After aerosol therapy
d. After chest physiotherapy
20. A patient with no known allergies is to receive
penicillin every 6 hours.
21. When administering the medication, the nurse
observes a fine rash on the patient’s skin. The
most appropriate nursing action would be to:
a. Withhold the moderation and notify the
physician
b. Administer the medication and notify
the physician
c. Administer the medication with an
antihistamine
d. Apply corn starch soaks to the rash
22. All of the following nursing interventions are
correct when using the Z- track method of drug
injection except:
a. Prepare the injection site with alcohol
b. Use a needle that’s a least 1” long
c. Aspirate for blood before injection
d. Rub the site vigorously after the
injection to promote absorption
23. The correct method for determining the vastus
lateralis site for I.M. injection is to:
a. Locate the upper aspect of the upper
outer quadrant of the buttock about 5 to
8 cm below the iliac crest
b. Palpate the lower edge of the acromion
process and the midpoint lateral aspect
of the arm
c. Palpate a 1” circular area anterior to the
umbilicus
d. Divide the area between the greater
femoral trochanter and the lateral
femoral condyle into thirds, and select
the middle third on the anterior of the
thigh
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24. The mid-deltoid injection site is seldom used for
I.M. injections because it:
a. Can accommodate only 1 ml or less of
medication
b. Bruises too easily
c. Can be used only when the patient is
lying down
d. Does not readily parenteral medication
25. The appropriate needle size for insulin injection
is:
a. 18G, 1 ½” long
b. 22G, 1” long
c. 22G, 1 ½” long
d. 25G, 5/8” long
26. The appropriate needle gauge for intradermal
injection is:
a. 20G
b. 22G
c. 25G
d. 26G
27. Parenteral penicillin can be administered as an:
a. IM injection or an IV solution
b. IV or an intradermal injection
c. Intradermal or subcutaneous injection
d. IM or a subcutaneous injection
28. The physician orders gr 10 of aspirin for a
patient. The equivalent dose in milligrams is:
a. 0.6 mg
b. 10 mg
c. 60 mg
d. 600 mg
29. The physician orders an IV solution of dextrose
5% in water at 100ml/hour. What would the
flow rate be if the drop factor is 15 gtt = 1 ml?
a. 5 gtt/minute
b. 13 gtt/minute
c. 25 gtt/minute
d. 50 gtt/minute
30. Which of the following is a sign or symptom of a
hemolytic reaction to blood transfusion?
a. Hemoglobinuria
b. Chest pain
c. Urticaria
d. Distended neck veins
31. Which of the following conditions may require
fluid restriction?
a.
b.
c.
d.
Fever
Chronic Obstructive Pulmonary Disease
Renal Failure
Dehydration
32. All of the following are common signs and
symptoms of phlebitis except:
a. Pain or discomfort at the IV insertion site
b. Edema and warmth at the IV insertion
site
c. A red streak exiting the IV insertion site
d. Frank bleeding at the insertion site
33. The best way of determining whether a patient
has learned to instill ear medication properly is
for the nurse to:
a. Ask the patient if he/she has used ear
drops before
b. Have the patient repeat the nurse’s
instructions using her own words
c. Demonstrate the procedure to the
patient and encourage to ask questions
d. Ask the patient to demonstrate the
procedure
34. Which of the following types of medications can
be administered via gastrostomy tube?
a. Any oral medications
b. Capsules whole contents are dissolve in
water
c. Enteric-coated tablets that are
thoroughly dissolved in water
d. Most tablets designed for oral use,
except for extended-duration
compounds
35. A patient who develops hives after receiving an
antibiotic is exhibiting drug:
a. Tolerance
b. Idiosyncrasy
c. Synergism
d. Allergy
36. A patient has returned to his room after femoral
arteriography. All of the following are
appropriate nursing interventions except:
a. Assess femoral, popliteal, and pedal
pulses every 15 minutes for 2 hours
b. Check the pressure dressing for
sanguineous drainage
c. Assess vital signs every 15 minutes for 2
hours
d. Order a hemoglobin and hematocrit
count 1 hour after the arteriography
37. The nurse explains to a patient that a cough:
a. Is a protective response to clear the
respiratory tract of irritants
b. Is primarily a voluntary action
c. Is induced by the administration of an
antitussive drug
d. Can be inhibited by “splinting” the
abdomen
38. An infected patient has chills and begins
shivering. The best nursing intervention is to:
a. Apply iced alcohol sponges
b. Provide increased cool liquids
c. Provide additional bedclothes
d. Provide increased ventilation
39. A clinical nurse specialist is a nurse who has:
a. Been certified by the National League for
Nursing
b. Received credentials from the Philippine
Nurses’ Association
c. Graduated from an associate degree
program and is a registered professional
nurse
d. Completed a master’s degree in the
prescribed clinical area and is a
registered professional nurse.
40. The purpose of increasing urine acidity through
dietary means is to:
a. Decrease burning sensations
b. Change the urine’s color
c. Change the urine’s concentration
d. Inhibit the growth of microorganisms
41. Clay colored stools indicate:
a. Upper GI bleeding
b. Impending constipation
c. An effect of medication
d. Bile obstruction
42. In which step of the nursing process would the
nurse ask a patient if the medication she
administered relieved his pain?
a. Assessment
b. Analysis
c. Planning
d. Evaluation
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43. All of the following are good sources of vitamin A
except:
a. White potatoes
b. Carrots
c. Apricots
d. Egg yolks
44. Which of the following is a primary nursing
intervention necessary for all patients with a
Foley Catheter in place?
a. Maintain the drainage tubing and
collection bag level with the patient’s
bladder
b. Irrigate the patient with 1% Neosporin
solution three times a daily
c. Clamp the catheter for 1 hour every 4
hours to maintain the bladder’s elasticity
d. Maintain the drainage tubing and
collection bag below bladder level to
facilitate drainage by gravity
45. The ELISA test is used to:
a. Screen blood donors for antibodies to
human immunodeficiency virus (HIV)
b. Test blood to be used for transfusion for
HIV antibodies
c. Aid in diagnosing a patient with AIDS
d. All of the above
46. The two blood vessels most commonly used for
TPN infusion are the:
a. Subclavian and jugular veins
b. Brachial and subclavian veins
c. Femoral and subclavian veins
d. Brachial and femoral veins
47. Effective skin disinfection before a surgical
procedure includes which of the following
methods?
a. Shaving the site on the day before
surgery
b. Applying a topical antiseptic to the skin
on the evening before surgery
c. Having the patient take a tub bath on
the morning of surgery
d. Having the patient shower with an
antiseptic soap on the evening v=before
and the morning of surgery
48. When transferring a patient from a bed to a
chair, the nurse should use which muscles to
avoid back injury?
a. Abdominal muscles
157
b. Back muscles
c. Leg muscles
d. Upper arm muscles
49. Thrombophlebitis typically develops in patients
with which of the following conditions?
a. Increases partial thromboplastin time
b. Acute pulsus paradoxus
c. An impaired or traumatized blood vessel
wall
d. Chronic Obstructive Pulmonary Disease
(COPD)
50. In a recumbent, immobilized patient, lung
ventilation can become altered, leading to such
respiratory complications as:
a. Respiratory acidosis, ateclectasis, and
hypostatic pneumonia
b. Appneustic breathing, atypical
pneumonia and respiratory alkalosis
c. Cheyne-Strokes respirations and
spontaneous pneumothorax
d. Kussmail’s respirations and
hypoventilation
51. Immobility impairs bladder elimination, resulting
in such disorders as
a. Increased urine acidity and relaxation of
the perineal muscles, causing
incontinence
b. Urine retention, bladder distention, and
infection
c. Diuresis, natriuresis, and decreased
urine specific gravity
d. Decreased calcium and phosphate levels
in the urine
ANSWERS AND RATIONALE – FOUNDATION OF
NURSING
1. D. In the circular chain of infection, pathogens
must be able to leave their reservoir and be
transmitted to a susceptible host through a
portal of entry, such as broken skin.
2. C. Respiratory isolation, like strict isolation,
requires that the door to the door patient’s
room remain closed. However, the patient’s
room should be well ventilated, so opening the
window or turning on the ventricular is
desirable. The nurse does not need to wear
gloves for respiratory isolation, but good hand
washing is important for all types of isolation.
3. A. Leukopenia is a decreased number of
leukocytes (white blood cells), which are
important in resisting infection. None of the
other situations would put the patient at risk for
contracting an infection; taking broad- spectrum
antibiotics might actually reduce the infection
risk.
4. A. Soaps and detergents are used to help
remove bacteria because of their ability to lower
the surface tension of water and act as
emulsifying agents. Hot water may lead to skin
irritation or burns.
5. A. Depending on the degree of exposure to
pathogens, hand washing may last from 10
seconds to 4 minutes. After routine patient
contact, hand washing for 30 seconds effectively
minimizes the risk of pathogen transmission.
6. B. The urinary system is normally free of
microorganisms except at the urinary meatus.
Any procedure that involves entering this system
must use surgically aseptic measures to maintain
a bacteria-free state.
7. C. All invasive procedures, including surgery,
catheter insertion, and administration of
parenteral therapy, require sterile technique to
maintain a sterile environment. All equipment
must be sterile, and the nurse and the physician
must wear sterile gloves and maintain surgical
asepsis. In the operating room, the nurse and
physician are required to wear sterile gowns,
gloves, masks, hair covers, and shoe covers for
all invasive procedures. Strict isolation requires
the use of clean gloves, masks, gowns and
equipment to prevent the transmission of highly
communicable diseases by contact or by
airborne routes. Terminal disinfection is the
disinfection of all contaminated supplies and
equipment after a patient has been discharged
158
8.
9.
10.
11.
12.
13.
14.
to prepare them for reuse by another patient.
The purpose of protective (reverse) isolation is
to prevent a person with seriously impaired
resistance from coming into contact who
potentially pathogenic organisms.
C. The edges of a sterile field are considered
contaminated. When sterile items are allowed to
come in contact with the edges of the field, the
sterile items also become contaminated.
B. Hair on or within body areas, such as the
nose, traps and holds particles that contain
microorganisms. Yawning and hiccupping do not
prevent microorganisms from entering or
leaving the body. Rapid eye movement marks
the stage of sleep during which dreaming occurs.
D. The inside of the glove is always considered to
be clean, but not sterile.
A. The back of the gown is considered clean, the
front is contaminated. So, after removing gloves
and washing hands, the nurse should untie the
back of the gown; slowly move backward away
from the gown, holding the inside of the gown
and keeping the edges off the floor; turn and
fold the gown inside out; discard it in a
contaminated linen container; then wash her
hands again.
B. According to the Centers for Disease Control
(CDC), blood-to-blood contact occurs most
commonly when a health care worker attempts
to cap a used needle. Therefore, used needles
should never be recapped; instead they should
be inserted in a specially designed puncture
resistant, labeled container. Wearing gloves is
not always necessary when administering an I.M.
injection. Enteric precautions prevent the
transfer of pathogens via feces.
A. Nurses and other health care professionals
previously believed that massaging a reddened
area with lotion would promote venous return
and reduce edema to the area. However,
research has shown that massage only increases
the likelihood of cellular ischemia and necrosis
to the area.
B. Before a blood transfusion is performed, the
blood of the donor and recipient must be
checked for compatibility. This is done by blood
typing (a test that determines a person’s blood
type) and cross-matching (a procedure that
determines the compatibility of the donor’s and
recipient’s blood after the blood types has been
matched). If the blood specimens are
incompatible, hemolysis and antigen-antibody
reactions will occur.
159
15. A. Platelets are disk-shaped cells that are
essential for blood coagulation. A platelet count
determines the number of thrombocytes in
blood available for promoting hemostasis and
assisting with blood coagulation after injury. It
also is used to evaluate the patient’s potential
for bleeding; however, this is not its primary
purpose. The normal count ranges from 150,000
to 350,000/mm3. A count of 100,000/mm3 or
less indicates a potential for bleeding; count of
less than 20,000/mm3 is associated with
spontaneous bleeding.
16. D. Leukocytosis is any transient increase in the
number of white blood cells (leukocytes) in the
blood. Normal WBC counts range from 5,000 to
100,000/mm3. Thus, a count of 25,000/mm3
indicates leukocytosis.
17. A. Fatigue, muscle cramping, and muscle
weaknesses are symptoms of hypokalemia (an
inadequate potassium level), which is a potential
side effect of diuretic therapy. The physician
usually orders supplemental potassium to
prevent hypokalemia in patients receiving
diuretics. Anorexia is another symptom of
hypokalemia. Dysphagia means difficulty
swallowing.
18. A. Pregnancy or suspected pregnancy is the only
contraindication for a chest X-ray. However, if a
chest X-ray is necessary, the patient can wear a
lead apron to protect the pelvic region from
radiation. Jewelry, metallic objects, and buttons
would interfere with the X-ray and thus should
not be worn above the waist. A signed consent is
not required because a chest X-ray is not an
invasive examination. Eating, drinking and
medications are allowed because the X-ray is of
the chest, not the abdominal region.
19. A. Obtaining a sputum specimen early in this
morning ensures an adequate supply of bacteria
for culturing and decreases the risk of
contamination from food or medication.
20. A. Initial sensitivity to penicillin is commonly
manifested by a skin rash, even in individuals
who have not been allergic to it previously.
Because of the danger of anaphylactic shock, he
nurse should withhold the drug and notify the
physician, who may choose to substitute
another drug. Administering an antihistamine is
a dependent nursing intervention that requires a
written physician’s order. Although applying
corn starch to the rash may relieve discomfort, it
is not the nurse’s top priority in such a
potentially life-threatening situation.
21. D. The Z-track method is an I.M. injection
technique in which the patient’s skin is pulled in
such a way that the needle track is sealed off
after the injection. This procedure seals
medication deep into the muscle, thereby
minimizing skin staining and irritation. Rubbing
the injection site is contraindicated because it
may cause the medication to extravasate into
the skin.
22. D. The vastus lateralis, a long, thick muscle that
extends the full length of the thigh, is viewed by
many clinicians as the site of choice for I.M.
injections because it has relatively few major
nerves and blood vessels. The middle third of the
muscle is recommended as the injection site.
The patient can be in a supine or sitting position
for an injection into this site.
23. A. The mid-deltoid injection site can
accommodate only 1 ml or less of medication
because of its size and location (on the deltoid
muscle of the arm, close to the brachial artery
and radial nerve).
24. D. A 25G, 5/8” needle is the recommended size
for insulin injection because insulin is
administered by the subcutaneous route. An
18G, 1 ½” needle is usually used for I.M.
injections in children, typically in the vastus
lateralis. A 22G, 1 ½” needle is usually used for
adult I.M. injections, which are typically
administered in the vastus lateralis or
ventrogluteal site.
25. D. Because an intradermal injection does not
penetrate deeply into the skin, a small-bore 25G
needle is recommended. This type of injection is
used primarily to administer antigens to
evaluate reactions for allergy or sensitivity
studies. A 20G needle is usually used for I.M.
injections of oil- based medications; a 22G
needle for I.M. injections; and a 25G needle, for
I.M. injections; and a 25G needle, for
subcutaneous insulin injections.
26. A. Parenteral penicillin can be administered I.M.
or added to a solution and given I.V. It cannot be
administered subcutaneously or intradermally.
27. D. gr 10 x 60mg/gr 1 = 600 mg
28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
29. A. Hemoglobinuria, the abnormal presence of
hemoglobin in the urine, indicates a hemolytic
reaction (incompatibility of the donor’s and
recipient’s blood). In this reaction, antibodies in
the recipient’s plasma combine rapidly with
donor RBC’s; the cells are hemolyzed in either
circulatory or reticuloendothelial system.
30.
31.
32.
33.
34.
35.
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Hemolysis occurs more rapidly in ABO
incompatibilities than in Rh incompatibilities.
Chest pain and urticarial may be symptoms of
impending anaphylaxis. Distended neck veins are
an indication of hypervolemia.
C. In real failure, the kidney loses their ability to
effectively eliminate wastes and fluids. Because
of this, limiting the patient’s intake of oral and
I.V. fluids may be necessary. Fever, chronic
obstructive pulmonary disease, and dehydration
are conditions for which fluids should be
encouraged.
D. Phlebitis, the inflammation of a vein, can be
caused by chemical irritants (I.V. solutions or
medications), mechanical irritants (the needle or
catheter used during venipuncture or
cannulation), or a localized allergic reaction to
the needle or catheter. Signs and symptoms of
phlebitis include pain or discomfort, edema and
heat at the I.V. insertion site, and a red streak
going up the arm or leg from the I.V. insertion
site.
D. Return demonstration provides the most
certain evidence for evaluating the effectiveness
of patient teaching.
D. Capsules, enteric-coated tablets, and most
extended duration or sustained release products
should not be dissolved for use in a gastrostomy
tube. They are pharmaceutically manufactured
in these forms for valid reasons, and altering
them destroys their purpose. The nurse should
seek an alternate physician’s order when an
ordered medication is inappropriate for delivery
by tube.
D. A drug-allergy is an adverse reaction resulting
from an immunologic response following a
previous sensitizing exposure to the drug. The
reaction can range from a rash or hives to
anaphylactic shock. Tolerance to a drug means
that the patient experiences a decreasing
physiologic response to repeated administration
of the drug in the same dosage. Idiosyncrasy is
an individual’s unique hypersensitivity to a drug,
food, or other substance; it appears to be
genetically determined. Synergism, is a drug
interaction in which the sum of the drug’s
combined effects is greater than that of their
separate effects.
D. A hemoglobin and hematocrit count would be
ordered by the physician if bleeding were
suspected. The other answers are appropriate
nursing interventions for a patient who has
undergone femoral arteriography.
36. A. Coughing, a protective response that clears
the respiratory tract of irritants, usually is
involuntary; however it can be voluntary, as
when a patient is taught to perform coughing
exercises. An antitussive drug inhibits coughing.
Splinting the abdomen supports the abdominal
muscles when a patient coughs.
37. C. In an infected patient, shivering results from
the body’s attempt to increase heat production
and the production of neutrophils and
phagocytotic action through increased skeletal
muscle tension and contractions. Initial
vasoconstriction may cause skin to feel cold to
the touch. Applying additional bed clothes helps
to equalize the body temperature and stop the
chills. Attempts to cool the body result in further
shivering, increased metabloism, and thus
increased heat production.
38. D. A clinical nurse specialist must have
completed a master’s degree in a clinical
specialty and be a registered professional nurse.
The National League of Nursing accredits
educational programs in nursing and provides a
testing service to evaluate student nursing
competence but it does not certify nurses. The
American Nurses Association identifies
requirements for certification and offers
examinations for certification in many areas of
nursing, such as medical surgical nursing. These
certification (credentialing) demonstrates that
the nurse has the knowledge and the ability to
provide high quality nursing care in the area of
her certification. A graduate of an associate
degree program is not a clinical nurse specialist:
however, she is prepared to provide bed side
nursing with a high degree of knowledge and
skill. She must successfully complete the
licensing examination to become a registered
professional nurse.
39. D. Microorganisms usually do not grow in an
acidic environment.
40. D. Bile colors the stool brown. Any inflammation
or obstruction that impairs bile flow will affect
the stool pigment, yielding light, clay-colored
stool. Upper GI bleeding results in black or tarry
stool. Constipation is characterized by small,
hard masses. Many medications and foods will
discolor stool – for example, drugs containing
iron turn stool black.; beets turn stool red.
41. D. In the evaluation step of the nursing process,
the nurse must decide whether the patient has
achieved the expected outcome that was
identified in the planning phase.
161
42. A. The main sources of vitamin A are yellow and
green vegetables (such as carrots, sweet
potatoes, squash, spinach, collard greens,
broccoli, and cabbage) and yellow fruits (such as
apricots, and cantaloupe). Animal sources
include liver, kidneys, cream, butter, and egg
yolks.
43. D. Maintaing the drainage tubing and collection
bag level with the patient’s bladder could result
in reflux of urine into the kidney. Irrigating the
bladder with Neosporin and clamping the
catheter for 1 hour every 4 hours must be
prescribed by a physician.
44. D. The ELISA test of venous blood is used to
assess blood and potential blood donors to
human immunodeficiency virus (HIV). A positive
ELISA test combined with various signs and
symptoms helps to diagnose acquired
immunodeficiency syndrome (AIDS)
45. D. Tachypnea (an abnormally rapid rate of
breathing) would indicate that the patient was
still hypoxic (deficient in oxygen).The partial
pressures of arterial oxygen and carbon dioxide
listed are within the normal range. Eupnea refers
to normal respiration.
46. D. Studies have shown that showering with an
antiseptic soap before surgery is the most
effective method of removing microorganisms
from the skin. Shaving the site of the intended
surgery might cause breaks in the skin, thereby
increasing the risk of infection; however, if
indicated, shaving, should be done immediately
before surgery, not the day before. A topical
antiseptic would not remove microorganisms
and would be beneficial only after proper
cleaning and rinsing. Tub bathing might transfer
organisms to another body site rather than rinse
them away.
47. C. The leg muscles are the strongest muscles in
the body and should bear the greatest stress
when lifting. Muscles of the abdomen, back, and
upper arms may be easily injured.
48. C. The factors, known as Virchow’s triad,
collectively predispose a patient to
thromboplebitis; impaired venous return to the
heart, blood hypercoagulability, and injury to a
blood vessel wall. Increased partial
thromboplastin time indicates a prolonged
bleeding time during fibrin clot formation,
commonly the result of anticoagulant (heparin)
therapy. Arterial blood disorders (such as pulsus
paradoxus) and lung diseases (such as COPD) do
not necessarily impede venous return of injure
vessel walls.
49. A. Because of restricted respiratory movement, a
recumbent, immobilize patient is at particular
risk for respiratory acidosis from poor gas
exchange; atelectasis from reduced surfactant
and accumulated mucus in the bronchioles, and
hypostatic pneumonia from bacterial growth
caused by stasis of mucus secretions.
50. B. The immobilized patient commonly suffers
from urine retention caused by decreased
muscle tone in the perineum. This leads to
bladder distention and urine stagnation, which
provide an excellent medium for bacterial
growth leading to infection. Immobility also
results in more alkaline urine with excessive
amounts of calcium, sodium and phosphate, a
gradual decrease in urine production, and an
increased specific gravity.
PRACTICE TEST II Maternal and Child Health
1. For the client who is using oral contraceptives,
the nurse informs the client about the need to
take the pill at the same time each day to
accomplish which of the following?
a. Decrease the incidence of nausea
b. Maintain hormonal levels
c. Reduce side effects
d. Prevent drug interactions
2. When teaching a client about contraception.
Which of the following would the nurse include
as the most effective method for preventing
sexually transmitted infections?
a. Spermicides
b. Diaphragm
c. Condoms
d. Vasectomy
3. When preparing a woman who is 2 days
postpartum for discharge, recommendations for
which of the following contraceptive methods
would be avoided?
a. Diaphragm
b. Female condom
c. Oral contraceptives
d. Rhythm method
4. For which of the following clients would the
nurse expect that an intrauterine device would
not be recommended?
a. Woman over age 35
b. Nulliparous woman
c. Promiscuous young adult
d. Postpartum client
5. A client in her third trimester tells the nurse,
“I’m constipated all the time!” Which of the
following should the nurse recommend?
a. Daily enemas
b. Laxatives
c. Increased fiber intake
d. Decreased fluid intake
6. Which of the following would the nurse use as
the basis for the teaching plan when caring for a
pregnant teenager concerned about gaining too
much weight during pregnancy?
a. 10 pounds per trimester
b. 1 pound per week for 40 weeks
c. ½ pound per week for 40 weeks
d. A total gain of 25 to 30 pounds
162
7. The client tells the nurse that her last menstrual
period started on January 14 and ended on
January 20. Using Nagele’s rule, the nurse
determines her EDD to be which of the
following?
a. September 27
b. October 21
c. November 7
d. December 27
8. When taking an obstetrical history on a pregnant
client who states, “I had a son born at 38 weeks
gestation, a daughter born at 30 weeks gestation
and I lost a baby at about 8 weeks,” the nurse
should record her obstetrical history as which of
the following?
a. G2 T2 P0 A0 L2
b. G3 T1 P1 A0 L2
c. G3 T2 P0 A0 L2
d. G4 T1 P1 A1 L2
9. When preparing to listen to the fetal heart rate
at 12 weeks’ gestation, the nurse would use
which of the following?
a. Stethoscope placed midline at the
umbilicus
b. Doppler placed midline at the
suprapubic region
c. Fetoscope placed midway between the
umbilicus and the xiphoid process
d. External electronic fetal monitor placed
at the umbilicus
10. When developing a plan of care for a client
newly diagnosed with gestational diabetes,
which of the following instructions would be the
priority?
a. Dietary intake
b. Medication
c. Exercise
d. Glucose monitoring
11. A client at 24 weeks gestation has gained 6
pounds in 4 weeks. Which of the following would
be the priority when assessing the client?
a. Glucosuria
b. Depression
c. Hand/face edema
d. Dietary intake
12. A client 12 weeks’ pregnant come to the
emergency department with abdominal
163
cramping and moderate vaginal bleeding.
Speculum examination reveals 2 to 3 cms
cervical dilation. The nurse would document
these findings as which of the following?
a. Threatened abortion
b. Imminent abortion
c. Complete abortion
d. Missed abortion
13. Which of the following would be the priority
nursing diagnosis for a client with an ectopic
pregnancy?
a. Risk for infection
b. Pain
c. Knowledge Deficit
d. Anticipatory Grieving
14. Before assessing the postpartum client’s uterus
for firmness and position in relation to the
umbilicus and midline, which of the following
should the nurse do first?
a. Assess the vital signs
b. Administer analgesia
c. Ambulate her in the hall
d. Assist her to urinate
15. Which of the following should the nurse do
when a primipara who is lactating tells the nurse
that she has sore nipples?
a. Tell her to breast feed more frequently
b. Administer a narcotic before breast
feeding
c. Encourage her to wear a nursing
brassiere
d. Use soap and water to clean the nipples
16. The nurse assesses the vital signs of a client, 4
hours’ postpartum that are as follows: BP 90/60;
temperature 100.4ºF; pulse 100 weak, thready;
R 20 per minute. Which of the following should
the nurse do first?
a. Report the temperature to the physician
b. Recheck the blood pressure with
another cuff
c. Assess the uterus for firmness and
position
d. Determine the amount of lochia
17. The nurse assesses the postpartum vaginal
discharge (lochia) on four clients. Which of the
following assessments would warrant
notification of the physician?
a. A dark red discharge on a 2-day
postpartum client
b. A pink to brownish discharge on a client
who is 5 days postpartum
c. Almost colorless to creamy discharge on
a client 2 weeks after delivery
d. A bright red discharge 5 days after
delivery
18. A postpartum client has a temperature of
101.4ºF, with a uterus that is tender when
palpated, remains unusually large, and not
descending as normally expected. Which of the
following should the nurse assess next?
a. Lochia
b. Breasts
c. Incision
d. Urine
19. Which of the following is the priority focus of
nursing practice with the current early
postpartum discharge?
a. Promoting comfort and restoration of
health
b. Exploring the emotional status of the
family
c. Facilitating safe and effective self-and
newborn care
d. Teaching about the importance of family
planning
20. Which of the following actions would be least
effective in maintaining a neutral thermal
environment for the newborn?
a. Placing infant under radiant warmer
after bathing
b. Covering the scale with a warmed
blanket prior to weighing
c. Placing crib close to nursery window for
family viewing
d. Covering the infant’s head with a knit
stockinette
21. A newborn who has an asymmetrical Moro
reflex response should be further assessed for
which of the following?
a. Talipes equinovarus
b. Fractured clavicle
c. Congenital hypothyroidism
d. Increased intracranial pressure
22. During the first 4 hours after a male
circumcision, assessing for which of the
following is the priority?
a. Infection
b. Hemorrhage
c. Discomfort
d. Dehydration
23. The mother asks the nurse. “What’s wrong with
my son’s breasts? Why are they so enlarged?”
Whish of the following would be the best
response by the nurse?
a. “The breast tissue is inflamed from the
trauma experienced with birth”
b. “A decrease in material hormones
present before birth causes
enlargement,”
c. “You should discuss this with your
doctor. It could be a malignancy”
d. “The tissue has hypertrophied while the
baby was in the uterus”
24. Immediately after birth the nurse notes the
following on a male newborn: respirations 78;
apical hearth rate 160 BPM, nostril flaring; mild
intercostal retractions; and grunting at the end
of expiration. Which of the following should the
nurse do?
a. Call the assessment data to the
physician’s attention
b. Start oxygen per nasal cannula at 2
L/min.
c. Suction the infant’s mouth and nares
d. Recognize this as normal first period of
reactivity
25. The nurse hears a mother telling a friend on the
telephone about umbilical cord care. Which of
the following statements by the mother
indicates effective teaching?
a. “Daily soap and water cleansing is best”
b. ‘Alcohol helps it dry and kills germs”
c. “An antibiotic ointment applied daily
prevents infection”
d. “He can have a tub bath each day”
26. A newborn weighing 3000 grams and feeding
every 4 hours needs 120 calories/kg of body
weight every 24 hours for proper growth and
development. How many ounces of 20 cal/oz
formula should this newborn receive at each
feeding to meet nutritional needs?
a. 2 ounces
164
b. 3 ounces
c. 4 ounces
d. 6 ounces
27. The postterm neonate with meconium-stained
amniotic fluid needs care designed to especially
monitor for which of the following?
a. Respiratory problems
b. Gastrointestinal problems
c. Integumentary problems
d. Elimination problems
28. When measuring a client’s fundal height, which
of the following techniques denotes the correct
method of measurement used by the nurse?
a. From the xiphoid process to the
umbilicus
b. From the symphysis pubis to the xiphoid
process
c. From the symphysis pubis to the fundus
d. From the fundus to the umbilicus
29. A client with severe preeclampsia is admitted
with of BP 160/110, proteinuria, and severe
pitting edema. Which of the following would be
most important to include in the client’s plan of
care?
a. Daily weights
b. Seizure precautions
c. Right lateral positioning
d. Stress reduction
30. A postpartum primipara asks the nurse, “When
can we have sexual intercourse again?” Which of
the following would be the nurse’s best
response?
a. “Anytime you both want to.”
b. “As soon as choose a contraceptive
method.”
c. “When the discharge has stopped and
the incision is healed.”
d. “After your 6 weeks examination.”
31. When preparing to administer the vitamin K
injection to a neonate, the nurse would select
which of the following sites as appropriate for
the injection?
a. Deltoid muscle
b. Anterior femoris muscle
c. Vastus lateralis muscle
d. Gluteus maximus muscle
165
32. When performing a pelvic examination, the
nurse observes a red swollen area on the right
side of the vaginal orifice. The nurse would
document this as enlargement of which of the
following?
a. Clitoris
b. Parotid gland
c. Skene’s gland
d. Bartholin’s gland
33. To differentiate as a female, the hormonal
stimulation of the embryo that must occur
involves which of the following?
a. Increase in maternal estrogen secretion
b. Decrease in maternal androgen
secretion
c. Secretion of androgen by the fetal gonad
d. Secretion of estrogen by the fetal gonad
34. A client at 8 weeks’ gestation calls complaining
of slight nausea in the morning hours. Which of
the following client interventions should the
nurse question?
a. Taking 1 teaspoon of bicarbonate of
soda in an 8-ounce glass of water
b. Eating a few low-sodium crackers before
getting out of bed
c. Avoiding the intake of liquids in the
morning hours
d. Eating six small meals a day instead of
thee large meals
35. The nurse documents positive ballottement in
the client’s prenatal record. The nurse
understands that this indicates which of the
following?
a. Palpable contractions on the abdomen
b. Passive movement of the unengaged
fetus
c. Fetal kicking felt by the client
d. Enlargement and softening of the uterus
36. During a pelvic exam the nurse notes a purpleblue tinge of the cervix. The nurse documents
this as which of the following?
a. Braxton-Hicks sign
b. Chadwick’s sign
c. Goodell’s sign
d. McDonald’s sign
37. During a prenatal class, the nurse explains the
rationale for breathing techniques during
preparation for labor based on the
understanding that breathing techniques are
most important in achieving which of the
following?
a. Eliminate pain and give the expectant
parents something to do
b. Reduce the risk of fetal distress by
increasing uteroplacental perfusion
c. Facilitate relaxation, possibly reducing
the perception of pain
d. Eliminate pain so that less analgesia and
anesthesia are needed
38. After 4 hours of active labor, the nurse notes
that the contractions of a primigravida client are
not strong enough to dilate the cervix. Which of
the following would the nurse anticipate doing?
a. Obtaining an order to begin IV oxytocin
infusion
b. Administering a light sedative to allow
the patient to rest for several hour
c. Preparing for a cesarean section for
failure to progress
d. Increasing the encouragement to the
patient when pushing begins
39. A multigravida at 38 weeks’ gestation is
admitted with painless, bright red bleeding and
mild contractions every 7 to 10 minutes. Which
of the following assessments should be avoided?
a. Maternal vital sign
b. Fetal heart rate
c. Contraction monitoring
d. Cervical dilation
40. Which of the following would be the nurse’s
most appropriate response to a client who asks
why she must have a cesarean delivery if she has
a complete placenta previa?
a. “You will have to ask your physician
when he returns.”
b. “You need a cesarean to prevent
hemorrhage.”
c. “The placenta is covering most of your
cervix.”
d. “The placenta is covering the opening of
the uterus and blocking your baby.”
41. The nurse understands that the fetal head is in
which of the following positions with a face
presentation?
a. Completely flexed
b. Completely extended
c. Partially extended
d. Partially flexed
42. With a fetus in the left-anterior breech
presentation, the nurse would expect the fetal
heart rate would be most audible in which of the
following areas?
a. Above the maternal umbilicus and to the
right of midline
b. In the lower-left maternal abdominal
quadrant
c. In the lower-right maternal abdominal
quadrant
d. Above the maternal umbilicus and to the
left of midline
43. The amniotic fluid of a client has a greenish tint.
The nurse interprets this to be the result of
which of the following?
a. Lanugo
b. Hydramnio
c. Meconium
d. Vernix
44. A patient is in labor and has just been told she
has a breech presentation. The nurse should be
particularly alert for which of the following?
a. Quickening
b. Ophthalmia neonatorum
c. Pica
d. Prolapsed umbilical cord
45. When describing dizygotic twins to a couple, on
which of the following would the nurse base the
explanation?
a. Two ova fertilized by separate sperm
b. Sharing of a common placenta
c. Each ova with the same genotype
d. Sharing of a common chorion
46. Which of the following refers to the single cell
that reproduces itself after conception?
a. Chromosome
b. Blastocyst
c. Zygote
d. Trophoblast
47. In the late 1950s, consumers and health care
professionals began challenging the routine use
of analgesics and anesthetics during childbirth.
Which of the following was an outgrowth of this
concept?
a. Labor, delivery, recovery, postpartum
(LDRP)
166
b. Nurse-midwifery
c. Clinical nurse specialist
d. Prepared childbirth
48. A client has a midpelvic contracture from a
previous pelvic injury due to a motor vehicle
accident as a teenager. The nurse is aware that
this could prevent a fetus from passing through
or around which structure during childbirth?
a. Symphysis pubis
b. Sacral promontory
c. Ischial spines
d. Pubic arch
49. When teaching a group of adolescents about
variations in the length of the menstrual cycle,
the nurse understands that the underlying
mechanism is due to variations in which of the
following phases?
a. Menstrual phase
b. Proliferative phase
c. Secretory phase
d. Ischemic phase
50. When teaching a group of adolescents about
male hormone production, which of the
following would the nurse include as being
produced by the Leydig cells?
a. Follicle-stimulating hormone
b. Testosterone
c. Leuteinizing hormone
d. Gonadotropin releasing hormone
167
ANSWERS AND RATIONALE – MATERNAL AND
CHILD HEALTH
1. B. Regular timely ingestion of oral contraceptives
is necessary to maintain hormonal levels of the
drugs to suppress the action of the
hypothalamus and anterior pituitary leading to
inappropriate secretion of FSH and LH.
Therefore, follicles do not mature, ovulation is
inhibited, and pregnancy is prevented. The
estrogen content of the oral site contraceptive
may cause the nausea, regardless of when the
pill is taken. Side effects and drug interactions
may occur with oral contraceptives regardless of
the time the pill is taken.
2. C. Condoms, when used correctly and
consistently, are the most effective
contraceptive method or barrier against
bacterial and viral sexually transmitted
infections. Although spermicides kill sperm, they
do not provide reliable protection against the
spread of sexually transmitted infections,
especially intracellular organisms such as HIV.
Insertion and removal of the diaphragm along
with the use of the spermicides may cause
vaginal irritations, which could place the client at
risk for infection transmission. Male sterilization
eliminates spermatozoa from the ejaculate, but
it does not eliminate bacterial and/or viral
microorganisms that can cause sexually
transmitted infections.
3. A. The diaphragm must be fitted individually to
ensure effectiveness. Because of the changes to
the reproductive structures during pregnancy
and following delivery, the diaphragm must be
refitted, usually at the 6 weeks’ examination
following childbirth or after a weight loss of 15
lbs or more. In addition, for maximum
effectiveness, spermicidal jelly should be placed
in the dome and around the rim. However,
spermicidal jelly should not be inserted into the
vagina until involution is completed at
approximately 6 weeks. Use of a female condom
protects the reproductive system from the
introduction of semen or spermicides into the
vagina and may be used after childbirth. Oral
contraceptives may be started within the first
postpartum week to ensure suppression of
ovulation. For the couple who has determined
the female’s fertile period, using the rhythm
method, avoidance of intercourse during this
period, is safe and effective.
4. C. An IUD may increase the risk of pelvic
inflammatory disease, especially in women with
more than one sexual partner, because of the
increased risk of sexually transmitted infections.
An UID should not be used if the woman has an
active or chronic pelvic infection, postpartum
infection, endometrial hyperplasia or carcinoma,
or uterine abnormalities. Age is not a factor in
determining the risks associated with IUD use.
Most IUD users are over the age of 30. Although
there is a slightly higher risk for infertility in
women who have never been pregnant, the IUD
is an acceptable option as long as the riskbenefit ratio is discussed. IUDs may be inserted
immediately after delivery, but this is not
recommended because of the increased risk and
rate of expulsion at this time.
5. C. During the third trimester, the enlarging
uterus places pressure on the intestines. This
coupled with the effect of hormones on smooth
muscle relaxation causes decreased intestinal
motility (peristalsis). Increasing fiber in the diet
will help fecal matter pass more quickly through
the intestinal tract, thus decreasing the amount
of water that is absorbed. As a result, stool is
softer and easier to pass. Enemas could
precipitate preterm labor and/or electrolyte loss
and should be avoided. Laxatives may cause
preterm labor by stimulating peristalsis and may
interfere with the absorption of nutrients. Use
for more than 1 week can also lead to laxative
dependency. Liquid in the diet helps provide a
semisolid, soft consistency to the stool. Eight to
ten glasses of fluid per day are essential to
maintain hydration and promote stool
evacuation.
6. D. To ensure adequate fetal growth and
development during the 40 weeks of a
pregnancy, a total weight gain 25 to 30 pounds is
recommended: 1.5 pounds in the first 10 weeks;
9 pounds by 30 weeks; and 27.5 pounds by 40
weeks. The pregnant woman should gain less
weight in the first and second trimester than in
the third. During the first trimester, the client
should only gain 1.5 pounds in the first 10
weeks, not 1 pound per week. A weight gain of ½
pound per week would be 20 pounds for the
total pregnancy, less than the recommended
amount.
7. B. To calculate the EDD by Nagele’s rule, add 7
days to the first day of the last menstrual period
and count back 3 months, changing the year
appropriately. To obtain a date of September 27,
8.
9.
10.
11.
168
7 days have been added to the last day of the
LMP (rather than the first day of the LMP), plus 4
months (instead of 3 months) were counted
back. To obtain the date of November 7, 7 days
have been subtracted (instead of added) from
the first day of LMP plus November indicates
counting back 2 months (instead of 3 months)
from January. To obtain the date of December
27, 7 days were added to the last day of the LMP
(rather than the first day of the LMP) and
December indicates counting back only 1 month
(instead of 3 months) from January.
D. The client has been pregnant four times,
including current pregnancy (G). Birth at 38
weeks’ gestation is considered full term (T),
while birth form 20 weeks to 38 weeks is
considered preterm (P). A spontaneous abortion
occurred at 8 weeks (A). She has two living
children (L).
B. At 12 weeks gestation, the uterus rises out of
the pelvis and is palpable above the symphysis
pubis. The Doppler intensifies the sound of the
fetal pulse rate so it is audible. The uterus has
merely risen out of the pelvis into the abdominal
cavity and is not at the level of the umbilicus.
The fetal heart rate at this age is not audible
with a stethoscope. The uterus at 12 weeks is
just above the symphysis pubis in the abdominal
cavity, not midway between the umbilicus and
the xiphoid process. At 12 weeks the FHR would
be difficult to auscultate with a fetoscope.
Although the external electronic fetal monitor
would project the FHR, the uterus has not risen
to the umbilicus at 12 weeks.
A. Although all of the choices are important in
the management of diabetes, diet therapy is the
mainstay of the treatment plan and should
always be the priority. Women diagnosed with
gestational diabetes generally need only diet
therapy without medication to control their
blood sugar levels. Exercise, is important for all
pregnant women and especially for diabetic
women, because it burns up glucose, thus
decreasing blood sugar. However, dietary intake,
not exercise, is the priority. All pregnant women
with diabetes should have periodic monitoring
of serum glucose. However, those with
gestational diabetes generally do not need daily
glucose monitoring. The standard of care
recommends a fasting and 2- hour postprandial
blood sugar level every 2 weeks.
C. After 20 weeks’ gestation, when there is a
rapid weight gain, preeclampsia should be
12.
13.
14.
15.
suspected, which may be caused by fluid
retention manifested by edema, especially of the
hands and face. The three classic signs of
preeclampsia are hypertension, edema, and
proteinuria. Although urine is checked for
glucose at each clinic visit, this is not the priority.
Depression may cause either anorexia or
excessive food intake, leading to excessive
weight gain or loss. This is not, however, the
priority consideration at this time. Weight gain
thought to be caused by excessive food intake
would require a 24-hour diet recall. However,
excessive intake would not be the primary
consideration for this client at this time.
B. Cramping and vaginal bleeding coupled with
cervical dilation signifies that termination of the
pregnancy is inevitable and cannot be
prevented. Thus, the nurse would document an
imminent abortion. In a threatened abortion,
cramping and vaginal bleeding are present, but
there is no cervical dilation. The symptoms may
subside or progress to abortion. In a complete
abortion all the products of conception are
expelled. A missed abortion is early fetal
intrauterine death without expulsion of the
products of conception.
B. For the client with an ectopic pregnancy,
lower abdominal pain, usually unilateral, is the
primary symptom. Thus, pain is the priority.
Although the potential for infection is always
present, the risk is low in ectopic pregnancy
because pathogenic microorganisms have not
been introduced from external sources. The
client may have a limited knowledge of the
pathology and treatment of the condition and
will most likely experience grieving, but this is
not the priority at this time.
D. Before uterine assessment is performed, it is
essential that the woman empty her bladder. A
full bladder will interfere with the accuracy of
the assessment by elevating the uterus and
displacing to the side of the midline. Vital sign
assessment is not necessary unless an
abnormality in uterine assessment is identified.
Uterine assessment should not cause acute pain
that requires administration of analgesia.
Ambulating the client is an essential component
of postpartum care, but is not necessary prior to
assessment of the uterus.
A. Feeding more frequently, about every 2
hours, will decrease the infant’s frantic, vigorous
sucking from hunger and will decrease breast
engorgement, soften the breast, and promote
169
ease of correct latching-on for feeding. Narcotics
administered prior to breast feeding are passed
through the breast milk to the infant, causing
excessive sleepiness. Nipple soreness is not
severe enough to warrant narcotic analgesia. All
postpartum clients, especially lactating mothers,
should wear a supportive brassiere with wide
cotton straps. This does not, however, prevent
or reduce nipple soreness. Soaps are drying to
the skin of the nipples and should not be used
on the breasts of lactating mothers. Dry nipple
skin predisposes to cracks and fissures, which
can become sore and painful.
16. D. A weak, thready pulse elevated to 100 BPM
may indicate impending hemorrhagic shock. An
increased pulse is a compensatory mechanism of
the body in response to decreased fluid volume.
Thus, the nurse should check the amount of
lochia present. Temperatures up to 100.48F in
the first 24 hours after birth are related to the
dehydrating effects of labor and are considered
normal. Although rechecking the blood pressure
may be a correct choice of action, it is not the
first action that should be implemented in light
of the other data. The data indicate a potential
impending hemorrhage. Assessing the uterus for
firmness and position in relation to the umbilicus
and midline is important, but the nurse should
check the extent of vaginal bleeding first. Then it
would be appropriate to check the uterus, which
may be a possible cause of the hemorrhage.
17. D. Any bright red vaginal discharge would be
considered abnormal, but especially 5 days after
delivery, when the lochia is typically pink to
brownish. Lochia rubra, a dark red discharge, is
present for 2 to 3 days after delivery. Bright red
vaginal bleeding at this time suggests late
postpartum hemorrhage, which occurs after the
first 24 hours following delivery and is generally
caused by retained placental fragments or
bleeding disorders. Lochia rubra is the normal
dark red discharge occurring in the first 2 to 3
days after delivery, containing epithelial cells,
erythrocyes, leukocytes and decidua. Lochia
serosa is a pink to brownish serosanguineous
discharge occurring from 3 to 10 days after
delivery that contains decidua, erythrocytes,
leukocytes, cervical mucus, and microorganisms.
Lochia alba is an almost colorless to yellowish
discharge occurring from 10 days to 3 weeks
after delivery and containing leukocytes,
decidua, epithelial cells, fat, cervical mucus,
cholesterol crystals, and bacteria.
18. A. The data suggests an infection of the
endometrial lining of the uterus. The lochia may
be decreased or copious, dark brown in
appearance, and foul smelling, providing further
evidence of a possible infection. All the client’s
data indicate a uterine problem, not a breast
problem. Typically, transient fever, usually
101ºF, may be present with breast
engorgement. Symptoms of mastitis include
influenza-like manifestations. Localized infection
of an episiotomy or C-section incision rarely
causes systemic symptoms, and uterine
involution would not be affected. The client data
do not include dysuria, frequency, or urgency,
symptoms of urinary tract infections, which
would necessitate assessing the client’s urine.
19. C. Because of early postpartum discharge and
limited time for teaching, the nurse’s priority is
to facilitate the safe and effective care of the
client and newborn. Although promoting
comfort and restoration of health, exploring the
family’s emotional status, and teaching about
family planning are important in
postpartum/newborn nursing care, they are not
the priority focus in the limited time presented
by early post-partum discharge.
20. C. Heat loss by radiation occurs when the
infant’s crib is placed too near cold walls or
windows. Thus placing the newborn’s crib close
to the viewing window would be least effective.
Body heat is lost through evaporation during
bathing. Placing the infant under the radiant
warmer after bathing will assist the infant to be
rewarmed. Covering the scale with a warmed
blanket prior to weighing prevents heat loss
through conduction. A knit cap prevents heat
loss from the head a large head, a large body
surface area of the newborn’s body.
21. B. A fractured clavicle would prevent the normal
Moro response of symmetrical sequential
extension and abduction of the arms followed by
flexion and adduction. In talipes equinovarus
(clubfoot) the foot is turned medially, and in
plantar flexion, with the heel elevated. The feet
are not involved with the Moro reflex.
Hypothyroiddism has no effect on the primitive
reflexes. Absence of the Moror reflex is the most
significant single indicator of central nervous
system status, but it is not a sign of increased
intracranial pressure.
22. B. Hemorrhage is a potential risk following any
surgical procedure. Although the infant has been
given vitamin K to facilitate clotting, the
23.
24.
25.
26.
27.
170
prophylactic dose is often not sufficient to
prevent bleeding. Although infection is a
possibility, signs will not appear within 4 hours
after the surgical procedure. The primary
discomfort of circumcision occurs during the
surgical procedure, not afterward. Although
feedings are withheld prior to the circumcision,
the chances of dehydration are minimal.
B. The presence of excessive estrogen and
progesterone in the maternal- fetal blood
followed by prompt withdrawal at birth
precipitates breast engorgement, which will
spontaneously resolve in 4 to 5 days after birth.
The trauma of the birth process does not cause
inflammation of the newborn’s breast tissue.
Newborns do not have breast malignancy. This
reply by the nurse would cause the mother to
have undue anxiety. Breast tissue does not
hypertrophy in the fetus or newborns.
D. The first 15 minutes to 1 hour after birth is
the first period of reactivity involving respiratory
and circulatory adaptation to extrauterine life.
The data given reflect the normal changes during
this time period. The infant’s assessment data
reflect normal adaptation. Thus, the physician
does not need to be notified and oxygen is not
needed. The data do not indicate the presence
of choking, gagging or coughing, which are signs
of excessive secretions. Suctioning is not
necessary.
B. Application of 70% isopropyl alcohol to the
cord minimizes microorganisms (germicidal) and
promotes drying. The cord should be kept dry
until it falls off and the stump has healed.
Antibiotic ointment should only be used to treat
an infection, not as a prophylaxis. Infants should
not be submerged in a tub of water until the
cord falls off and the stump has completely
healed.
B. To determine the amount of formula needed,
do the following mathematical calculation. 3 kg x
120 cal/kg per day = 360 calories/day feeding q 4
hours = 6 feedings per day = 60 calories per
feeding: 60 calories per feeding; 60 calories per
feeding with formula 20 cal/oz = 3 ounces per
feeding. Based on the calculation. 2, 4 or 6
ounces are incorrect.
A. Intrauterine anoxia may cause relaxation of
the anal sphincter and emptying of meconium
into the amniotic fluid. At birth some of the
meconium fluid may be aspirated, causing
mechanical obstruction or chemical
pneumonitis. The infant is not at increased risk
28.
29.
30.
31.
32.
for gastrointestinal problems. Even though the
skin is stained with meconium, it is noninfectious
(sterile) and nonirritating. The postterm
meconium- stained infant is not at additional risk
for bowel or urinary problems.
C. The nurse should use a nonelastic, flexible,
paper measuring tape, placing the zero point on
the superior border of the symphysis pubis and
stretching the tape across the abdomen at the
midline to the top of the fundus. The xiphoid and
umbilicus are not appropriate landmarks to use
when measuring the height of the fundus
(McDonald’s measurement).
B. Women hospitalized with severe
preeclampsia need decreased CNS stimulation to
prevent a seizure. Seizure precautions provide
environmental safety should a seizure occur.
Because of edema, daily weight is important but
not the priority. Preclampsia causes vasospasm
and therefore can reduce utero-placental
perfusion. The client should be placed on her left
side to maximize blood flow, reduce blood
pressure, and promote diuresis. Interventions to
reduce stress and anxiety are very important to
facilitate coping and a sense of control, but
seizure precautions are the priority.
C. Cessation of the lochial discharge signifies
healing of the endometrium. Risk of hemorrhage
and infection are minimal 3 weeks after a
normal vaginal delivery. Telling the client
anytime is inappropriate because this response
does not provide the client with the specific
information she is requesting. Choice of a
contraceptive method is important, but not the
specific criteria for safe resumption of sexual
activity. Culturally, the 6- weeks’ examination
has been used as the time frame for resuming
sexual activity, but it may be resumed earlier.
C. The middle third of the vastus lateralis is the
preferred injection site for vitamin K
administration because it is free of blood vessels
and nerves and is large enough to absorb the
medication. The deltoid muscle of a newborn is
not large enough for a newborn IM injection.
Injections into this muscle in a small child might
cause damage to the radial nerve. The anterior
femoris muscle is the next safest muscle to use
in a newborn but is not the safest. Because of
the proximity of the sciatic nerve, the gluteus
maximus muscle should not be until the child
has been walking 2 years.
D. Bartholin’s glands are the glands on either
side of the vaginal orifice. The clitoris is female
171
33.
34.
35.
36.
37.
38.
erectile tissue found in the perineal area above
the urethra. The parotid glands are open into the
mouth. Skene’s glands open into the posterior
wall of the female urinary meatus.
D. The fetal gonad must secrete estrogen for the
embryo to differentiate as a female. An increase
in maternal estrogen secretion does not affect
differentiation of the embryo, and maternal
estrogen secretion occurs in every pregnancy.
Maternal androgen secretion remains the same
as before pregnancy and does not affect
differentiation. Secretion of androgen by the
fetal gonad would produce a male fetus.
A. Using bicarbonate would increase the amount
of sodium ingested, which can cause
complications. Eating low-sodium crackers
would be appropriate. Since liquids can increase
nausea avoiding them in the morning hours
when nausea is usually the strongest is
appropriate. Eating six small meals a day would
keep the stomach full, which often decrease
nausea.
B. Ballottement indicates passive movement of
the unengaged fetus. Ballottement is not a
contraction. Fetal kicking felt by the client
represents quickening. Enlargement and
softening of the uterus is known as Piskacek’s
sign.
B. Chadwick’s sign refers to the purple-blue tinge
of the cervix. Braxton Hicks contractions are
painless contractions beginning around the 4th
month. Goodell’s sign indicates softening of the
cervix. Flexibility of the uterus against the cervix
is known as McDonald’s sign.
C. Breathing techniques can raise the pain
threshold and reduce the perception of pain.
They also promote relaxation. Breathing
techniques do not eliminate pain, but they can
reduce it. Positioning, not breathing, increases
uteroplacental perfusion.
A. The client’s labor is hypotonic. The nurse
should call the physical and obtain an order for
an infusion of oxytocin, which will assist the
uterus to contact more forcefully in an attempt
to dilate the cervix. Administering light sedative
would be done for hypertonic uterine
contractions. Preparing for cesarean section is
unnecessary at this time. Oxytocin would
increase the uterine contractions and hopefully
progress labor before a cesarean would be
necessary. It is too early to anticipate client
pushing with contractions.
39. D. The signs indicate placenta previa and vaginal
exam to determine cervical dilation would not
be done because it could cause hemorrhage.
Assessing maternal vital signs can help
determine maternal physiologic status. Fetal
heart rate is important to assess fetal well-being
and should be done. Monitoring the contractions
will help evaluate the progress of labor.
40. D. A complete placenta previa occurs when the
placenta covers the opening of the uterus, thus
blocking the passageway for the baby. This
response explains what a complete previa is and
the reason the baby cannot come out except by
cesarean delivery. Telling the client to ask the
physician is a poor response and would increase
the patient’s anxiety. Although a cesarean would
help to prevent hemorrhage, the statement does
not explain why the hemorrhage could occur.
With a complete previa, the placenta is covering
the entire cervix, not just most of it.
41. B. With a face presentation, the head is
completely extended. With a vertex
presentation, the head is completely or partially
flexed. With a brow (forehead) presentation, the
head would be partially extended.
42. D. With this presentation, the fetal upper torso
and back face the left upper maternal abdominal
wall. The fetal heart rate would be most audible
above the maternal umbilicus and to the left of
the middle. The other positions would be
incorrect.
43. C. The greenish tint is due to the presence of
meconium. Lanugo is the soft, downy hair on the
shoulders and back of the fetus. Hydramnios
represents excessive amniotic fluid. Vernix is the
white, cheesy substance covering the fetus.
44. D. In a breech position, because of the space
between the presenting part and the cervix,
prolapse of the umbilical cord is common.
Quickening is the woman’s first perception of
fetal movement. Ophthalmia neonatorum
usually results from maternal gonorrhea and is
conjunctivitis. Pica refers to the oral intake of
nonfood substances.
45. A. Dizygotic (fraternal) twins involve two ova
fertilized by separate sperm. Monozygotic
(identical) twins involve a common placenta,
same genotype, and common chorion.
46. C. The zygote is the single cell that reproduces
itself after conception. The chromosome is the
material that makes up the cell and is gained
from each parent. Blastocyst and trophoblast are
later terms for the embryo after zygote.
47. D. Prepared childbirth was the direct result of
the 1950’s challenging of the routine use of
analgesic and anesthetics during childbirth. The
LDRP was a much later concept and was not a
direct result of the challenging of routine use of
analgesics and anesthetics during childbirth.
Roles for nurse midwives and clinical nurse
specialists did not develop from this challenge.
48. C. The ischial spines are located in the mid-pelvic
region and could be narrowed due to the
previous pelvic injury. The symphysis pubis,
sacral promontory, and pubic arch are not part
of the mid-pelvis.
49. B. Variations in the length of the menstrual cycle
are due to variations in the proliferative phase.
The menstrual, secretory and ischemic phases
do not contribute to this variation.
50. B. Testosterone is produced by the Leyding cells
in the seminiferous tubules. Follicle-stimulating
hormone and leuteinzing hormone are released
by the anterior pituitary gland. The
hypothalamus is responsible for releasing
gonadotropin-releasing hormone.
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173
MEDICAL SURGICAL NURSING
1. Marco who was diagnosed with brain tumor was
scheduled for craniotomy. In preventing the
development of cerebral edema after surgery,
the nurse should expect the use of:
a. Diuretics
b. Antihypertensive
c. Steroids
d. Anticonvulsants
2. Halfway through the administration of blood,
the female client complains of lumbar pain. After
stopping the infusion Nurse Hazel should:
a. Increase the flow of normal saline
b. Assess the pain further
c. Notify the blood bank
d. Obtain vital signs.
3. Nurse Maureen knows that the positive
diagnosis for HIV infection is made based on
which of the following:
a. A history of high risk sexual behaviors.
b. Positive ELISA and western blot tests
c. Identification of an associated
opportunistic infection
d. Evidence of extreme weight loss and
high fever
4. Nurse Maureen is aware that a client who has
been diagnosed with chronic renal failure
recognizes an adequate amount of high-biologicvalue protein when the food the client selected
from the menu was:
a. Raw carrots
b. Apple juice
c. Whole wheat bread
d. Cottage cheese
5. Kenneth who has diagnosed with uremic
syndrome has the potential to develop
complications. Which among the following
complications should the nurse anticipates:
a. Flapping hand tremors
b. An elevated hematocrit level
c. Hypotension
d. Hypokalemia
6. A client is admitted to the hospital with benign
prostatic hyperplasia, the nurse most relevant
assessment would be:
a. Flank pain radiating in the groin
b. Distention of the lower abdomen
c. Perineal edema
d. Urethral discharge
7. A client has undergone with penile implant.
After 24 hrs of surgery, the client’s scrotum was
edematous and painful. The nurse should:
a. Assist the client with sitz bath
b. Apply war soaks in the scrotum
c. Elevate the scrotum using a soft support
d. Prepare for a possible incision and
drainage.
8. Nurse hazel receives emergency laboratory
results for a client with chest pain and
immediately informs the physician. An increased
myoglobin level suggests which of the following?
a. Liver disease
b. Myocardial damage
c. Hypertension
d. Cancer
9. Nurse Maureen would expect the client with
mitral stenosis would demonstrate symptoms
associated with congestion in the:
a. Right atrium
b. Superior vena cava
c. Aorta
d. Pulmonary
10. A client has been diagnosed with hypertension.
The nurse priority nursing diagnosis would be:
a. Ineffective health maintenance
b. Impaired skin integrity
c. Deficient fluid volume
d. Pain
11. Nurse Hazel teaches the client with angina about
common expected side effects of nitroglycerin
including:
a. high blood pressure
b. stomach cramps
c. headache
d. shortness of breath
12. The following are lipid abnormalities. Which of
the following is a risk factor for the development
of atherosclerosis and PVD?
a. High levels of low density lipid (LDL)
cholesterol
b. High levels of high density lipid (HDL)
cholesterol
c. Low concentration triglycerides
d. Low levels of LDL cholesterol.
13. Which of the following represents a significant
risk immediately after surgery for repair of aortic
aneurysm?
a. Potential wound infection
b. Potential ineffective coping
c. Potential electrolyte balance
d. Potential alteration in renal perfusion
14. Nurse Josie should instruct the client to eat
which of the following foods to obtain the best
supply of Vitamin B12?
a. dairy products
b. vegetables
c. Grains
d. Broccoli
15. Karen has been diagnosed with aplastic anemia.
The nurse monitors for changes in which of the
following physiologic functions?
a. Bowel function
b. Peripheral sensation
c. Bleeding tendencies
d. Intake and out put
16. Lydia is scheduled for elective splenectomy.
Before the clients goes to surgery, the nurse in
charge final assessment would be:
a. signed consent
b. vital signs
c. name band
d. empty bladder
17. What is the peak age range in acquiring acute
lymphocytic leukemia (ALL)?
a. 4 to 12 years.
b. 20 to 30 years
c. 40 to 50 years
d. 60 60 70 years
18. Marie with acute lymphocytic leukemia suffers
from nausea and headache. These clinical
manifestations may indicate all of the following
except
a. effects of radiation
b. chemotherapy side effects
c. meningeal irritation
d. gastric distension
19. A client has been diagnosed with Disseminated
Intravascular Coagulation (DIC). Which of the
following is contraindicated with the client?
a. Administering Heparin
b. Administering Coumadin
174
c. Treating the underlying cause
d. Replacing depleted blood products
20. Which of the following findings is the best
indication that fluid replacement for the client
with hypovolemic shock is adequate?
a. Urine output greater than 30ml/hr
b. Respiratory rate of 21 breaths/minute
c. Diastolic blood pressure greater than 90
mmhg
d. Systolic blood pressure greater than 110
mmhg
21. Which of the following signs and symptoms
would Nurse Maureen include in teaching plan
as an early manifestation of laryngeal cancer?
a. Stomatitis
b. Airway obstruction
c. Hoarseness
d. Dysphagia
22. Karina a client with myasthenia gravis is to
receive immunosuppressive therapy. The nurse
understands that this therapy is effective
because it:
a. Promotes the removal of antibodies that
impair the transmission of impulses
b. Stimulates the production of
acetylcholine at the neuromuscular
junction.
c. Decreases the production of
autoantibodies that attack the
acetylcholine receptors.
d. Inhibits the breakdown of acetylcholine
at the neuromuscular junction.
23. A female client is receiving IV Mannitol. An
assessment specific to safe administration of the
said drug is:
a. Vital signs q4h
b. Weighing daily
c. Urine output hourly
d. Level of consciousness q4h
24. Patricia a 20 year old college student with
diabetes mellitus requests additional
information about the advantages of using a pen
like insulin delivery devices. The nurse explains
that the advantages of these devices over
syringes include:
a. Accurate dose delivery
b. Shorter injection time
175
c. Lower cost with reusable insulin
cartridges
d. Use of smaller gauge needle.
25. A male client’s left tibia is fractures in an
automobile accident, and a cast is applied. To
assess for damage to major blood vessels from
the fracture tibia, the nurse in charge should
monitor the client for:
a. Swelling of the left thigh
b. Increased skin temperature of the foot
c. Prolonged reperfusion of the toes after
blanching
d. Increased blood pressure
26. After a long leg cast is removed, the male client
should:
a. Cleanse the leg by scrubbing with a brisk
motion
b. Put leg through full range of motion
twice daily
c. Report any discomfort or stiffness to the
physician
d. Elevate the leg when sitting for long
periods of time.
27. While performing a physical assessment of a
male client with gout of the great toe,
NurseVivian should assess for additional tophi
(urate deposits) on the:
a. Buttocks
b. Ears
c. Face
d. Abdomen
28. Nurse Katrina would recognize that the
demonstration of crutch walking with tripod gait
was understood when the client places weight
on the:
a. Palms of the hands and axillary regions
b. Palms of the hand
c. Axillary regions
d. Feet, which are set apart
29. Mang Jose with rheumatoid arthritis states, “the
only time I am without pain is when I lie in bed
perfectly still”. During the convalescent stage,
the nurse in charge with Mang Jose should
encourage:
a. Active joint flexion and extension
b. Continued immobility until pain subsides
c. Range of motion exercises twice daily
d. Flexion exercises three times daily
30. A male client has undergone spinal surgery, the
nurse should:
a. Observe the client’s bowel movement
and voiding patterns
b. Log-roll the client to prone position
c. Assess the client’s feet for sensation and
circulation
d. Encourage client to drink plenty of fluids
31. Marina with acute renal failure moves into the
diuretic phase after one week of therapy. During
this phase the client must be assessed for signs
of developing:
a. Hypovolemia
b. renal failure
c. metabolic acidosis
d. hyperkalemia
32. Nurse Judith obtains a specimen of clear nasal
drainage from a client with a head injury. Which
of the following tests differentiates mucus from
cerebrospinal fluid (CSF)?
a. Protein
b. Specific gravity
c. Glucose
d. Microorganism
33. A 22 year old client suffered from his first tonicclonic seizure. Upon awakening the client asks
the nurse, “What caused me to have a seizure?
Which of the following would the nurse include
in the primary cause of tonic-clonic seizures in
adults more the 20 years?
a. Electrolyte imbalance
b. Head trauma
c. Epilepsy
d. Congenital defect
34. What is the priority nursing assessment in the
first 24 hours after admission of the client with
thrombotic CVA?
a. Pupil size and papillary response
b. cholesterol level
c. Echocardiogram
d. Bowel sounds
35. Nurse Linda is preparing a client with multiple
sclerosis for discharge from the hospital to
home. Which of the following instruction is most
appropriate?
a. “Practice using the mechanical aids that
you will need when future disabilities
arise”.
b. “Follow good health habits to change
the course of the disease”.
c. “Keep active, use stress reduction
strategies, and avoid fatigue.
d. “You will need to accept the necessity
for a quiet and inactive lifestyle”.
36. The nurse is aware the early indicator of hypoxia
in the unconscious client is:
a. Cyanosis
b. Increased respirations
c. Hypertension
d. Restlessness
37. A client is experiencing spinal shock. Nurse
Myrna should expect the function of the bladder
to be which of the following?
a. Normal
b. Atonic
c. Spastic
d. Uncontrolled
38. Which of the following stage the carcinogen is
irreversible?
a. Progression stage
b. Initiation stage
c. Regression stage
d. Promotion stage
39. Among the following components thorough pain
assessment, which is the most significant?
a. Effect
b. Cause
c. Causing factors
d. Intensity
40. A 65 year old female is experiencing flare up of
pruritus. Which of the client’s action could
aggravate the cause of flare ups?
a. Sleeping in cool and humidified
environment
b. Daily baths with fragrant soap
c. Using clothes made from 100% cotton
d. Increasing fluid intake
41. Atropine sulfate (Atropine) is contraindicated in
all but one of the following client?
a. A client with high blood
b. A client with bowel obstruction
c. A client with glaucoma
176
d. A client with U.T.I
42. Among the following clients, which among them
is high risk for potential hazards from the
surgical experience?
a. 67-year-old client
b. 49-year-old client
c. 33-year-old client
d. 15-year-old client
43. Nurse Jon assesses vital signs on a client
undergone epidural anesthesia.
44. Which of the following would the nurse assess
next?
a. Headache
b. Bladder distension
c. Dizziness
d. Ability to move legs
45. Nurse Katrina should anticipate that all of the
following drugs may be used in the attempt to
control the symptoms of Meniere's disease
except:
a. Antiemetics
b. Diuretics
c. Antihistamines
d. Glucocorticoids
46. Which of the following complications associated
with tracheostomy tube?
a. Increased cardiac output
b. Acute respiratory distress syndrome
(ARDS)
c. Increased blood pressure
d. Damage to laryngeal nerves
47. Nurse Faith should recognize that fluid shift in a
client with burn injury results from increase in
the:
a. Total volume of circulating whole blood
b. Total volume of intravascular plasma
c. Permeability of capillary walls
d. Permeability of kidney tubules
48. An 83-year-old woman has several ecchymotic
areas on her right arm. The bruises are probably
caused by:
a. increased capillary fragility and
permeability
b. increased blood supply to the skin
c. self-inflicted injury
d. elder abuse
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49. Nurse Anna is aware that early adaptation of
client with renal carcinoma is:
a. Nausea and vomiting
b. flank pain
c. weight gain
d. intermittent hematuria
50. A male client with tuberculosis asks Nurse Brian
how long the chemotherapy must be continued.
Nurse Brian’s accurate reply would be:
a. 1 to 3 weeks
b. 6 to 12 months
c. 3 to 5 months
d. 3 years and more
51. A client has undergone laryngectomy. The
immediate nursing priority would be:
a. Keep trachea free of secretions
b. Monitor for signs of infection
c. Provide emotional support
d. Promote means of communication
ANSWERS AND RATIONALE – MEDICAL SURGICAL
NURSING
1. C. Glucocorticoids (steroids) are used for their
anti-inflammatory action, which decreases the
development of edema.
2. A. The blood must be stopped at once, and then
normal saline should be infused to keep the line
patent and maintain blood volume.
3. B. These tests confirm the presence of HIV
antibodies that occur in response to the
presence of the human immunodeficiency virus
(HIV).
4. D. One cup of cottage cheese contains
approximately 225 calories, 27g of protein, 9g of
fat, 30mg cholesterol, and 6g of carbohydrate.
Proteins of high biologic value (HBV) contain
optimal levels of amino acids essential for life.
5. A. Elevation of uremic waste products causes
irritation of the nerves, resulting in flapping
hand tremors.
6. B. This indicates that the bladder is distended
with urine, therefore palpable.
7. C. Elevation increases lymphatic drainage,
reducing edema and pain.
8. B. Detection of myoglobin is a diagnostic tool to
determine whether myocardial damage has
occurred.
9. D. When mitral stenosis is present, the left
atrium has difficulty emptying its contents into
the left ventricle because there is no valve to
prevent back ward flow into the pulmonary vein,
the pulmonary circulation is under pressure.
10. A. Managing hypertension is the priority for the
client with hypertension. Clients with
hypertension frequently do not experience pain,
deficient volume, or impaired skin integrity. It is
the asymptomatic nature of hypertension that
makes it so difficult to treat.
11. C. Because of its widespread vasodilating effects,
nitroglycerin often produces side effects such as
headache, hypotension and dizziness.
12. A. An increased in LDL cholesterol concentration
has been documented at risk factor for the
development of atherosclerosis. LDL cholesterol
is not broken down into the liver but is
deposited into the wall of the blood vessels.
13. D. There is a potential alteration in renal
perfusion manifested by decreased urine output.
The altered renal perfusion may be related to
renal artery embolism, prolonged hypotension,
or prolonged aortic cross-clamping during the
surgery.
178
14. A. Good source of vitamin B12 are dairy
products and meats.
15. C. Aplastic anemia decreases the bone marrow
production of RBC’s, white blood cells, and
platelets. The client is at risk for bruising and
bleeding tendencies.
16. B. An elective procedure is scheduled in advance
so that all preparations can be completed ahead
of time. The vital signs are the final check that
must be completed before the client leaves the
room so that continuity of care and assessment
is provided for.
17. A. The peak incidence of Acute Lymphocytic
Leukemia (ALL) is 4 years of age. It is uncommon
after 15 years of age.
18. D. Acute Lymphocytic Leukemia (ALL) does not
cause gastric distention. It does invade the
central nervous system, and clients experience
headaches and vomiting from meningeal
irritation.
19. B. Disseminated Intravascular Coagulation (DIC)
has not been found to respond to oral
anticoagulants such as Coumadin.
20. A. Urine output provides the most sensitive
indication of the client’s response to therapy for
hypovolemic shock. Urine output should be
consistently greater than 30 to 35 mL/hr.
21. C. Early warning signs of laryngeal cancer can
vary depending on tumor location. Hoarseness
lasting 2 weeks should be evaluated because it is
one of the most common warning signs.
22. C. Steroids decrease the body’s immune
response thus decreasing the production of
antibodies that attack the acetylcholine
receptors at the neuromuscular junction
23. C. The osmotic diuretic mannitol is
contraindicated in the presence of inadequate
renal function or heart failure because it
increases the intravascular volume that must be
filtered and excreted by the kidney.
24. A. These devices are more accurate because
they are easily to used and have improved
adherence in insulin regimens by young people
because the medication can be administered
discreetly.
25. C. Damage to blood vessels may decrease the
circulatory perfusion of the toes, this would
indicate the lack of blood supply to the
extremity.
26. D. Elevation will help control the edema that
usually occurs.
27. B. Uric acid has a low solubility, it tends to
precipitate and form deposits at various sites
179
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
where blood flow is least active, including
cartilaginous tissue such as the ears.
B. The palms should bear the client’s weight to
avoid damage to the nerves in the axilla.
A. Active exercises, alternating extension,
flexion, abduction, and adduction, mobilize
exudates in the joints relieves stiffness and pain.
C. Alteration in sensation and circulation
indicates damage to the spinal cord, if these
occurs notify physician immediately.
A. In the diuretic phase fluid retained during the
oliguric phase is excreted and may reach 3 to 5
liters daily, hypovolemia may occur and fluids
should be replaced.
C. The constituents of CSF are similar to those of
blood plasma. An examination for glucose
content is done to determine whether a body
fluid is a mucus or a CSF. A CSF normally contains
glucose.
B. Trauma is one of the primary causes of brain
damage and seizure activity in adults. Other
common causes of seizure activity in adults
include neoplasms, withdrawal from drugs and
alcohol, and vascular disease.
A. It is crucial to monitor the pupil size and
papillary response to indicate changes around
the cranial nerves.
C. The nurse most positive approach is to
encourage the client with multiple sclerosis to
stay active, use stress reduction techniques and
avoid fatigue because it is important to support
the immune system while remaining active.
D. Restlessness is an early indicator of hypoxia.
The nurse should suspect hypoxia in unconscious
client who suddenly becomes restless.
B. In spinal shock, the bladder becomes
completely atonic and will continue to fill unless
the client is catheterized.
A. Progression stage is the change of tumor from
the preneoplastic state or low degree of
malignancy to a fast growing tumor that cannot
be reversed.
D. Intensity is the major indicative of severity of
pain and it is important for the evaluation of the
treatment.
B. The use of fragrant soap is very drying to skin
hence causing the pruritus.
C. Atropine sulfate is contraindicated with
glaucoma patients because it increases
intraocular pressure.
A. A 67 year old client is greater risk because the
older adult client is more likely to have a lesseffective immune system.
43. B. The last area to return sensation is in the
perineal area, and the nurse in charge should
monitor the client for distended bladder.
44. D. Glucocorticoids play no significant role in
disease treatment.
45. D. Tracheostomy tube has several potential
complications including bleeding, infection and
laryngeal nerve damage.
46. C. In burn, the capillaries and small vessels
dilate, and cell damage cause the release of a
histamine-like substance. The substance causes
the capillary walls to become more permeable
and significant quantities of fluid are lost.
47. A. Aging process involves increased capillary
fragility and permeability. Older adults have a
decreased amount of subcutaneous fat and
cause an increased incidence of bruise like
lesions caused by collection of extravascular
blood in loosely structured dermis.
48. D. Intermittent pain is the classic sign of renal
carcinoma. It is primarily due to capillary erosion
by the cancerous growth.
49. B. Tubercle bacillus is a drug resistant organism
and takes a long time to be eradicated. Usually a
combination of three drugs is used for minimum
of 6 months and at least six months beyond
culture conversion.
50. A. Patent airway is the most priority; therefore
removal of secretions is necessary
PSYCHIATRIC NURSING
1. Marco approached Nurse Trish asking for advice
on how to deal with his alcohol addiction. Nurse
Trish should tell the client that the only effective
treatment for alcoholism is:
a. Psychotherapy
b. Alcoholics anonymous (A.A.)
c. Total abstinence
d. Aversion Therapy
2. Nurse Hazel is caring for a male client who
experience false sensory perceptions with no
basis in reality. This perception is known as:
a. Hallucinations
b. Delusions
c. Loose associations
d. Neologisms
3. Nurse Monet is caring for a female client who
has suicidal tendency. When accompanying the
client to the restroom, Nurse Monet should…
a. Give her privacy
b. Allow her to urinate
c. Open the window and allow her to get
some fresh air
d. Observe her
4. Nurse Maureen is developing a plan of care for a
female client with anorexia nervosa. Which
action should the nurse include in the plan?
a. Provide privacy during meals
b. Set-up a strict eating plan for the client
c. Encourage client to exercise to reduce
anxiety
d. Restrict visits with the family
5. A client is experiencing anxiety attack. The most
appropriate nursing intervention should include?
a. Turning on the television
b. Leaving the client alone
c. Staying with the client and speaking in
short sentences
d. Ask the client to play with other clients
6. A female client is admitted with a diagnosis of
delusions of GRANDEUR. This diagnosis reflects a
belief that one is:
a. Being Killed
b. Highly famous and important
c. Responsible for evil world
d. Connected to client unrelated to oneself
180
7. A 20 year old client was diagnosed with
dependent personality disorder. Which behavior
is not likely to be evidence of ineffective
individual coping?
a. Recurrent self-destructive behavior
b. Avoiding relationship
c. Showing interest in solitary activities
d. Inability to make choices and decision
without advise
8. A male client is diagnosed with schizotypal
personality disorder. Which signs would this
client exhibit during social situation?
a. Paranoid thoughts
b. Emotional affect
c. Independence need
d. Aggressive behavior
9. Nurse Claire is caring for a client diagnosed with
bulimia. The most appropriate initial goal for a
client diagnosed with bulimia is?
a. Encourage to avoid foods
b. Identify anxiety causing situations
c. Eat only three meals a day
d. Avoid shopping plenty of groceries
10. Nurse Tony was caring for a 41 year old female
client. Which behavior by the client indicates
adult cognitive development?
a. Generates new levels of awareness
b. Assumes responsibility for her actions
c. Has maximum ability to solve problems
and learn new skills
d. Her perception are based on reality
11. A neuromuscular blocking agent is administered
to a client before ECT therapy. The Nurse should
carefully observe the client for?
a. Respiratory difficulties
b. Nausea and vomiting
c. Dizziness
d. Seizures
12. A 75 year old client is admitted to the hospital
with the diagnosis of dementia of the
Alzheimer’s type and depression. The symptom
that is unrelated to depression would be?
a. Apathetic response to the environment
b. “I don’t know” answer to questions
c. Shallow of labile effect
d. Neglect of personal hygiene
181
13. Nurse Trish is working in a mental health facility;
the nurse priority nursing intervention for a
newly admitted client with bulimia nervosa
would be to?
a. Teach client to measure I & O
b. Involve client in planning daily meal
c. Observe client during meals
d. Monitor client continuously
14. Nurse Patricia is aware that the major health
complication associated with intractable
anorexia nervosa would be?
a. Cardiac dysrhythmias resulting to
cardiac arrest
b. Glucose intolerance resulting in
protracted hypoglycemia
c. Endocrine imbalance causing cold
amenorrhea
d. Decreased metabolism causing cold
intolerance
15. Nurse Anna can minimize agitation in a
disturbed client by?
a. Increasing stimulation
b. limiting unnecessary interaction
c. increasing appropriate sensory
perception
d. ensuring constant client and staff
contact
16. A 39 year old mother with obsessive-compulsive
disorder has become immobilized by her
elaborate hand washing and walking rituals.
Nurse Trish recognizes that the basis of O.C.
disorder is often:
a. Problems with being too conscientious
b. Problems with anger and remorse
c. Feelings of guilt and inadequacy
d. Feeling of unworthiness and
hopelessness
17. Mario is complaining to other clients about not
being allowed by staff to keep food in his room.
Which of the following interventions would be
most appropriate?
a. Allowing a snack to be kept in his room
b. Reprimanding the client
c. Ignoring the clients behavior
d. Setting limits on the behavior
18. Conney with borderline personality disorder who
is to be discharge soon threatens to “do
something” to herself if discharged. Which of the
following actions by the nurse would be most
important?
a. Ask a family member to stay with the
client at home temporarily
b. Discuss the meaning of the client’s
statement with her
c. Request an immediate extension for the
client
d. Ignore the clients statement because it’s
a sign of manipulation
19. Joey a client with antisocial personality disorder
belches loudly. A staff member asks Joey, “Do
you know why people find you repulsive?” this
statement most likely would elicit which of the
following client reaction?
a. Depensiveness
b. Embarrassment
c. Shame
d. Remorsefulness
20. Which of the following approaches would be
most appropriate to use with a client suffering
from narcissistic personality disorder when
discrepancies exist between what the client
states and what actually exist?
a. Rationalization
b. Supportive confrontation
c. Limit setting
d. Consistency
21. Cely is experiencing alcohol withdrawal exhibits
tremors, diaphoresis and hyperactivity. Blood
pressure is 190/87 mmhg and pulse is 92 bpm.
Which of the medications would the nurse
expect to administer?
a. Naloxone (Narcan)
b. Benzlropine (Cogentin)
c. Lorazepam (Ativan)
d. Haloperidol (Haldol)
22. Which of the following foods would the nurse
Trish eliminate from the diet of a client in
alcohol withdrawal?
a. Milk
b. Orange Juice
c. Soda
d. Regular Coffee
23. Which of the following would Nurse Hazel
expect to assess for a client who is exhibiting
late signs of heroin withdrawal?
a. Yawning & diaphoresis
b. Restlessness & Irritability
c. Constipation & steatorrhea
d. Vomiting and Diarrhea
24. To establish open and trusting relationship with
a female client who has been hospitalized with
severe anxiety, the nurse in charge should?
a. Encourage the staff to have frequent
interaction with the client
b. Share an activity with the client
c. Give client feedback about behavior
d. Respect client’s need for personal space
25. Nurse Monette recognizes that the focus of
environmental (MILIEU) therapy is to:
a. Manipulate the environment to bring
about positive changes in behavior
b. Allow the client’s freedom to determine
whether or not they will be involved in
activities
c. Role play life events to meet individual
needs
d. Use natural remedies rather than drugs
to control behavior
26. Nurse Trish would expect a child with a diagnosis
of reactive attachment disorder to:
a. Have more positive relation with the
father than the mother
b. Cling to mother & cry on separation
c. Be able to develop only superficial
relation with the others
d. Have been physically abuse
27. When teaching parents about childhood
depression Nurse Trina should say?
a. It may appear acting out behavior
b. Does not respond to conventional
treatment
c. Is short in duration & resolves easily
d. Looks almost identical to adult
depression
28. Nurse Perry is aware that language development
in autistic child resembles:
a. Scanning speech
b. Speech lag
c. Shuttering
d. Echolalia
29. A 60 year old female client who lives alone tells
the nurse at the community health center “I
really don’t need anyone to talk to”. The TV is
182
my best friend. The nurse recognizes that the
client is using the defense mechanism known as?
a. Displacement
b. Projection
c. Sublimation
d. Denial
30. When working with a male client suffering
phobia about black cats, Nurse Trish should
anticipate that a problem for this client would
be?
a. Anxiety when discussing phobia
b. Anger toward the feared object
c. Denying that the phobia exist
d. Distortion of reality when completing
daily routines
31. Linda is pacing the floor and appears extremely
anxious. The duty nurse approaches in an
attempt to alleviate Linda’s anxiety. The most
therapeutic 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 client
32. Nurse Penny is aware that the symptoms that
distinguish post-traumatic stress disorder from
other anxiety disorder would be:
a. Avoidance of situation & certain
activities that resemble the stress
b. Depression and a blunted affect when
discussing the traumatic situation
c. Lack of interest in family & others
d. Re-experiencing the trauma in dreams or
flashback
33. Nurse Benjie is communicating with a male client
with substance-induced persisting dementia; the
client cannot remember facts and fills in the
gaps with imaginary information. Nurse Benjie is
aware that this is typical of?
a. Flight of ideas
b. Associative looseness
c. Confabulation
d. Concretism
34. Nurse Joey is aware that the signs & symptoms
that would be most specific for diagnosis
anorexia are?
a. Excessive weight loss, amenorrhea &
abdominal distension
b. Slow pulse, 10% weight loss & alopecia
183
c. Compulsive behavior, excessive fears &
nausea
d. Excessive activity, memory lapses & an
increased pulse
35. A characteristic that would suggest to Nurse
Anne that an adolescent may have bulimia
would be:
a. Frequent regurgitation & re-swallowing
of food
b. Previous history of gastritis
c. Badly stained teeth
d. Positive body image
36. Nurse Monette is aware that extremely
depressed clients seem to do best in settings
where they have:
a. Multiple stimuli
b. Routine Activities
c. Minimal decision making
d. Varied Activities
37. To further assess a client’s suicidal potential.
Nurse Katrina should be especially alert to the
client expression of:
a. Frustration & fear of death
b. Anger & resentment
c. Anxiety & loneliness
d. Helplessness & hopelessness
38. A nursing care plan for a male client with bipolar
I disorder should include:
a. Providing a structured environment
b. Designing activities that will require the
client to maintain contact with reality
c. Engaging the client in conversing about
current affairs
d. Touching the client provide assurance
39. When planning care for a female client using
ritualistic behavior, Nurse Gina must recognize
that the ritual:
a. Helps the client focus on the inability to
deal with reality
b. Helps the client control the anxiety
c. Is under the client’s conscious control
d. Is used by the client primarily for
secondary gains
40. A 32 year old male graduate student, who has
become increasingly withdrawn and neglectful
of his work and personal hygiene, is brought to
the psychiatric hospital by his parents. After
detailed assessment, a diagnosis of
schizophrenia is made. It is unlikely that the
client will demonstrate:
a. Low self esteem
b. Concrete thinking
c. Effective self-boundaries
d. Weak ego
41. A 23 year old client has been admitted with a
diagnosis of schizophrenia says to the nurse
“Yes, its march, March is little woman”. That’s
literal you know”. These statement illustrate:
a. Neologisms
b. Echolalia
c. Flight of ideas
d. Loosening of association
42. A long term goal for a paranoid male client who
has unjustifiably accused his wife of having many
extramarital affairs would be to help the client
develop:
a. Insight into his behavior
b. Better self-control
c. Feeling of self-worth
d. Faith in his wife
43. A male client who is experiencing disordered
thinking about food being poisoned is admitted
to the mental health unit. The nurse uses which
communication technique to encourage the
client to eat dinner?
a. Focusing on self-disclosure of own food
preference
b. Using open ended question and silence
c. Offering opinion about the need to eat
d. Verbalizing reasons that the client may
not choose to eat
44. Nurse Nina is assigned to care for a client
diagnosed with Catatonic Stupor. When Nurse
Nina enters the client’s room, the client is found
lying on the bed with a body pulled into a fetal
position. Nurse Nina should?
a. Ask the client direct questions to
encourage talking
b. Rake the client into the dayroom to be
with other clients
c. Sit beside the client in silence and
occasionally ask open-ended question
d. Leave the client alone and continue with
providing care to the other clients
45. Nurse Tina is caring for a client with delirium and
states that “look at the spiders on the wall”.
What should the nurse respond to the client?
a. “You’re having hallucination, there are
no spiders in this room at all”
b. “I can see the spiders on the wall, but
they are not going to hurt you”
c. “Would you like me to kill the spiders”
d. “I know you are frightened, but I do not
see spiders on the wall”
46. Nurse Jonel is providing information to a
community group about violence in the family.
Which statement by a group member would
indicate a need to provide additional
information?
a. “Abuse occurs more in low-income
families”
b. “Abuser Are often jealous or selfcentered”
c. “Abuser use fear and intimidation”
d. “Abuser usually have poor self-esteem”
47. During electroconvulsive therapy (ECT) the client
receives oxygen by mask via positive pressure
ventilation. The nurse assisting with this
procedure knows that positive pressure
ventilation is necessary because?
a. Anesthesia is administered during the
procedure
b. Decrease oxygen to the brain increases
confusion and disorientation
c. Grand mal seizure activity depresses
respirations
d. Muscle relaxations given to prevent
injury during seizure activity depress
respirations.
48. When planning the discharge of a client with
chronic anxiety, Nurse Chris evaluates
achievement of the discharge maintenance
goals. Which goal would be most appropriately
having been included in the plan of care
requiring evaluation?
a. The client eliminates all anxiety from
daily situations
b. The client ignores feelings of anxiety
c. The client identifies anxiety producing
situations
d. The client maintains contact with a crisis
counselor
184
49. Nurse Tina is caring for a client with depression
who has not responded to antidepressant
medication. The nurse anticipates that what
treatment procedure may be prescribed.
a. Neuroleptic medication
b. Short term seclusion
c. Psychosurgery
d. Electroconvulsive therapy
50. Mario is admitted to the emergency room with
drug-included anxiety related to over ingestion
of prescribed antipsychotic medication. The
most important piece of information the nurse
in charge should obtain initially is the:
a. Length of time on the med.
b. Name of the ingested medication & the
amount ingested
c. Reason for the suicide attempt
d. Name of the nearest relative & their
phone number
185
ANSWERS AND RATIONALE – PSYCHIATRIC
NURSING
1. Answer: C
Rationale: Total abstinence is the only effective
treatment for alcoholism
2. Answer: A
Rationale: Hallucinations are visual, auditory,
gustatory, tactile or olfactory perceptions that
have no basis in reality.
3. Answer: D
Rationale: The Nurse has a responsibility to
observe continuously the acutely suicidal client.
The Nurse should watch for clues, such as
communicating suicidal thoughts, and messages;
hoarding medications and talking about death.
4. Answer: B
Rationale: Establishing a consistent eating plan
and monitoring client’s weight are important to
this disorder.
5. Answer: C
Rationale: Appropriate nursing interventions for
an anxiety attack include using short sentences,
staying with the client, decreasing stimuli,
remaining calm and medicating as needed.
6. Answer:B
Rationale: Delusion of grandeur is a false belief
that one is highly famous and important.
7. Answer: D
Rationale: Individual with dependent personality
disorder typically shows indecisiveness
submissiveness and clinging behavior so that
others will make decisions with them.
8. Answer: A
Rationale: Clients with schizotypal personality
disorder experience excessive social anxiety that
can lead to paranoid thoughts
9. Answer: B
Rationale: Bulimia disorder generally is a
maladaptive coping response to stress and
underlying issues. The client should identify
anxiety causing situation that stimulate the
bulimic behavior and then learn new ways of
coping with the anxiety.
10. Answer: A
Rationale: An adult age 31 to 45 generates new
level of awareness.
11. Answer: A
Rationale: Neuromuscular Blocker, such as
SUCCINYLCHOLINE (Anectine) produces
respiratory depression because it inhibits
contractions of respiratory muscles.
12. Answer: C
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Rationale: With depression, there is little or no
emotional involvement therefore little alteration
in affect.
Answer: D
Rationale: These clients often hide food or force
vomiting; therefore they must be carefully
monitored.
Answer: A
Rationale: These clients have severely depleted
levels of sodium and potassium because of their
starvation diet and energy expenditure, these
electrolytes are necessary for cardiac
functioning.
Answer: B
Rationale: Limiting unnecessary interaction will
decrease stimulation and agitation.
Answer: C
Rationale: Ritualistic behavior seen in this
disorder is aimed at controlling guilt and
inadequacy by maintaining an absolute set
pattern of behavior.
Answer: D
Rationale: The nurse needs to set limits in the
client’s manipulative behavior to help the client
control dysfunctional behavior. A consistent
approach by the staff is necessary to decrease
manipulation.
Answer: B
Rationale: Any suicidal statement must be
assessed by the nurse. The nurse should discuss
the client’s statement with her to determine its
meaning in terms of suicide.
Answer: A
Rationale: When the staff member ask the client
if he wonders why others find him repulsive, the
client is likely to feel defensive because the
question is belittling. The natural tendency is to
counterattack the threat to self-image.
Answer: B
Rationale: The nurse would specifically use
supportive confrontation with the client to point
out discrepancies between what the client states
and what actually exists to increase
responsibility for self.
Answer: C
Rationale: The nurse would most likely
administer benzodiazepine, such as lorazepan
(ativan) to the client who is experiencing
symptom: The client’s experiences symptoms of
withdrawal because of the rebound
phenomenon when the sedation of the CNS
from alcohol begins to decrease.
Answer: D
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
186
Rationale: Regular coffee contains caffeine
which acts as psychomotor stimulants and leads
to feelings of anxiety and agitation. Serving
coffee top the client may add to tremors or
wakefulness.
Answer: D
Rationale: Vomiting and diarrhea are usually the
late signs of heroin withdrawal, along with
muscle spasm, fever, nausea, repetitive,
abdominal cramps and backache.
Answer: D
Rationale: Moving to a client’s personal space
increases the feeling of threat, which increases
anxiety.
Answer: A
Rationale: Environmental (MILIEU) therapy aims
at having everything in the client’s surrounding
area toward helping the client.
Answer: C
Rationale: Children who have experienced
attachment difficulties with primary caregiver
are not able to trust others and therefore relate
superficially
Answer: A
Rationale: Children have difficulty verbally
expressing their feelings, acting out behavior,
such as temper tantrums, may indicate
underlying depression.
Answer: D
Rationale: The autistic child repeats sounds or
words spoken by others.
Answer: D
Rationale: The client statement is an example of
the use of denial, a defense that blocks problem
by unconscious refusing to admit they exist
Answer: A
Rationale: Discussion of the feared object
triggers an emotional response to the object.
Answer: B
Rationale: The nurse presence may provide the
client with support & feeling of control.
Answer: D
Rationale: Experiencing the actual trauma in
dreams or flashback is the major symptom that
distinguishes post-traumatic stress disorder from
other anxiety disorder.
Answer: C
Rationale: Confabulation or the filling in of
memory gaps with imaginary facts is a defense
mechanism used by people experiencing
memory deficits.
Answer: A
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
Rationale: These are the major signs of anorexia
nervosa. Weight loss is excessive (15% of
expected weight)
Answer: C
Rationale: Dental enamel erosion occurs from
repeated self-induced vomiting.
Answer: B
Rationale: Depression usually is both emotional
& physical. A simple daily routine is the best,
least stressful and least anxiety producing.
Answer: D
Rationale: The expression of these feeling may
indicate that this client is unable to continue the
struggle of life.
Answer: A
Rationale: Structure tends to decrease agitation
and anxiety and to increase the client’s feeling of
security.
Answer: B
Rationale: The rituals used by a client with
obsessive compulsive disorder help control the
anxiety level by maintaining a set pattern of
action.
Answer: C
Rationale: A person with this disorder would not
have adequate self-boundaries
Answer: D
Rationale: Loose associations are thoughts that
are presented without the logical connections
usually necessary for the listening to interpret
the message.
Answer: C
Rationale: Helping the client to develop feeling
of self-worth would reduce the client’s need to
use pathologic defenses.
Answer: B
Rationale: Open ended questions and silence are
strategies used to encourage clients to discuss
their problem in descriptive manner.
Answer: C
Rationale: Clients who are withdrawn may be
immobile and mute, and require consistent,
repeated interventions. Communication with
withdrawn clients requires much patience from
the nurse. The nurse facilitates communication
with the client by sitting in silence, asking openended question and pausing to provide
opportunities for the client to respond.
Answer: D
Rationale: When hallucination is present, the
nurse should reinforce reality with the client.
Answer: A
187
47.
48.
49.
50.
Rationale: Personal characteristics of abuser
include low self-esteem, immaturity,
dependence, insecurity and jealousy.
Answer: D
Rationale: A short acting skeletal muscle relaxant
such as succinylcholine (Anectine) is
administered during this procedure to prevent
injuries during seizure.
Answer: C
Rationale: Recognizing situations that produce
anxiety allows the client to prepare to cope with
anxiety or avoid specific stimulus.
Answer: D
Rationale: Electroconvulsive therapy is an
effective treatment for depression that has not
responded to medication
Answer: B
Rationale: In an emergency, lives saving facts are
obtained first. The name and the amount of
medication ingested are of outmost important in
treating this potentially life threatening
situation.
FOUNDATION OF PROFESSIONAL NURSING
PRACTICE
Situation 1 - Mr. Ibarra is assigned to the triage area and
while on duty, he assesses the condition of Mrs. Simon
who came in with asthma. She has difficulty breathing
and her respiratory rate is 40 per minute. Mr. Ibarra is
asked to inject the client epinephrine 0.3mg
subcutaneously
1. The indication for epinephrine injection for Mrs
Simon is to:
a. Reduce anaphylaxis
b. Relieve hypersensitivity to allergen
c. Relieve respirator distress due to bronchial spasm
d. Restore client’s cardiac rhythm
2. When preparing the epinephrine injection from an
ampule, the nurse initially:
a. Taps the ampule at the top to allow fluid to flow to
the base of the ampule
b. Checks expiration date of the medication ampule
c. Removes needle cap of syringe and pulls plunger to
expel air
d. Breaks the neck of the ampule with a gauze wrapped
around it
3. Mrs. Simon is obese. When administering a
subcutaneous injection to an obese patient, it is best
for the nurse to:
a Inject needle at a 15 degree angle' over the stretched
skin of the client
b. Pinch skin at the Injection site and use airlock
technique
c. Pull skin of patient down to administer the drug in a Z
track
d. Spread skin or pinch at the injection site and inject
needle at a 45-90 degree angle
4. When preparing for a subcutaneous injection, the
proper size of syringe and needle would be:
a. Syringe 3-5ml and needle gauge 21 to 23
b. Tuberculin syringe 1 mi with needle gauge 26 or 27
c. Syringe 2ml and needle gauge 22
d. Syringe 1-3ml and needle gauge 25 to 27
5. The rationale for giving medications through the
subcutaneous route is;
188
a. There are many alternative sites for subcutaneous
injection
b. Absorption time of the medicine is slower
c. There are less pain receptors in this area
d. The medication can be injected while the client is in
any position
Situation 2 - The use of massage and meditation to help
decrease stress and pain have been strongly
recommended based on documented testimonials.
6. Martha wants to do a study on, this topic. "Effects of
massage and meditation on stress and pain." The type
of research that best suits this topic is:
a. applied research
b. qualitative research
c. basic research
d. quantitative research
7. The type of research design that does not manipulate
independent variable is:
a. experimental design
b. quasi-experimental design
c. non-experimental design
d. quantitative design
8. This research topic has the potential to contribute to
nursing because it seeks to:
a. include new modalities of care
b. resolve a clinical problem
c. clarify an ambiguous modality of care
d. enhance client care
9. Martha does review of related literature for the
purpose of:
a. determine statistical treatment of data research
b. gathering data about what is already known or
unknown
c. to identify if problem can be replicated
d. answering the research question
10. Client’s rights should be protected when doing
research using human subjects. Martha identifies these
rights as follows EXCEPT:
a. right of self-determination
b. right to compensation
c. right of privacy
d. right not to be harmed
189
Situation 3 - Richard has a nursing diagnosis of
ineffective airway clearance related to excessive
secretions and is at risk for infection because of retained
secretions. Part of Nurse Mario's nursing care plan is to
loosen and remove excessive secretions in the airway,
11. Mario listens to Richard's bilateral sounds and finds
that congestion is in the upper lobes of the lungs. The
appropriate position to drain the anterior and posterior
apical segments of the lungs when Mario does
percussion would be:
a. Client lying on his back then flat on his abdomen on
Trendelenburg position
b. Client seated upright in bed or on a chair then leaning
forward in sitting position then flat on his back and on
his abdomen
c. Client lying flat on his back and then flat on his
abdomen
d. Client lying on his right then left side on
Trendelenburg position
12. When documenting outcome of Richard's treatment
Mario should include the following in his recording
EXCEPT:
a. Color, amount and consistent of sputum
b. Character of breath sounds and respirator/rate before
and after procedure
c. Amount of fluid intake of client before and after the
procedure
d. Significant changes in vital signs
13. When assessing Richard for chest percussion or
chest vibration and postural drainage Mario would
focus on the following EXCEPT:
a. Amount of food and fluid taken during the last meal
before treatment
b. Respiratory rate, breath sounds and location of
congestion
c. Teaching the client's relatives to perform 'the
procedure
d. Doctor's order regarding position restriction and
client's tolerance for lying flat
14. Mario prepares Richard for postural drainage and
percussion. Which of the flowing is a special
consideration when doing the procedure?
a. Respiratory rate of 16 to 20 per minute
b. Client can tolerate sitting and lying position
c. Client has no signs of infection
d. Time of fast food and fluid intake of the client
15. The purpose of chest percussion and vibration is to
loosen secretions in the lungs. The difference between
the procedure is;
a. Percussion uses only one hand white vibration uses
both hands
b. Percussion delivers cushioned blows to the chest with
cupped palms while gently shakes secretion loose on the
exhalation cycle
c. In both percussion and vibration the hands are on top
of each other and hand action is in tune with client's
breath rhythm
d. Percussion slaps the chest to loosen secretions while
vibration shakes the secretions along with the inhalation
of air
Situation 4 - A 61 year old man, Mr. Regalado, is
admitted to the private ward for observation; after
complaints of severe chest pain. You are assigned to take
care of the client.
16. When doing an initial assessment, the best way for
you to identify the client’s priority problem is to:
a. Interview the client for chief complaints and other
symptoms
b. Talk to the relatives to gather data about history of
illness
c. Do auscultation to check for chest congestion
d. Do a physical examination white asking the client
relevant questions
17. Upon establishing Mr. Regalado's nursing needs,
the next nursing approach would be to:
a. introduce the client to the ward staff to put the client
and family at ease
b. Give client and relatives a brief tour of the physical set
up the unit
c. Take his vital signs for a baseline assessment
d. Establish priority needs and implement appropriate
interventions
18. 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 days
b. Ask him what he means by this statement
c. Check his physical environment to decrease noise level
d. Take his blood pressure before sleeping and upon
waking up
19. Mr. Regalado's lower extremities are swollen and
shiny. He has pitting pedal edema. When taking care of
Mr. Regalado, which of the following intervention
would be the most appropriate immediate nursing
approach.
a. Moisturize lower extremities to prevent skin irritation
b. Measure fluid intake and output to decrease edema
c. Elevate lower extremities for postural drainage
d. Provide the client a list of food low in sodium
20. Mr. Regalado will be discharged from your unit
within the hour. Nursing actions when preparing a
client for discharge include all EXCEPT:
a. Making a final physical assessment before client
leaves the hospital
b. Giving instructions about his medication regimen
c. Walking the client to the hospital exit to ensure his
safety
d. Proper recording of pertinent data
Situation 5 - Nancy, mother of 2 young kids. 36 years old,
had a mammogram and was told that she has breast
cysts and that she may need surgery. This causes her
anxiety as shown by increase in her pulse and respiratory
rate, sweating and feelings of tension.
21. Considering her level of anxiety, the nurse can best
assist Nancy by:
a. Giving her activities to divert her attention
b. Giving detailed explanations about the treatments she
will undergo
c. Preparing her and her family in case surgery is not
successful
d. Giving her clear but brief information at the level of
her understanding
23. The nurse visits Nancy and prods her to eat her
food. Nancy replies "what's the use? My time is running
out. The nurse's best response would be:
a. "The doctor ordered full diet for you so that you will
be strong for surgery."
b. "I understand how you fee! but you have 1o try for
your children's sake."
c. "Have you told your, doctor how you feel? Are you
changing your mind) about surgery?"
d. "You sound like you are giving up."
24. The nurse feels sad about Nancy's illness and tells
her head nurse during the end of shift endorsement
that "it's unfair for Nancy to have cancer when she is
still so young and with two kinds. The best response of
the head nurse would be:
a. Advise the nurse to "be strong and learn to control her
feelings"
b. Assign the nurse to another client to avoid sympathy
for the client
c. Reassure the nurse that the client has hope if she goes
through all statements prescribed for her
c. Ask the other nurses what they feel about the patient
to find out if they share the same feelings
25. Realizing that she feels angry about Nancy's
condition, the nurse Seams that being self-aware is a
conscious process that she should do in any situation
like this because:
a. This is a necessary part of the nurse -client
relationship process
b. The nurse is a role model for the client and should be
strong
C. How the nurse thinks and feels affect her actions
towards her client and her work
d. The nurse has to be therapeutic at all times and
should not be affected
22. Nancy blames God for her situation. She is easily
provoked to tears and wants to be left alone, refusing
to eat or talk to her family. A religious person before,
she now refuses to pray or go to church stating that
God has abandoned her. The nurse understands that
Nancy is grieving for her self and is in the stage of:
Situation 6 – Mrs. Seva, 32 years old, asks you about
possible problems regarding her elimination now that
she is in the menopausal stage.
a. bargaining
b. denial
c. anger
d. acceptance
a. Hold urine, as long as she can before emptying the
bladder to strengthen her sphincters muscles
b. If burning sensation is experienced while voiding,
drink pineapple-juice
c. After urination, wipe from anal area up towards the
190
26. Instruction on health promotion regarding urinary
elimination is important. Which would you include?
191
pubis
d. Jell client to empty the bladder at each voiding
27. Mrs. Seva also tells the nurse that she is often
constipated. Because she is aging, what physical
changes predispose her to constipation?
a. inhibition of the parasympathetic reflex
b. weakness of sphincter muscles of the anus
c. loss of tone of the smooth muscles of the color
d. decreased ability to absorb fluids in the lower
intestines
28. The nurse understands that one of these factors
contributes to constipation:
a. excessive exercise
b. high fiber diet
c. no regular tine for defecation daily
d. prolonged use of laxatives
29. Mrs. Seva talks about rear of being incontinent due
to a prior experience of dribbling urine when laughing
or sneezing and when she has a full bladder. Your most
appropriate .instruction would be to:
a. tell client to drink less fluids to avoid accidents
b. instruct client to start wearing thin adult diapers
c. ask the client to bring change of underwear "just in
case"
d. teach client pelvic exercise to strengthen perineal
muscles
30. Mrs. Seva asked for instructions for skin care for her
mother who has urinary incontinence and is almost
always in bed. Your instruction would focus on
prevention of skin irritation and breakdown by
a. Using thick diapers to absorb urine well
b. Drying the skin with baby powder to prevent or mask
the smell of ammonia
c. Thorough washing, rising and during of skin area that
get wet with urine
d. Making sure that linen are smooth and dry at all times
a. Carol with a tumor in the brain
b. Theresa with anemia
c. Sonny Boy with a fracture in the femur
d. Brigette with diarrhea
32. 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. Cyanosis
b. Hypoxia
c. Hypoxemia
d. Anemia
33. You will nasopharyngeal suctioning Mr. Abad. Your
guide for the length of insertion of the tubing for an
adult would be:
a. tip of the nose to the base of the .neck
b. the distance from the tip of the nose to the middle of
the cheek
c. the distance from the tip of the nose to the tip of the
ear lobe
d. eight to ten inches
34. 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 to
ensure that all secretions are removed
b. Using gloves to prevent introduction of pathogens to
the respiratory system
c. Applying no suction while inserting the catheter
d. Rotating catheter as it is inserted with gentle suction
35. Myrna has difficulty breathing when on her back
and must sit upright in bed to breath, effectively and
comfortably. The nurse documents this condition as:
a. Apnea
b. Orthopnea
c. Dyspnea
d. Tachypnea
Situation 7 - Using Maslow's need theory, Airway,
Breathing and Circulation are the physiological needs
vital to life. The nurse's knowledge and ability to identify
and immediately intervene to meet these needs is
important to save lives.
Situation 8 - You are assigned to screen for
hypertension: Your task is to take blood pressure
readings and you are informed about avoiding the
common mistakes in BP taking that lead to 'false or
inaccurate blood pressure readings.
31. Which of these clients has a problem with the
transport of oxygen from the lungs to the tissues:
36. When taking blood pressure reading the cuff should
be:
a. deflated fully then immediately start second reading
for same client
b deflated quickly after inflating up to 180 mmHg
c. large enough to wrap around upper arm of the adult
client 1 cm above brachial artery
d. inflated to 30 mmHg above the estimated systolic BP
based on palpation of radial or bronchial artery
37. Chronic Obstructive Pulmonary Disease (COPD) in
one of the leading causes of death worldwide and is a
preventable disease. The primary cause of COPD is:
a. tobacco hack
b. bronchitis
c. asthma
d. cigarette smoking
38. In your health education class for clients with
diabetes you teach, them the areas, for control .
Diabetes which include all EXCEPT:
a. regular physical activity
b. thorough knowledge of foot care
c. prevention nutrition
d. proper nutrition
39. You teach your clients the difference between, Type
I (IDDM) and Type II (NDDM) Diabetes. Which of the
following is true?
a. both types diabetes mellitus clients are all prone to
developing ketosis
b. Type II (NIDDM) is more common and is also
preventable compared to Type I (IDDM) diabetes which
is genetic in etiology
c. Type I (IDDM) is characterized by fasting
hyperglycemia
d. Type II (IDDM) is characterized by abnormal immune
response
40. Lifestyle-related diseases in general share areas
common risk factors. These are the following except
a. physical activity
b. smoking
c. genetics
d. nutrition
Situation 9 - Nurse Rivera witnesses a vehicular accident
near the hospital where she works. She decides to get
involved and help the victims of the accident.
41. Her priority nursing action would be to:
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a. Assess damage to property
b. Assist in the police investigation since she is a witness
c. Report the incident immediately to the local police
authorities
d. Assess the extent of injuries incurred by the victims, of
the accident
42. Priority attention should be given to which of these
clients?
a. Linda who shows severe anxiety due to trauma of the
accident
b. Ryan who has chest injury, is pate and with difficulty
of breathing
c. Noel who has lacerations on the arms with mildbleeding
c. Andy whose left ankle swelled and has some abrasions
43. In the emergency room, Nurse Rivera is assigned to
attend to the client with .lacerations on the arms, while
assessing the extent of the wound the nurse observes
that the wound is now starting to bleed profusely. The
most immediate nursing action would be to:
a. Apply antiseptic to prevent infection
b. Clean the wound vigorously of contaminants
c. Control and. reduce bleeding of the wound
d. Bandage the wound and elevate the arm
44. The nurse applies pressure dressing on the bleeding
site. This intervention is done to:
a. Reduce the need to change dressing frequently
b. Allow the pus to surface faster
c. Protect the wound from micro organisms in the air
d. Promote hemostasis
45. After the treatment, the client is sent home and
asked to come back for follow-up care. Your
responsibilities when the client is to be discharged
include the following EXCEPT:
a. Encouraging the client to go to the, outpatient clinic
for follow up care
b. Accurate recording, of treatment done and
instructions given to client
c. Instructing the client to see you after discharge for
further assistance
d. Providing instructions regarding wound care
Situation 10 - While working in the clinic, a new client,
Geline, 35 years old, arrives for her doctor's
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appointment. As the clinic nurse, you are to assist the
client fiil up forms, gather data and make an assessment.
46. The nurse purpose of your initial nursing interview
is to:
a. Record pertinent information in the client chart for
health team to read
b Assist the client find solutions to her health concerns
c. Understand her lifestyle, health needs and possible
problems to develop a plan of care
d. Make nursing diagnoses for identified health problems
47. While interviewing Geline, she starts to moan and
doubles up in pain, She tells you that this pain occurs
about an hour after taking black coffee without
breakfast for a few weeks now. You will record this as
follows:
a. Claims to have abdominal pains after intake of coffee
unrelieved by analgesics
b. After drinking coffee, the client experienced severe
abdominal pain
c. Client complained of intermittent abdominal pain an
hour after drinking coffee
d. Client reported abdominal pain an hour after drinking
black coffee for three weeks now
48. Geline tells you that she drinks black coffee
frequently within the day to "have energy and be wide
awake" and she eats nothing for breakfast and eats
strictly vegetable salads for lunch and dinner to lose
weight. She has lost weight during the past two weeks,
in planning a healthy balanced diet with Geline, you
will:
a. Start her off with a cleansing diet to free her body of
toxins then change to a vegetarian, diet and drink plenty
of fluids
b. Plan a high protein, diet; low carbohydrate diet for her
considering her favorite food
c. Instruct her to attend classes in nutrition to find food
rich in complex carbohydrates to maintain daily high
energy level
d. Discuss with her the importance of eating a variety of
food from the major food groups with plenty of fluids
49. Geline tells you that she drinks 4-5 cups of black
coffee and diet cola drinks. She also smokes up to a
pack of cigarettes daily. She confesses that she is in her
2nd month of pregnancy but she does not want to
become fat that is why she limits her food intake. You
warn or caution her about which of the following?
a. Caffeine products affect the central nervous system
and may cause the mother to have a "nervous
breakdown"
b. Malnutrition and its possible effects on growth and
development problems in the unborn fetus
c. Caffeine causes a stimulant effect on both the mother
and the baby
d. Studies show conclusively that caffeine causes mental
retardation
50. Your health education plan for Geline stresses
proper diet for a pregnant woman and the prevention
of non-communicable diseases that are influenced by
her lifestyle these include of the following EXCEPT:
a. Cardiovascular diseases
b. Cancer
c. Diabetes Mellitus
d. Osteoporosis
Situation 11 - Management of nurse practitioners is
done by qualified nursing leaders who have had clinical
experience and management experience.
51. An example of a management function of a nurse is:
a. Teaching patient do breathing and coughing exercises
b. Preparing for a surprise party for a client
c. Performing nursing procedures for clients
d. Directing and evaluating the staff nurses
52. Your head nurse in the unit believes that the staff
nurses are not capable of decision making so she makes
the decisions for everyone without consulting anybody.
This type of leadership is:
a. Laissez faire leadership
b. Democratic leadership
c. Autocratic leadership
d. Managerial leadership
53. When the head nurse in your ward plots and
approves your work schedules and directs your work,
she is demonstrating:
a. Responsibility
b. Delegation
c. Accountability
d. Authority
54. The following tasks can be safely delegated' by a
nurse to a non-nurse health worker EXCEPT:
a. Transfer a client from bed to chair
b. Change IV infusions
c. Irrigation of a nasogastric tube
d. Take vital signs
55. You made a mistake in giving the medicine to the
wrong client You notify the client’s doctor and write an
incident report. You are demonstrating:
a. Responsibility
b. Accountability
c. Authority
d. Autocracy
Situation 12 – Mr. Dizon, 84 years old, is brought to the
.Emergency Room for complaint of hypertension flushed
face, severe headache, and nausea. You are doing the
initial assessment of vital signs.
56. You are to measure the client’s initial blood
pressure reading by doing all of the following EXCEPT:
a. Take the blood pressure reading on both arms for
comparison
b. Listen to and identify the phases of Korotkoff’s sounds
c. Pump the cuff up to around 50 mmHg above the point
where the pulse is obliterated
d. Observe procedures for infection control
Mr. Dizon smokes and drinks coffee. When taking the
blood pressure of a client who recently smoked or
drank coffee, how long should be the nurse wait before
taking the client’s blood pressure for accurate reading?
a. 15 minutes
b. 30 minutes
c. 1 hour
d. 5 minutes
60. While the client has the pulse oximeter on his
fingertip, you notice that the sunlight is shining on .the
area where the oximeter is. Your action will be to:
a. Set and turn on the alarm of the oximeter
b. Do nothing since there is no identified problem
c. Cover the fingertip sensor with a towel or bedsheet
d. Change the location of the sensor every four hours
Situation 13 - The nurse's understanding of ethico-legal
responsibilities will guide his/her nursing practice.
61. The principles that .govern right and proper
conducts of a person regarding life, biology and the
health professions is referred to as:
a. Morality
b. Religion
c. Values
d. Bioethics
57. A pulse oximeter is attached to Mr. Dizon’s finger
to:
62. The purpose of having nurses’ code of ethics is:
a. Determine if the client’s hemoglobin level is low and if
he needs blood transfusion
b. Check level of client’s tissue perfusion
c. Measure the efficacy of the client’s anti hypertensive
medications
d. Detect oxygen saturation of arterial blood before
symptoms of hypoxemia develops
a. Delineate the scope and areas of nursing practice
b. Identify nursing action recommended for specific
healthcare situations
c. To help the public understand professional conduct,
expected of nurses
d. To define the roles and functions of the health care
giver, nurses, clients
58. After a few hours in the Emergency Room, Mr.
Dizon is admitted to the ward with an order of hourly
monitoring of blood pressure. The nurse finds that the
cuff is too narrow and this will cause the blood pressure
reading to be:
63. The most important nursing responsibility where
ethical situations emerge in patient care is to:
a. Inconsistent
b. low systolic and high diastolic pressure
c. higher than what the reading should be
d. lower than what the reading should be
59. Through the client’s health history, you gather that
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a. Act only when advised that the action is ethically
sound
b. Not take sides remain neutral and fair
c. Assume that ethical questions are the responsibility: of
the health team
d. Be accountable for his or her own actions
64. You inform the patient about his rights which
include the following EXCEPT:
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a. Right to expect reasonable continuity of care
b. Right to consent to or decline to participate in
research studies or experiments
c. Right to obtain information about another patient
d. Right to expect that the records about his care will be
treated as confidential
65. The principle states that a person has unconditional
worth and has the capacity to determine his own
destiny.
a. Bioethics
b. Justice
c. Fidelity
d. Autonomy
Situation 14 – Your director of nursing wants to improve
the quality of health care offered in the hospital. As a
staff nurse in that hospital you know that this entails
quality assurance programs.
66. The following mechanisms can be utilized as part of
the quality assessment program of your hospital
EXCEPT:
a. Patient satisfaction surveys provided
b. Peer review clinical records of care of client
c. RO of the Nursing Intervention Classification
d.
67. The nurse of the Standards of Nursing Practice is
important in the hospital. Which of the following
statements best describes what it is?
a. These are statements that describe the maximum or
highest level of acceptable performance in nursing
practice.
b. It refers to the scope of nursing as defined in Republic
Act 9173
c. It is a license issued by the Professional Regulation
Commission to protect the public from substandard
nursing practice.
d. The Standards of care includes the various steps of the
nursing process and the standards of professional
performance.
68. You are taking care of critically ill client and the
doctor in charge calls to order a DNR (do not
resuscitate) for the client. Which of the following is the
appropriate action when getting DNR order over the
phone?
a. Have the registered nurse, family spokesperson, nurse
supervisor and doctor sign
b. Have two nurses validate the phone order, both
nurses sign the order and the doctor should sign his
order within 24 hours.
c. Have the registered nurse, family and doctor sign the
order
d. Have 1 nurse take the order and sign it and have the
doctor sign it within 24 hours
69. To ensure the client safety before starting blood
transfusion the following are needed before the
procedure can be done EXCEPT:
a. take baseline vital signs
b. blood should be warmed to room temperature for 30
minutes before blood transfusion is administered
c. have two nurses verify client identification, blood
type, unit number and expiration date of blood
d. get a consent signed for blood transfusion
70. Part of standards of care has to do with the use of
restraints. Which of the following statements is NOT
true?
a. Doctor’s order for restraints should be signed within
24 hours
b. Remove and reapply restraints every two hours
c. Check client’s pulse, blood pressure and circulation
every four hours
d. Offer food and toileting every two hours
Situation 15 – During the NUTRITION EDUCATION class
discussion a 58 year old man, Mr. Bruno shows increased
interest.
71. Mr. Bruno asks what the "normal" allowable salt
intake is. Your best response to Mr. Bruno is:
a. 1 tsp of salt/day with iodine and sprinkle of MSG
b. 5 gms per day or 1 tsp of table salt/day
c. 1 tbsp of salt/day with some patis and toyo
d. 1 tsp of salt/day but not patis or toyo
72. Your instructions to reduce or limit salt intake
include all the following EXCEPT:
a. eat natural food with little or no salt added
b. limit use of table salt and use condiments instead
c. use herbs and spices
d. limit intake of preserved or processed food
73. Teaching strategies and approaches when giving
nutrition education is influenced by age, sex and
immediate concerns of the group. Your presentation
for a group of young mothers would be best if you
focus on:
a. diets limited in salt and fat
b. harmful effect on drugs and alcohol intake
c. commercial preparation of dishes
d. cooking demonstration and meal planning
74. Cancer cure is dependent on
a. use of alternative methods of healing
b. watching out for warning signs of cancer
c. proficiency in doing breast self-examination
d. early detection and prompt treatment
75. The role of the health worker in health education is
to:
a. report incidence of non-communicable disease to
community health center
b. educate as many people about warning signs of noncommunicable diseases
c. focus on smoking cessation projects
d. monitor clients with hypertension
Situation 16 – You are assigned to take care of 10
patients during the morning shift. The endorsement
includes the IV infusion and medications for these
clients.
76. Mr. Felipe, 36 years old is to be given 2700ml of
D5RL to infuse for 18 hours starting at 8am. At what
rate should the IV fluid be flowing hourly?
a. 100 ml/hour
b. 210 ml/hour
c. 150 ml/hour
d. 90 ml/hour
77. Mr. Atienza is to receive 150mg/hour of D5W IV
infusion for 12 hours for a total of 1800ml. He is also
losing gastric fluid which must be replaced every two
hours. Between 8am to 10am. Mr. Atienza has lost
250ml of gastric fluid. How much fluid should he
receive at 11am?
a. 350 ml/hour
b. 275 ml/hour
c. 400 ml/hour
d. 200 ml/hour
78. You are to apply a transdermal patch of
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nitroglycerin to your client. The following important
guidelines to observe EXCEPT:
a. Apply to hairlines clean are of the skin not subject to
much wrinkling
b. Patches may be applied to distal part of the
extremities like forearm
c. Change application and site regularly to prevent
irritation of the skin
d. Wear gloves to avoid any medication of your hand
79. You will be applying eye drops to Miss Romualdez.
After checking all the necessary information and
cleaning the affected eyelid and eyelashes you
administer the ophthalmic drops by instilling the eye
drops.
a. directly onto the cornea
b. pressing on the lacrimal duct
c. into the outer third of the lower conjunctival sac
d. from the inner canthus going towards the side of the
eye
80. When applying eye ointment, the following
guidelines apply EXCEPT:
a. squeeze about 2 cm of ointment and gently close but
not squeeze eye
b. apply ointment from the inner canthus going outward
of the affected eye
c. discard the first bead of the eye ointment before
application because the tube likely to expel more than
desired amount of ointment
d. hold the tube above the conjunctival sac do not let tip
touch the conjuctiva
Situation 17 – The staff nurse supervisor request all the
staff nurses to “brainstorm” and learn ways to instruct
diabetic clients on self-administration of insulin. She
wants to ensure that there are nurses available daily to
do health education classess.
81. The plan of the nurse supervisor is an example of
a. in service education process
b. efficient management of human resources
c. increasing human resources
d. primary prevention
82. When Mrs. Guevarra, a nurse, delegates aspects of
the clients care to the nurse-aide who is an unlicensed
staff, Mrs. Guevarra.
197
a. makes the assignment to teach the staff member
b. is assigning the responsibility to the aide but not the
accountability for those tasks
c. does not have to supervise or evaluate the aide
d. most know how to perform task delegated
d. wellness center
83. Connie, the-new nurse, appears tired and sluggish
and lacks the enthusiasms she give six weeks ago when
she started the job. The nurse supervisor should:
a. Goals and interventions to be followed by client are
based on nurse's priorities
b. Goals and intervention developed by nurse and client
should be approved by the doctor
c. Nurse will decide goals and, interventions needed to
meet client goals
d. Client will decide the goals and interventions required
to meet her goals
a. empathize with the nurse and listen to her
b. tell her to take the day off
c. discuss how she is adjusting to her new job
d. ask about her family life
84. Process of formal negotiations of working
conditions between a group of registered nurses and
employer is:
a. grievance
b. arbitration
c. collective bargaining
d. strike
85. You are attending a certification program on
cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is;
a. professional course towards credits
b. in-service education
c. advance training
d. continuing education
Situation 18 - There are various developments in health
education that the nurse should know about.
86. The provision of health information in the rural
areas nationwide through television and radio
programs and video conferencing is referred to as:
a. Community health program
b. Telehealth program
c. Wellness program
d. Red cross program
87. A nearby community provides blood pressure
screening, height and weight measurement smoking
cessation classes and aerobics class services. This type
of program is referred to as:
a. outreach program
b. hospital extension program
c. barangay health center
88. Part of teaching client in health promotion is
responsibility for one’s health. When Danica states she
need to improve her nutritional status this means:
89. Nurse Beatrice is providing tertiary prevention to
Mrs. De Villa. An example of tertiary provestion is:
a. Marriage counseling
b. Self-examination for breast cancer
c. Identifying complication of diabetes
d. Poison, control
90. Mrs. Ostrea has a schedule for Pap Smear. She has a
strong family history of cervical cancer. This is an
example of:
a. tertiary prevention
b. secondary prevention
c. health screening
d. primary prevention
Situation: 19 - Ronnie has a vehicular accident where he
sustained injury to his left ankle. In the Emergency
Room, you notice how anxious he looks.
91. You establish rapport with him and to reduce his
anxiety you initially
a. Take him to the radiology, section for X-ray of affected
extremity
b. Identify yourself and state your purpose in being with
the client
c. Talk to the physician for an order of Valium
d. Do inspection and palpation to check extent of his
injuries
92. While doing your assessment, Ronnie asks you "Do I
have a fracture? I don't want to have a cast.” The most
appropriate nursing response would be:
a. "You have to have an X-ray first to know if you have a
fracture."
b. "Why do you; sound so scared? It is just a cast and it's
not painful"
c. "You seem to be concerned about being in a cast."
d. "Based on my assessment, there doesn’t seem to be a
fracture."
198
199
ANSWER KEY - FOUNDATION OF PROFESSIONAL
NURSING PRACTICE
1. C
2. B
3. D
4. D
5. B
6. B
7. C
8. D
9. B
10. B
11. B
12. C
13. C
14. D
15. A
16. A
17. C
18. B
19. A
20. C
21. D
22. C
23. D
24. D
25. C
26. D
27. C
28. D
29. D
30. C
31. B
32. C
33. C
34. C
35. B
36. D
37. D
38. B
39. B
40. C
41. D
42. B
43. D
44. D
45. C
46. C
47. D
48. D
49. B
50. D
51. D
52. C
53. D
54. B
55. B
56. C
57. D
58. C
59. B
60. C
61. D
62. C
63. D
64. C
65. D
66. D
67. A
68. D
69. D
70. C
71. B
72. B
73. D
74. D
75. B
76. C
77. 78. B
79. B
80. C
81. C
82. B
83. C
84. C
85. B
86. B
87. A
88. D
89. C
90. B
91. B
92. C
COMMUNITY HEALTH NURSING AND CARE OF THE
MOTHER AND CHILD
Situation 1 - Nurse Minette is an independent Nurse
Practitioner following-up referred clients in their
respective homes. Here she handles a case of
POSTPARTIAL MOTHER AND FAMILY focusing on HOME
CARE.
1. Nurse Minette needs to schedule a first home visit to
OB client Leah. When is a first home-care visit typically
made?
a. Within 4 days after discharge
b. Within 24 hours after discharge
c. Within 1 hour after discharge
d. Within 1 week of discharge
2. Leah is developing constipation from being on bed
rest. What measures would you suggest she take to
help prevent this?
a. Eat more frequent small meals instead of three large
one daily
b. Walk for at least half an hour daily to stimulate
peristalsis
c. Drink more milk, increased calcium intake prevents
constipation
d. Drink eight full glasses of fluid such as water daily
3. If you were Minette, which of the following actions,
would alert you that a new mother is entering a
postpartial at taking-hold phase?
a. She urges the baby to stay awake so that she can
breast-feed him in her
b. She tells you she was in a lot of pain all during labor
c. She says that she has not selected a name fir the baby
as yet
d. She sleeps as if exhausted from the effort of labor
4. At 6-week postpartum visit what should this
postpartial mother's fundic height be?
a. Inverted and palpable at the cervix
b. Six fingerbreadths below the umbilicus
c. No longer palpable on her abdomen
d. One centimeter above the symphysis pubis
5. This postpartal mother wants to loose the weight she
gained in pregnancy, so she is reluctant to increase her
200
calorin intake for breast-feeding. By how much should a
lactating mother increase her caloric intake during the
first 6 months after birth?
a. 350 kcal/day
b. 5CO kcal/day
c. 200 kcal/day
d. 1,000 kcal/day
Situation 2 - As the CPES is applicable for all professional
nurse, the professional growth and development of
Nurses with specialties shall be addressed by a Specialty
Certification Council.
The following questions apply to these special groups of
nurses.
6. Which of the following serves as the legal basis and
statute authority for the Board of nursing to
promulgate measures to effect the creation of a
Specialty Certification Council and promulgate
professional development programs for this group of
nurse-professionals?
a. R.A. 7610
b. R.A. 223
c. R.A. 9173
d. R.A. 7164
7. By force of law, therefore, the PRC-Board of Nursing
released Resolution No. 14 Series of the entitled:
"Adoption of a Nursing Specialty Certification Program
and Creation of Nursing Specialty Certification Council."
This rule-making power is called:
a. Quasi-Judicial Power
b. Regulatory Power
c. Quasi/Legislative Power
d. Executive/Promulgation Power
8. Under the PRC-Board of Nursing Resolution
promulgating the adoption of a Nursing SpecialtyCertification Program and Council, which two (2) of the
following serves as the strongest for its enforcement?
(a) Advances made in science aid technology have
provided the climate for specialization in almost all
aspects of human endeavor and
(b) As necessary consequence, there has emerged a new
concept known as globalization which seeks to remove
barriers in trade, .industry and services imposed by the
national laws of countries all over the world; and
(c) Awareness of this development should impel the
nursing sector to prepare our people in the services
sector to meet .the above challenges; and
201
(d) Current trends of specialization in nursing practice
recognized by; the International Council of Nurses (ICN)
of which the Philippines is a member for the benefit of
the Filipino in terms of deepening and refining nursing
practice and enhancing the quality of nursing care.
be acceptable TRUTHS applied to Community Health
Nursing Practice.
a. b & c are strong justification
b. a & b are strong justification
c. a & c are strong justification
d. a & d are strong justification
a. Cure of illnesses
b. Prevention of illness
c. Rehabilitation back to health
d. Promotion of health
9. Which of the following is NOT a correct statement as
regards Specialty Certification?
12. In community health nursing, which of the following
is our unit of service as nurses?
a. The Board of Nursing intended to create the Nursing
Specialty Certification Program as a means of
perpetuating the creation of an elite force of Filipino
Nurse Professionals
b. The Board of Nursing shall oversee the administration
of the NSCP through the various Nursing Specialty
Boards which will eventually, be created
c. The Board of Nursing at the time exercised their
powers under R.A. 7164 in order to adopt the creation of
the Nursing Specialty Certification /council and Program
d. The Board of Nursing consulted nursing leaders of
national nursing associations and other concerned
nursing groups which later decided to ask a special group
of nurses of .the program for nursing specialty
certification
a. The Community
b. The Extended Members of every family
c. The individual members of the Barangay
d. The Family
10. The NSCC was created for the purpose of
implementing the Nursing Specialty policy under the
direct supervision and stewardship of the Board of
Nursing. Who shall comprise the NSCC?
14. In community health nursing it is important to take
into account the family health with an equally
important need to perform ocular inspection of the
areas activities which are powerful elements of:
a. A Chairperson who is the current President of the APO
a member from .the Academe, and the last member
coming from the Regulatory Board
b. The Chairperson and members of the Regulatory
Board ipso facto acts as the CPE Council
c. A Chairperson, chosen from among the Regulatory
Board Members, a Vice Chairperson appointed by the
BON at-large; two other members also chosen at-large;
and one representing the consumer group
d. A Chairperson who is the President of the Association
from the Academe; a member from the Regulatory
Board, and the last member coming from the APO
a. evaluation
b. assessment
c. implementation
d. planning
Situation 3 - Nurse Anna is a new BSEN graduate and has
just passed her Licensure Examination for Nurses in the
Philippines. She has likewise been hired as a new
Community Health Nurse in one of the Rural Health
Units in their City, which of the following conditions may
11. Which of the following is the primary focus of
community health nursing practice?
13. A very important part of the Community Health
Nursing Assessment Process includes
a. the application of professional judgment in estimating
importance of facts to family and community
b. evaluation structures arid qualifications of health
center team
c. coordination with other sectors in relation to health
concerns
d. carrying out nursing procedures as per plan of action
15. The initial step in the PLANNING process in order to
engage in any nursing project or parties at the
community level involves:
a. goal-setting
b. monitoring
c. evaluation of data
d. provision of data
Situation 4 - Please continue responding as a
professional nurse in these other health situations
through the following questions.
16. Transmission of HIV from an infected individual to
another person occurs:
a. Most frequency in nurses with needlesticks
b. Only if there is a large viral load in the blood
c. Most commonly as a result of sexual contact
d. In all infants born to women with HIV infection
a. Prostaglandins released from the cut fallopian tubes
can kill sperm
b. Sperm cannot enter the uterus, because the cervical
entrance is blocked
c. Sperm can no longer reach the ova, because the
fallopian tubes are blocked
d. The ovary no longer releases ova, as there is no where
for them to go
17. The medical record of a client reveals a condition in
which the fetus cannot pass through the maternal
pelvis. The nurse interprets this as:
22. The Dators are a couple undergoing testing for
infertility. Infertility is said to exist when:
a. Contracted pelvis
b. Maternal disproportion
c. Cervical insufficiency
d. Fetopelvic disproportion
a. a woman has no uterus
b. a woman has no children
c. a couple has been trying to conceive for 1 year
d. a couple has wanted a child for 6 months
18. The nurse would anticipate a cesarean birth for a
client who has which infection present at the onset of
labor?
23. Another client names Lilia is diagnosed as having
endometriosis. This condition interferes with the
fertility because:
a. Herpes simplex virus
b. Human papilloma virus
c. Hepatitis
d. Toxoplasmosia
a. endometrial implants can block the fallopian tubes
b. the uterine cervix becomes inflamed and swollen
c. ovaries stop producing adequate estrogen
d. pressure on the pituitary leads to decreased FSH levels
19. After a vaginal examination, the nurse»e
determines that the client's fetus is in an occiput
posterior position. The nurse would anticipate that the
client will have:
24. Lilia is scheduled to have a hysterosalpingogram.
Which of the following, instructions would you give her
regarding this procedure?
a. A precipitous birth
b. Intense back pain
c. Frequent leg cramps
d. Nausea and vomiting
20. The rationales for using a prostaglandin gel for a
client prior to the induction of labor is to:
a. Soften and efface the cervix
b. Numb cervical' pain receptors
c. Prevent cervical lacerations
d. Stimulate uterine contractions
Situation 5 - Nurse Lorena is a Family Planning and
Infertility Nurse Specialist and currently attends to
FAMILY PANNING CLIENTS AND INFERTILE COUPLES. The
following conditions pertain to meeting the nursing of
this particular population group.
21. Dina, 17 years old, asks you how a tubal ligation
prevents pregnancy. Which would be the best answer?
a. She will not be able to conceive for 3 months after the
procedure
b. The sonogram of the uterus will reveal any tumors
present
c. Many women experience mild bleeding as an after
effect
d. She may feel some cramping when the dye is inserted
25. Lilia's cousin on the other hand, knowing nurse
Lorena's specialization asks what artificial insemination
by donor entails. Which would be your best answer if
you were Nurse Lorena?
a. Donor sperm are introduced vaginally into the uterus
or cervix
b. Donor sperm are injected intra-abdominally into each
ovary
c. Artificial sperm are injected vaginally to test tubal
patency
d. The husband's sperm is administered intravenously
weekly
Situation 6 - There are other important basic knowledge
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203
in the performance of our task as Community Health
Nurse in relation to IMMUNIZATION these include:
26. The correct temperature to store vaccines in a
refrigerator is:
a. between -4 deg C and +8 deg C
b. between 2 deg C and +8 deg C
c. between -8 deg C and 0 deg C
d. between -8 deg C and +8 deg C
27. Which of the following vaccines is not done by
intramuscular (IM) injection?
a. Measles vaccine
b. DPT
c. Hepa B vaccines
d. DPT
28. This vaccine content is derived from RNA
recombinants:
a. Measles
b. Tetanus toxoids
c. Hepatitis B vaccines
d. DPT
29. This is the vaccine needed before a child reaches
one (1) year in order for him/her to qualify as a "fully
immunized child".
a. DPT
b. Measles
c. Hepatitis B
d. BCG
30. Which of the following dose of tetanus toxoid is
given to the mother to protect her .infant from
neonatal tetanus and likewise provide 10 years
protection for the mother?
a. Tetanus toxoid 3
b. Tetanus toxoid 2
c. Tetanus toxoid 1
d. Tetanus toxoid 4
Situation 7 - Records contain those, comprehensive
descriptions of patient's health conditions and needs and
at the same serve as evidences of every nurse's
accountability in the, care giving process. Nursing
records normally differ from institution to, institution
nonetheless they follow similar patterns of .meeting
needs for specifics, types of information. The following
pertalos to documentation/records management.
31. This special form used when the patient is admitted
to the unit. The nurse completes, the information in
this records particularly his/her .basic personal data,
current illness, previous health history, health history
of the family, emotional profile, environmental history
as well as physical assessment together with nursing
diagnosis on admission. What do you call this record?
a. Nursing Kardex
b. Nursing Health History and Assessment Worksheet
c. Medicine and Treatment Record
d. Discharge Summary
32. These, are sheets/forms which provide an efficient
and time saving way to record information that must
be obtained repeatedly at regular and/or short
intervals, of .time. This does not replace the progress
notes; instead this record of information on vital signs,
intake and output, treatment, postoperative care,
postpartum care, and diabetic regimen, etc., this is
used whenever specific measurements or observations
are needed to-be documented repeatedly. What is
this?
a. Nursing Kardex
b. Graphic Flow sheets
c. Discharge Summary
d. Medicine and Treatment Record
33. These records show all medications and treatment
provided on a repeated basis. What do you call this
record?
a. Nursing Health History and Assessment Worksheet
b. Discharge Summary
c. Nursing Kardex
d. Medicine and Treatment Record
34. This flip-over card is usually kept in a portable file at
the Nurses Station. It has 2-parts: the activity and
treatment section and a nursing care plan section. This
carries information about basic demographic data,
primary medical diagnosis, current orders of the
physician to be carried out by the nurse, written
nursing care plan, nursing orders, scheduled tests and
procedures, safety precautions in-patient care and
factors related to daily living activities/ this record is
used in the charge-of-shift reports or during the beside
rounds or walking rounds. What record is this?
a. Discharge Summary
b. Medicine and Treatment Record
c. Nursing Health History and Assessment Worksheet
d. Nursing Kardex
35. Most nurses regard this as conventional recording
of the date, time and mode by which the patient leaves
a healthcare unit but this record includes importantly,
directs of planning for discharge that starts soon after
the' person is admitted to a healthcare institution, it is
accepted that collaboration or multidisciplinary
involvement (of all members of the health team) in
discharge results in comprehensive care. What do you
call this?
a. Discharge Summary
b. Nursing Kardex
c. Medicine and Treatment Record
d. Nursing Health History and Assessment Worksheet
Situation 8 - As Filipino Professional Nurses we must be
knowledgeable, about the Code of Ethics for Filipino
Nurses and practice these by heart. The next questions
pertain to this Code of Ethics.
36. Which of the following is TRUE about the Code of
Ethics of Filipino Nurses?
a. The Philippine Nurses Association for being the
accredited professional organization was given the
privilege to formulate a Code of Ethics which the Board
of Nurses promulgated
b. Code of Nurses was first formulated in 1982 published
in the Proceedings of the Third Annual Convention of the
PNA House of Delegates
c. The present code utilized the Code of Good
Governance for the Professions in the Philippines
d. Certificate of Registration of registered nurses; may be
revoked or suspended for violations of any provisions of
the Code of Ethics
37. Based on the Code of Ethics for Filipino Nurses,
what is regarded as the hallmark of nursing
responsibility and accountability?
a. Human rights of clients, regardless of creed and
gender
b. The privilege of being a registered professional nurses
c. Health, being a fundamental right of every individual
d. Accurate documentation of actions and outcomes
38. Which of the following nurses behavior is regarded
as a violation of the Code of Ethics of Filipino Nurses?
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a. A nurse withholding harmful information to the family
members of a patient
b. A nurse declining commission sent by a doctor for her
referral
c. A nurse endorsing a person running for congress
d. Nurse Reviewers and/or nurse review center
managers who pays a considerable amount of cash for
reviewees who would memorize items from the
Licensure exams and submit these to them after the
examination
39. A nurse should be cognizant that professional
programs for specialty certification by the Board of
Nursing are accredited through the
a. Professional Regulation Commission
b. Nursing Specialty Certification Council
c. Association of Deans of Philippine Colleges of Nursing
d. Philippine Nurse Association
40. Mr. Santos, R.N. works in a nursing home, and he
knows that one of his duties is to be an advocate for his
patients. Mr. Santos knows a primary duty of an
advocate is to:
a. act as the patient's legal representative
b. complete all nursing responsibilities on time
c. safeguard the well being of every patient
d. maintain the patient's right to privacy
Situation 9 - Nurse Joanna works as an OB-Gyne Nurse
and attends to several HIGH-RISK PREGNANCIES:
Particularly women with preexisting of Newly Acquired
illness. The following conditions apply.
41. Bernadette is a 22-year old woman. Which
condition would make her more prone than others to
developing a Candida infection during pregnancy?
a. Her husband plays gold 6 days a week
b. She was over 35 when she became pregnant
c. She usually drinks tomato juice for breakfast
d. She has developed gestational diabetes
42. Bernadette develops a deep-vein thrombosis
following an auto accident and is prescribed heparin
sub-Q. What should Joanna educate her about in regard
to this?
a. Some infants will be born with allergic symptoms to
heparin
b. Her infant will be born with scattered petechiae on his
trunk
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c. Heparin can cause darkened skin in newborns
d. Heparin does not cross the placenta and so does not
affect a fetus
children with cough
c. Refer to the doctor
d. Teach the mother how to count her child's bearing
43. The cousin of Bernadette with sickle-cell anemia
alerted Joanna that she may need further instruction
on prenatal care. Which statement signifies this fact?
47. In responding to the care concerns of children with
severe disease, referral to the hospital of the essence
especially if the child manifests which of the following?
a. I've stopped jogging so I don't risk becoming
dehydrated
b. I take an iron pull every day to help grown new red
blood cells
c. I am careful to drink at least eight glasses of fluid
everyday
d. 1 understand why folic acid is important for red cell
formation
a. Wheezing
b. Stopped bleeding
c. Fast breathing
d. Difficulty to awaken
44. Bernadette routinely takes acetylsalicylic acid
(aspirin) for arthritis. Why should she limit or
discontinue this toward the end of pregnancy?
a. Giving of antibiotics
b. Taking of the temperature of the sick child
c. Provision of Careful Assessment
d. Weighing of the sick child
a. Aspirin can lead to deep vein thrombosis following
birth
b. Newborns develop a red rash from salicylate toxicity
c. Newborns develop withdrawal headaches from
salicylates
d. Salicyates can lead to increased maternal bleeding at
childbirth
45. Bernadette received a laceration on her leg from
her automotive accident. Why are lacerations of lower
extremities potentially more serious in pregnant
women than others?
48. Which of the following is the most important
responsibility of a nurse in the prevention of necessary
deaths from pneumonia and other severe diseases?
49. You were able to identify factors that lead to
respiratory problems in the community where your
health facility serves. Your primary role therefore in
order to reduce morbidity due to pneumonia is to:
a. Teach mothers how to recognize early signs and
symptoms of pneumonia
b. Make home visits to sick children
c. Refer cases to hospitals
d. Seek assistance and mobilize the BHWs to have a
meeting with mothers
a. Lacerations can provoke allergic responses because of
gonadothropic hormone
b. Increased bleeding can occur from uterine pressure on
leg veins
c. A woman is less able to keep the laceration clean
because o f her fatigue
d. Healing is limited during pregnancy, so these will not
heal until after birth
50. Which of the following is the principal focus on the
CARI program of the Department of Health?
Situation 10 - Still in your self-managed Child Health
Nursing Clinic, your encounter these cases pertaining to
the CARE OF CHILDREN WITH PULMONARY AFFECTIONS.
Situation 11 - You are working as a Pediatric Nurse in
your own Child Health Nursing Clinic, the following cases
pertain to ASSESSMENT AND CARE OP THE NEWBORN AT
RISK conditions.
46. Josie brought her 3-rnonths old child to your clinic
because of cough and colds. Which of the following is
your primary action?
a. Give contrimoxazole tablet or syrup
b. Assess the patient using the chart on management of
a. Enhancement of health team capabilities
b. Teach mothers how to detect signs and where to refer
c. Mortality reduction through early detection
d. Teach other community health workers how to assess
patients
51. Theresa, a mother with a 2 year old daughter asks,
"at what are can I be able to take the blood pressure of
my daughter as a routine procedure since hypertension
is common in the family?" Your answer to this is:
a. At 2 years you may
b. As early as 1 year old
c. When she's 3- years old
d. When she's 6 years old?
52. You typically gag children to inspect the back of
their throat. When is it important NOT to solicit a gag
reflex?
a. when a girl has a geographic tongue
b. when a boy has a possible inguinal hernia
c. when a child has symptoms of epiglottitis
d. when children are under 5 years of age
contraindication to immunization?
a. do not give DPT2 or DPT3 to a child who has
convulsions within 3 days of DPT1
b. do not give BOG if the child has known hepatitis .
c. do not give OPT to a child who has recurrent
convulsion or active neurologic disease
d. do not give BCG if the child has known AIDS
58. Which of the following statements about
immunization is NOT true:
a. Naloxone (Narcan)
b. Morphine Sulfate
c. Sodium Chloride
d. Penicillin G
a. A child with diarrhea who is due for OPV should
receive the OPV and make extra dose on the next visit
b. There is no contraindication to immunization if the
child is well enough to go home
c. There is no contraindication to immunization if the
child is well enough to go home and a child should be
immunized in the health center before referrals are both
correct
d. A child should be immunized in the center before
referral
54. Why are small-for-gestational-age newborns at risks
for difficulty maintaining body temperature?
59. A child with visible severe wasting or severe palmar
pallor may be classified as:
a. They do not have as many fat stores as other infant’s
b. They are more active than usual so throw off covers
c. Their skin is more susceptible to conduction of cold
d. They are preterm so are born relatively small in size
a. moderate malnutrition/anemia
b. severe malnutrition/anemia
c. not very tow weight no anemia
d. anemia/very low weight
55. Baby John develops hyperbilirubinemia. What is a
method used to treat hyperbilirubinemia in a newborn?
60. A child who has some palmar pallor can be
classified as:
a. Keeping infants in a warm arid dark environment
b. Administration of a cardiovascular stimulant
c. Gentle exercise to stop muscle breakdown
d. Early feeding to speed passage of meconium
a. moderate anemia/normal weight
b. severe malnutrition/anemia
c. anemia/very low weight
d. not very low eight to anemia
Situation 12 - You are the nurse in the Out-PatientDepartment and during your shift you encountered
multiple children's condition. The following questions
apply.
Situation 13 - Nette, a nurse palpates the abdomen of
Mrs. Medina, a primigravida. She is unsure of the date of
her last menstrual period. Leopold's Maneuver is done.
The obstetrician told mat she appears to be 20 weeks
pregnant. .
53. Baby John was given a drug at birth to reverse the
effects of a narcotic given to his mother in' labor. What
drug is commonly used for this?
56. You assessed a child with visible severe wasting, he
has:
a. edema
b. LBM
c. kwashiorkor
d. marasmus
57. Which of the following conditions is NOT true about
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61. Nette explains this because the fundus is:
a. At the level the umbilicus, and the fetal heart can be
heard with a fetoscope
b. 18 cm, and the baby is just about to move
c. is just over the symphysis, and fetal heart cannot be
heard
d. 28 cm, and fetal heart can be heard with a Doppler
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62. In doing Leopold's maneuver palpation which
among the following is NOT considered a good
preparation?
a. The woman should lie in a supine position wither
knees flexed slightly
b. The hands of the nurse should be cold so that
abdominal muscles would contract and tighten
c. Be certain that your hands are warm (by washing them
in warm water first if necessary)
d. The woman empties her bladder before palpation
63. In her pregnancy, she experienced fatigue and
drowsiness. This probably occurs because:
a. of high blood pressure
b. she is expressing pressure
c. the fetus utilizes her glucose stores and leaves her
with a Sow blood glucose
d. of the rapid growth of the fetus
64. The nurse assesses the woman at 20 weeks
gestation3 and expects the woman to report:
a. Spotting related to fetal implantation
b. Symptoms of diabetes as human placental lactogen is
released
c. Feeling fetal kicks
d. Nausea and vomiting related HCG production
65. If Mrs. Medina comes to you for check-up on June 2,
her EDO is June 11, what do you expect during
assessment?
a. Fundic ht 2 fingers below xyphoid process, engaged
b. Cervix close, uneffaced, FH-midway between the
umbilicus and symphysis pubis
c. Cervix open, fundic ht. 2 fingers below xyphoid
process, floating .
d. Fundic height at least at the level of the xyphoid
process, engaged
Situation 14: - Please continue responding as a
professional nurse in varied health situations through
the following questions.
66. Which of the following medications would the
nurse expect the physician to order for recurrent
convulsive seizures of a 10-year old child brought to
your clinic?
b. Nifedipine
c. Butorphanol
d. Diazepam
67. RhoGAM is given to Rh-negative women to prevent
maternal sensitization from occurring. The nurse is
aware that in addition to pregnancy, Rh-negative
women would also receive this medication after which
of the following?
a. Unsuccessful artificial insemination procedure
b. Blood transfusion after hemorrhage
c. Therapeutic or spontaneous abortion
d. Head injury from a car accident
68. Which of the following would the nurse include
when describing the pathophysiologv of gestational
diabetes?
a. Glucose levels decrease to accommodate fetal growth
b. Hypoinsulinemia develops early in the first trimester
c. Pregnancy fosters the development of carbohydrate
cravings
d. There is progressive resistance to the effects of insulin
69. When providing prenatal education to a pregnant
woman with asthma, which of the following would be
important for the nurse to do?
a. Demonstrate how to assess her blood glucose
b. Teach correct administration of subcutaneous
bronchodilators
c. Ensure she seeks treatment for any acute
exacerbation
d. Explain that she should avoid steroids during her
pregnancy
70. Which of the following conditions would cause an
insulin-dependent diabetic client the most difficulty
during her pregnancy?
a. Rh incompatibility
b. Placenta previa
c. Hyperemesis gravidarum
d. Abruption placentae
Situation 15 - One important toot a community health
nurse uses in the conduct of his/her activities is the CHN
Bag. Which of the following BEST DESCRIBES the use of
this vital facility for our practice?
71. The Community/Public Health Bag is:
a. Phenobarbital
a. a requirement for home visits
b. an essential and indispensable equipment of the
community health nurse
c. contains basic medications and articles used by the
community health nurse
d. a tool used by the Community health nurse is
rendering effective nursing procedure during a home
visit
72. What is the rationale in the use of bag technique
during home visit?
a. It helps render effective nursing care to clients or
other members of the family
b. It saves time and effort of the nurse in the
performance of nursing procedures
c. It should minimize or prevent the spread of infection
from individuals to families
d. It should not overshadow concerns for the patient
73. Which among the following is important in the use
of the bag technique during home visit?
a. Arrangement of the bag's contents must be
convenient to the nurse
b. The bag should contain all necessary supplies and
equipment ready for use
c. Be sure to thoroughly clean your bag especially when
exposed to communicable disease cases
d. Minimize if not totally prevent the spread of infection
74. This is an important procedure of the nurse during
home visits?
a. protection of the CHN bag
b. arrangement of the contents of the CHM bag
c. cleaning of the CHN bag
d. proper handwashing
75. In consideration of the steps in applying the bag
technique, which side of the paper lining of the CHN
bag is considered clean to make a non-contaminated
work area?
a. The lower lip
b. The outer surface
c. The upper lip
d. The inside surface
Situation 16 - As a Community Health Nurse relating with
people in different communities, and in the
implementation of health programs and projects you
experience vividly as well the varying forms of leadership
208
and management from the Barangay Level to the Local
Government/Municipal City Level.
76. The following statements can correctly be made
about Organization and management?
A. An organization (or company) is people. Values make
people persons: values give vitality, meaning and
direction to a company. As the people of an organization
value, so the company becomes.
B. Management is the process by which administration
achieves its mission, goals, and objectives
C. Management effectiveness can be measured in terms
of accomplishment of the purpose of the organization
while management efficiency is measured in terms of
the satisfaction of individual motives
D. Management principles are universal therefore one
need not be concerned about people, culture, values,
traditions and human relations.
a. B and C only
b. A, B and D only
c. A and D only
d. B, A, and C only
77. Management by Filipino values advocates the
consideration of the Filipino goals trilogy according to
the Filipino priority-values which are:
a. Family goals, national goals, organizational goals
b. Organizational goats, national goals, family goals
c. National goals, organizational goals, family goals
d. Family goals, organizational goals, national goals
78. Since the advocacy for the utilization of Filipino
value-system in management has been encouraged, the
Nursing sector is no except, management needs to
examine Filipino values and discover its positive
potentials and harness them to achieve:
a. Employee satisfaction
b. Organizational commits .ants, organizational
objectives and employee satisfaction
c. Employee objectives/satisfaction, commitments and
organizational objectives
d. Organizational objectives, commitments and
employee objective/satisfaction
79. The following statements can correctly be made
about an effective and efficient community or even
agency managerial-leader.
A. Considers the achievement and advancement of the
organization she/he represents as well as his people
209
B. Considers the recognition of individual efforts toward
the realization of organizational goals as well as the
welfare of his people
C. Considers the welfare of the organization above all
other consideration by higher administration
D. Considers its own recognition by higher
administration for purposes of promotion and prestige
a. Only C and D are correct
b. A, C and D are correct
c. B, C, and D are correct
d. Only A and B are correct
80. Whether management at the community or agency
level, there are 3 essential types of skills managers
must have, these are:
A. Human relation skills, technical skills, and cognitive
skills
B. Conceptual skills, human relation/behavioral skills,
and technical skills
C. Technical skills, budget and accounting skills, skills in
fund-raising
D. Manipulative skills, technical skills, resource
management skills
a. A and D are correct
b. B is correct
c. A is correct
d. C and D are correct
Situation 17 - You are actively practicing nurse who just
finished your Graduate Studies. You earned the value of
Research and would like to utilize the knowledge and
skills gained in the application of research to Nursing
service. The following questions apply to research.
81. Which type of research Inquiry investigates the
issue of human complexity (e.g. understanding the
human expertise)
a. Logical position
b. Naturalistic inquiry
c. Positivism
d. Quantitative Research
82. Which of the following studies is based on
quantitative research?
a. A study examining the bereavement process in
spouses of clients with terminal cancer
b. A study exploring factors influencing weight control
behavior
c. A study measuring the effects of sleep deprivation on
wound healing
d. A study examining client's feelings before, during and
after a bone marrow aspiration
83. Which of the following studies is based on
qualitative research?
a. A study examining clients reactions to stress after
open heart surgery
b. A study measuring nutrition and weight, loss/gain in
clients with cancer
c. A study examining oxygen levels after endotracheal
suctioning
d. A study measuring differences in blood pressure
before during and after a procedure
84. An 85 year old client in a nursing home tells a nurse,
"I signed the papers for that research study because the
doctor was so insistent and I want: him to continue
taking care of me." Which client right is being violated?
a. Right of self determination
b. Right to privacy and confidentiality
c. Right to full disclosure
d. Right not to be harmed
85. "A supposition or system of ideas that is proposed
to explain a given phenomenon," best defines:
a. a paradigm
b. a concept
c. a theory
d. a conceptual framework
Situation 18 - Nurse Michelle works with a Family
Nursing Team in Calbayog Province specifically handling
a UNICEF Project for Children. The following conditions
pertain, to CARE OP THE FAMILIES PRESCHOOLERS.
86. Ronnie asks constant questions. How many does a
typical 3-year-old ask in a day's time?
a. 1,200 or more
b. Less than 50
c. 100-200
d. 300-400
87. Ronnie will need to change to a new bed because
his baby sister will need Ronnie's old crib. What
measure would you suggest that his parents take to
help decrease sibling rivalry between Ronnie and his
new sister?
a. Move him to the new bed before the baby arrives
b. Explain that new sisters grow up to become best
friends
c. Tell him he will have to share with the new baby
d. Ask him to get his crib ready for the new baby
88. Ronnie's parents want to know how to react to him
when he begins to masturbate while watching
television. What would you suggest?
a. They refuse to allow him to watch television
b. They schedule a health check-up for sex-related
disease
c. They remind him that some activities are private
d. They give him "timeout" when this begins
89. How many words does a typical 12-month-old
infant use?
a. About 12 words
b. Twenty or more words
c. About 50 words
d. Two, plus "mama" and "dada"
90. As a nurse. You reviewed infant safety procedures
with Bryan's mother. What are two of the most
common types of accidents among infants?
a. Aspiration and falls
b. Falls and auto accidents
c. Poisoning and burns
d. Drowning and homicide
Situation 19 - Among common conditions found in
children especially among poor communities are ear
infection/problems. The following questions apply.
93. An ear discharge that has been present for more
than 14 days can be classified as:
a. mastoditis
b. chronic ear infection
c. acute ear infection
d. complicated ear infection
94. An ear discharge that has been present for jess than
14 days can be classified as:
a. chronic ear infection
b. mastoditis
c. acute ear infection
d. complicated ear infection
95. If the child has severe classification because of ear
problem, what would be the best thing that you as the
nurse can do?
a. instruct mother when to return immediately
b. refer urgently
c. give an antibiotic for 5 days
d. dry the ear by wicking
Situation 20 - If a child with diarrhea registers one sign in
the pink row and one in the yellow; row in the IMCI
Chart.
96. We can classify the patient as:
a. moderate dehydration
b. some dehydration
c. no dehydration
d. severe dehydration
91. A child with ear problem should be assessed for the
following EXCEPT:
97. The child with no dehydration needs home
treatment Which of the following is not included the
rules for home treatment in this case:
a is there any fever?
b. ear discharge
c. if discharge is present for how long?
d. ear pain
a. continue feeding the child
b. give oresol every 4 hours
c. know when to return to the health center
d. give the child extra fluids
92. If the child does not have ear problem, using IMCI,
what should you as the nurse do?
98. A child who has had diarrhea for 14 days but has no
sign of dehydration is classified as:
a. Check for ear discharge
b. Check for tender swellings, behind the ear
c. Check for ear pain
d. Go to the next question, check for malnutrition
a. severe persistent diarrhea
b. dysentery
c. severe dysentery b. dysentery
d. persistent diarrhea
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211
99. If the child has sunken eyes, drinking eagerly,
thirsty and skin pinch goes back slowly, the
classification would be:
a. no dehydration
b. moderate dehydration
c. some dehydration
d. severe dehydration
100. Carlo has had diarrhea for 5 days. There is no
blood in the stool, he is irritable. His eyes are sunken
the nurse offers fluid to Carlo and he drinks eagerly.
When the nurse pinched the abdomen, it goes back
slowly. How will you classify Carlo’s illness?
a. severe dehydration
b. no dehydration
c. some dehydration
d. moderate dehydration
ANSWER KEY: COMMUNITY HEALTH NURSING
AND CARE OF THE MOTHER AND CHILD
1. A
2. B
3. A
4. C
5. B
6. D
7. C
8. D
9. A
10. B
11. D
12. D
13. A
14. B
15. A
16. C
17. D
18. A
19. B
20. D
21. C
22. C
23. A
24. C
25. A
26. B
27. A
28. C
29. B
30. D
31. B
32. B
33. D
34. D
35. A
36. C
37. C
38. A
39. B
40. C
41. D
42. D
43. B
44. D
45. B
46. B
47. D
48. C
49. A
50. C
51. C
52. C
53. A
54. A
55. D
56. D
57. B
58. A
59. B
60.
61. A
62. B
63. D
64. C
65. A
66. A
67. C
68. D
69. C
70. C
71. B
72. A
73. D
74. D
75. B
76. D
77. D
78. D
79. D
80. C
81. B
82. C
83. A
84. A
85. C
86. D
87. A
88. C
89. A
90. A
91. A
92. D
93. B
94. C
95. B
96. D
97. B
98. D
99. C
100. C
212
213
Comprehensive Exam 1
Situation 1 - Concerted work efforts among members of
the surgical team is essential to the success of the
surgical procedure.
1. The sterile nurse or sterile personnel touch only
sterile supplies and instruments. When there is a need
for sterile supply which is not in the sterile field, who
hands out these items by opening its outer cover?
a. Circulating nurse
b. Anesthesiologist
c. Surgeon
d. Nursing aide
2. The OR team performs distinct roles for one surgical
procedure to be accomplished within a prescribed time
frame and deliver a standard patient outcome. White
the surgeon performs the surgical procedure, who
monitors the status of the client like urine output,
blood loss?
a. Scrub nurse
b. Surgeon
c. Anesthesiologist
d. Circulating nurse
3. Surgery schedules are communicated to the OR
usually a day prior to the procedure by the nurse of the
floor or ward where the patient is confined. For
orthopedic cases, what department is usually informed
to be present in the OR?
a. Security Division
b. Chaplaincy
c. Social Service Section
d. Pathology department
Situation 2 - You are assigned in the Orthopedic Ward
where clients are complaining of pain in varying degrees
upon movement of body parts.
6. Troy is a one day post open reduction and internal
fixation (ORIF) of the left hip and is in pain. Which of
the following observation would prompt you to call the
doctor?
a. Dressing is intact but partially soiled
b. Left foot is cold to touch and pedal pulse is absent
c. Left leg in limited functional anatomic position
d. BP 114/78, pulse of 82 beats/minute
7. There is an order of Demerol 50 mg I.M. now and
every 6 hours p r n. You injected Demerol at 5 pm. The
next dose of Demerol 50 mg I.M. is given:
a. When the client asks for the next dose
b. When the patient is in severe pain
c. At 11pm
d. At 12pm
8. You continuously evaluate the client's adaptation to
pain. Which of the following behaviors-indicate
appropriate adaptation?
a. Rehabilitation department
b. Laboratory department
c. Maintenance department
d. Radiology department
a. The client reports pain reduction and decreased
activity
b. The client denies existence of pain
c. The client can distract himself during pain episodes
d. The client reports independence from watchers
4. Minimally invasive surgery is very much into
technology. Aside from the usual surgical team who
else to be present when a client undergoes
laparoscopic surgery?
9. Pain in Ortho cases may not be mainly due to the
surgery. There might be other factors such as cultural
or psychological that influence pain. How can you alter
these factors as the nurse?
a. Information technician
b. Biomedical technician
c. Electrician
d. Laboratory technicial
a. Explain all the possible interventions that may cause
the client to worry.
b. Establish trusting relationship by giving his medication
on time
c. Stay with the client during pain episodes
d. Promote client's sense of control and participation in
pain control by listening to his concerns
5. In massive blood loss, prompt replacement of
compatible blood is crucial. What department needs to
be alerted to coordinate closely with the patient's
family for immediate blood component therapy?
10. In some hip surgeries, an epidural catheter for
Fentanyl epidural analgesia is given. What is your
nursing priority care in such a case?
record, disposal. You know that your institution is
covered by this policy it;
a. Instruct client to observe strict bed rest
b. Check for epidural catheter drainage
c. Administer analgesia through epidural catheter as
prescribed
d. Assess respiratory rate carefully
a. Your hospital is considered tertiary
b. Your hospital is in Metro Manila
c. It obtained permit to operate from DOH
d. Your hospital is Philhealth accredited
Situation 3 - Records are vital tools in any institution and
should be properly maintained for specific use and time.
11. The patient's medical record can work as a doubleedged swords. When can the medical record become
the doctor's/nurse worst enemy?
a. When the record is voluminous
b. When a medical record is subpoenaed in court
c. When it is missing
d. When the medical record is inaccurate, incomplete,
and inadequate
Situation 4 - In the OR, there are safety protocols that
should be followed. The OR nurse should be well versed
with all these to safeguard the safety and quality to
patient delivery outcome.
16. Which of the following should be given highest
priority when receiving patient in the OR?
a. Assess level of consciousness
b. Verify patient identification and informed consent
c. Assess vital signs
d. Check for jewelry, gown, manicure and dentures
12. Disposal of medical records in government
hospitals/institutions must be done in close
coordination with what agency?
17. Surgeries like I and D (incision and drainage) and
debribement are relatively short procedures but
considered ‘dirty cases’. When are these; procedures
best scheduled?
a. Department of Interior and Local Government (DILG)
b. Metro Manila Development Authority (MMDA)
c. Records Management Archives Office (RMAO)
d. Depart of Health (DOH)
a. Last case
b. In between cases
c. According to availability of anesthesiologist
d. According to the surgeon's preference
13. In the hospital, when you need-the medical record
of a discharged patient for research, you will request
permission through:
18. OR nurses should be aware that maintaining the
client's safety is the overall goal of nursing care during
the intraoperative phase. As the circulating nurse, you
make certain that throughout the procedure...
a. Doctor in charge
b. The hospital director
c. The nursing Service
d. Medical records section
14. You readmitted a client who was in another
department a month ago. Since you will need the
previous chart, from whom do you request the old
chart?
a. Central supply section
b. Previous doctor's clinic
c. Department where the patient was previously
admitted
d. Medical records section
15. Records Management and Archives Offices of the
DOH is responsible for implementing its policies on
214
a. the surgeon greets his client before induction of
anesthesia
b. the surgeon and anestheriologist are in tandem
c. strap made of strong non-abrasive material are
fastened securely around the joints of the knees and
ankles and around the 2 hands around an arm board
d. client is monitored throughout the surgery by the
assistant anesthesiologist
19. Another nursing check that should not be missed
before the induction of general anesthesia is:
a. check for presence underwear
b. check for presence dentures
c. check patient's
d. check baseline vital signs
215
20. Some different habits and hobbies affect
postoperative respiratory function. If your client
smokes 3 packs of cigarettes a day for the part 10 years,
you will anticipate increased risk for:
a. perioperative anxiety and stress
b. delayed coagulation time
c. delayed wound healing
d. postoperative respiratory function
Situation 5 - Nurses hold a variety of roles when
providing care to a perioperative patient.
21. Which of the following role would be the
responsibility of the scrub nurse?
a. Assess the readiness of the client prior to surgery
b. Ensure that the airway is adequate
c. Account for the number of sponges, needles, supplies,
Used during the surgical procedure
d. Evaluate the type of anesthesia appropriate for the
surgical client
22. As a perioperative nurse, how can you best meet
the safety need of the client after administering
preoperative narcotic?
a. Put side rails up and ask client not to get out of bed
b. Send the client to ORD with the family
c. Allow client to get up to go to the comfort room
d. Obtain consent form
23. It is the responsibility of the pre-op, nurse to do
skin prep for patients undergoing surgery. If hair at the
operative site is not shaved, what should be done to
make suturing easy and lessen chance of incision
infection?
a. Draped
b. Pulled
c. Clipped
d. Shampooed
24. It is also the nurse's function to determine when
infection is developing in the surgical incision. The
perioperative nurse should observe for what signs of
impending infection?
a. Localized heat and redness
b. Serosanguinous exudates and skin blanching
c. Separation of the incision
d. Blood clots and scar tissue are visible
25. Which of the following nursing intervention is done
when examining the incision wound and changing the
dressing?
a. Observe the dressing and type and odor of drainage if
any
b. Get patient's consent
c. Wash hands
d. Request the client to expose the incision wound
Situation 6 - Carlo, 16 years old, comes to the ER with
acute asthmatic attack. RR is 46/min and he appears to
be in acute respiratory distress.
26. Which of She following nursing actions should be
initiated first?
a. Promote emotional support
b. Administer oxygen at 6L/min
c. Suction the client every 30 min
d. Administer bronchodilator by nebulizer
27. Aminophylline was ordered for acute asthmatic
attack. The mother asked the nurse, what its indication
the nurse will say is:
a. Relax smooth muscles of the bronchial airway
b. Promote expectoration
c. Prevent thickening of secretions
d. Suppress cough
28. You will give health instructions to Carlo, a case of
bronchial asthma. The health instruction will include
the following EXCEPT:
a. Avoid emotional stress and extreme temperature
b. Avoid pollution like smoking
c. Avoid pollens, dust seafood
d. Practice respiratory isolation
29. The asthmatic client asked you what breathing
technique he can best practice when asthmatic attack
starts. What will be the best position?
a. Sit in high-Fowler's position with extended legs
b. Sit-up with shoulders back
c. Push on abdomen during exhalation
d. Lean forward 30-40 degrees with each exhalation
30. As a nurse you are always alerted to monitor status
asthmaticus who will likely and initially manifest
symptoms of:
a. metabolic alkalosis
b. respiratory acidosis
c. respiratory alkalosis
d. metabolic acidosis
Incident Report (IR)
c. Allow client to walk with relative to the OF?
d. Assess and periodically reassess individual client's risk
for falling
Situation 7 - Joint Commission on Accreditation of
Hospital Organization (JCAHP) patient safety goals and
requirements include the care and efficient use of
technology in the OR arid elsewhere in the healthcare
facility.
35. As a nurse you know you can improve on accuracy
of patient's identification by 2 patient identifiers,
EXCEPT:
31. As the head nurse in the OR, how can you improve
the effectiveness of clinical alarm systems?
a. limit suppliers to a few so that quality is maintained
b. implement a regular inventory of supplies and
equipment
c. Adherence to manufacturer's recommendation
d. Implement a regular maintenance and testing of alarm
systems
32. Over dosage of medication or anesthetic can
happen even with the aid of technology like infusion
pump, sphymomanometer, and similar
devices/machines. As a staff, how can you improve the
safety of using infusion pumps?
a. Check the functionality of the pump before use
b. Select your brand of infusion pump like you do with
your cellphone
C. Allow the technician to set the; infusion pump before
use
d. Verify the flow rate against your computation
33. JCAHOs universal protocol for surgical and invasive
procedures to prevent wrong site, wrong person, and
wrong procedures/surgery includes the following
EXCEPT:
a. Mark the operative site if possible
b. Conduct pre-procedure verification process
c. Take a video of the entire intra-operative procedure
d. Conduct time out immediately before starting the
procedure
34. You identified a potential risk of pre and post
operative clients. To reduce the risk of patient harm
resulting from fall, you can implement the following
EXCEPT:
a. Assess potential risk of fail associated with the
patient's the following EXCEPT: medication regimen
b. Take action to address any identified risks through
216
a. identify the client by his/her wrist tag and verify with
family members
b. identify client by his/her wrist tag and call his/her by
name
c. call the client by his/her case and bed number
d. call the patient by his/her name and bed number
Situation 8 - Team efforts is best demonstrated in the OR
36. If you are the nurse in charge for scheduling surgical
cases, what important information do you need to ask
the surgeon?
a. Who is your internist
b. Who is your assistant and anesthesiologist, and what
is your preferred time and type of surgery?
c. Who are your anesthesiologist, internist, and assistant
d. Who is your anesthesiologist.
37. In the OR, the nursing tandem for every surgery is:
a. Instrument technician and circulating nurse
b. Nurse anesthetist, nurse assistant, and instrument
technician
c. Scrub nurse and nurse anesthetist
d. Scrub and circulating nurses
38. While team effort is needed in the OR for efficient
and quality patient care delivery, we should limit the
number of people in the room for infection control.
Who comprise this team?
a. Surgeon, anesthesiologist, scrub nurse, radiologist,
orderly
b. Surgeon, assistants, scrub nurse, circulating nurse,
anesthesiologist
c. Surgeon, assistant surgeon, anesthesiologist, scrub
nurse, pathologist
d. Surgeon, assistant surgeon, anesthesiologist, intern,
scrub nurse
39. When surgery is on-going, who coordinates the
activities outside, including the family?
217
a. Orderly/clerk
b. Nurse supervisor
c. Circulating nurse
d. Anaesthesiologist
40. The breakdown in teamwork is often times a failure
in:
a. Electricity
b. Inadequate supply
c. Leg work
d. Communication
Situation 9 - Colostomy is a surgically created anus- It
can be temporary or permanent, depending on the
disease condition.
41. Skin care around the stoma is critical. Which of the
following is not indicated as a skin care barriers?
a. Apply liberal amount of mineral oil to the area
b. Use karaya paste and rings around the stoma
c. Clean the area daily with soap and water before
applying bag
d. Apply talcum powder twice a day
should be drained?
a. Sensation of taste
b. Sensation of pressure
c. Sensation of smell
d. Urge to defecate
Situation 10 - As a beginner in research, you are aware
that sampling is an essential element of the research
process.
46. What does a sample group represent?
a. Control group
b. Study subjects
c. General population
d. Universe
47. What is the most important characteristics of a
sample?
a. Randomization
b. Appropriate location
c. Appropriate number
d. Representativeness
42. What health instruction will enhance regulation of a
colostomy (defecation) of clients?
48. Random sampling ensures that each subject has:
a. Irrigate after lunch everyday
b. Eat fruits and vegetables in all three meals
c. Eat balanced meals at regular intervals
d. Restrict exercise to walking only
a. Been selected systematically
b. An equal change of selection
c. Been selected based on set criteria
d. Characteristics that match other samples
43. After ileostomy, which of the following condition is
NOT expected?
49. Which of the following sampling methods allows
the use of any group of research subject?
a. increased weight
b. Irritation of skin around the stoma
c. Liquid stool
d. Establishment of regular bowel movement
a. Purposive
b. Convenience
c. Snow-bail
d. Quota
44. The following are appropriate nursing interventions
during colostomy irrigation EXCEPT:
50. You decided to include 5 barangays in your
municipality and chose a sampling method that would
get representative samples from each barangay. What
should be the appropriate method for you to use in this
care?
a. Increase the irrigating solution flow rate when
abdominal cramps is felt
b. Insert 2-4 inches of an adequately lubricated catheter
to the stoma
c. Position client in semi-Fowler
d. Hand the solution 18 inches above the stoma
45. What sensation is used as a gauge so that patients
with ileostomy can determine how often their pouch
a. Cluster sampling
b. Random sampling
c. Stratifies sampling
d. Systematic sampling
Situation 11 -After an abdominal surgery, the circulating
and scrub nurses have critical responsibility about
sponge and Instrument count.
confidence?
51. When is the first sponge/instrument count
reported?
a. Patient's advocate
b. Educator
c. Patient's Liaison
d. Patient's arbiter
a. Before closing the subcutaneous layer
b. Before peritoneum is closed
c. Before dosing the skin
d. Before the fascia is sutured
57. As a nurse, you can help improve the effectiveness
of communication among healthcare givers
52. What major supportive layer of the abdominal wall
must be sutured with long tensile strength such as
cotton or nylon or silk suture?
a. Use of reminders of what to do
b. Using standardized list of abbreviations, acronyms,
and symbols
c. One-on-one oral endorsement
d. Text messaging and e-mail
a. Fascia
b. Muscle
c. Peritoneum
d. Skin
53. Like sutures, needles also vary in shape and uses. If
you are the scrub nurse for a patient who is prone to
keloid formation and has a low threshold of pain, what
needle would you prepare?
a. Round needle
b. A traumatic needle
c. Reverse cutting needle
d. Tapered needle
54. Another alternative "suture" for skin closure is the
use of _______________:
a. Staple
b. Therapeutic glue
c. Absorbent dressing
d. invisible suture
55. Like any nursing interventions, counts should be
documented. To whom does the scrub nurse report any
discrepancy of country so that immediate 'and
appropriate action in instituted?
a. Anesthesiologist
b. Surgeon
c. Or nurse supervisor
d. Circulating nurse
Situation 12 - As a nurse, you should be aware and
prepared of the different roles you play.
56. What role do you play, when you hold all clients’
information entrusted to you in the strictest
218
58. As a nurse, your primary focus in the workplace is
the client's safety. However, personal safety is also a
concern. You can communicate hazards to your coworkers through the use of the following EXCEPT:
a. Formal training
b. Posters
c. Posting IR in the bulletin board
d. Use of labels and signs
59. As a nurse, what is one of the best way to reconcile
medications across the continuum of care?
a. Endorse on a case-to-case basis
b. Communication a complete list of the patient's
medication to the next provider of service
c. Endorse in writing
d. Endorse the routine and 'stat' medications every shift
60. As a nurse, you protect yourself and co-workers
from misinformation and misrepresentations through
the following EXCEPT:
a. Provide information to clients about a variety of
services that can help alleviate the client's pain and
other conditions
b. Advising the client, by virtue of your expertise, that
which can contribute to the client's well-being
c. Health education among clients and significant others
regarding the use of chemical disinfectant
d. Endorsement thru trimedia to advertise your favorite
disinfectant solution
61. A one-day postoperative abdominal surgery client
has been complaining of severe throbbing abdominal
pain described as 9 in a 1-10 pain rating. Your
assessment reveals bowel sounds on all quadrants and
219
the dressing is dry and intact. What nursing
intervention would you take?
a. Medicate client as prescribed
b. Encourage client to do imagery
c. Encourage deep breathing and turning
d. Call surgeon stat
62. Pentoxicodone 5 mg IV every 8 hours was
prescribed for post abdominal pain. Which will be your
priority nursing action?
a. Check abdominal dressing for possible swelling
b. Explain the proper use of PCA to alleviate anxiety
c. Avoid overdosing to prevent dependence/tolerance
d. Monitor VS, more importantly RR .
63. The client complained of abdominal and pain. Your
nursing intervention that can alleviate pain is:
a. Instruct client to go to sleep and relax
b. Advice the client to close the lips and avoid deep
breathing and talking
c. Offer hot and clear soup
d. Turn to sides frequently and avoid too much talking
64. Surgical pain might be minimized by which nursing
action in the OR:
a. Skill of surgical team and lesser manipulation
b. Appropriate preparation For the scheduled procedure
c. Use of modem technology in closing the wound
d. Proper positioning and draping of clients
65. One very common cause of postoperative pain is:
a. Forceful traction during surgery
b. Prolonged surgery
c. Break in aseptic technique
d. Inadequate anesthetic
Situation 14 - You were on duty at the medical ward
when Zeny came in for admission for tiredness, cold
intolerance, constipation, and weight gain. Upon
examination, the doctor's diagnosis was hypothyroidism.
66. Your independent nursing care for hypothyroidism
includes:
a. administer sedative round the clock
b. administer thyroid hormone replacement
c. providing a cool, quiet, and comfortable environment
d. encourage to drink 6-8 glasses of water
67. As the nurse, you should anticipate to administer
which of the following medications to Zeny who is
diagnosed to be suffering from hypothyroidism?
a. Levothyroxine
b. Lidocaine
c. Lipitor
d. Levophed
68. Your appropriate nursing diagnosis for Zeny who is
suffering from hypothyroidism would probably include
which of the following?
a. Activity intolerance related to tiredness associated
with disorder
b. Risk to injury related to incomplete eyelid closure
c. Imbalance nutrition related to hypermetabolism
d. Deficient fluid volume related to diarrhea
69. Myxedema coma is a life threatening complication
of long standing and untreated hypothyroidism with
one of the following characteristics.
a. Hyperglycemia
b. hypothermia
c. hyperthermia
d. hypoglycemia
70. As a nurse, you know that the most common type
of goiter is related to a deficiency
a. thyroxine
b. thyrotropin
c. iron
d. iodine
Situation 15 - Mrs. Pichay is admitted to your ward. The
MD ordered "Prepared for thoracentesis this pm to
remove excess air from the pleural cavity."
71. Which of the following nursing responsibility is
essential in Mrs. Pichay who will undergo
thoracentesis?
a. Support, and reassure client during the procedure
b. Ensure that informed consent has been signed
c. Determine if client has allergic reaction to local
anesthesia
d. Ascertain if chest x-rays and other tests have been
prescribed and completed
72. Mrs. Pichay who is for thoracentesis is assisted by
the nurse to any of the following positions, EXCEPT:
a. straddling a chair with arms and head resting on the
back of the chair
b. lying on the unaffected side with the bed elevated 3040 degrees
c. lying prone with the head of the bed lowered 15-30
degrees
d. sitting on the edge of the bed with her feet supported
and arms and head on a padded overhead table
73. During thoracentesis, which of the following nursing
intervention will be most crucial?
a. Place patient in a quiet and cool room
b. Maintain strict aseptic technique
c. Advice patient to sit perfectly still during needle
insertion until it has been withdrawn from the chest
d. Apply pressure over the puncture site as soon as the
needle is withdrawn
74. To prevent leakage of fluid in the thoracic cavity,
how wilt you position the client after thoracentesis?
a. Place flat in bed
b. Turn on the unaffected side
c. Turn on the affected side
d. On bed rest
75. Chest x-ray was ordered after thoracentesis. When
you client asks what is the reason for another chest xray, you will explain:
a. to rule out pneumothorax
b. to rule out any possible perforation
c. to decongest
d. to rule out any foreign: body
Situation 16 - In the hospital, you are aware that we are
helped by the .use of a variety of equipment/devices to
enhance quality patient care delivery;
76. You are initiate an IV line to your patient, Kyle, 5,
who is febrile. What IV administration set will you
prepare?
a. Blood transfusion set
b. Macroset
c. Volumetric chamber
d. Microset
77. Kyle is diagnosed to have measles. What will your
protective personal attire include?
220
a. Gown
b. Eyewear
c. Face mask
d. Gloves
78. What will you do to ensure that Kyle, who is febrile,
will have a liberal oral fluid intake?
a. Provide a glass of fruit every meal
b. Regulate his IV to 30 drops per minute
c. Provide a calibrated pitcher of drinking water and juice
at the bedside and monitor intake and output
d. Provide a writing pad to record his intake
79. Before bedtime, you went to ensure Kyle's safety in
'bed. You will do which of the following:
a. Put the lights on
b. Put the side rails up
c. Test the call system
d. Lock the doors
80. Kyle's room is fully mechanized. What do you teach
the watcher and Kyle to alert the nurse for help?
a. How to lock side rails
b. Number of the telephone operator
c. Call system
d. Remote control
Situation 17 - Tony, 11 years old, has 'kissing tonsils' and
is scheduled for tonsillectomy and adenoidectomy or T
and A.
81. You are the nurse of Tony who will undergo T and A
in the morning. His mother asked you if Tony will be
put to sleep. Your teaching will focus on:
a. spinal anesthesia
b. anesthesiologist’s preference
c. local anesthesia
d. general anesthesia
82. Mothers of children undergoing tonsillectomy and
adenoidectomy usually ask what food prepared and
give their children after surgery. You as the nurse will
say:
a. balanced diet when fully awake
b. hot soup when awake
c. ice cream when fully awake
d. soft diet when fully awake
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83. The RR nurse should monitor for the most common
postoperative complication of:
a. hemorrhage
b. endotracheal tube perforation
c. esopharyngeal edema
d. epiglottis
84. The PACU nurse will maintain postoperative T and A
client in what position?
a. Supine with neck hyperextended and supported with
pillow
b. Prone with the head on pillow and tuned to the side
c. Semi-Fowler's with neck flexed
d. Reverse trendelenburg with extended neck
85. Tony is to be discharged in the afternoon of the
same day after tonsillectomy and adenoidectomy. You
as the RN will make sure that the family knows to:
a. offer osteorized feeding
b. offer soft foods for a week to minimize discomfort
while swallowing
c. supplement his diet with vitamin C rich juices to
enhance heating
d. offer clear liquid for 3 days to prevent irritation
Situation 18 - Rudy was diagnosed to have chronic renal
failure. Hemodialysis is ordered that an A-V shunt was
surgically created.
86. Which of the following action would be of highest
priority with regards to the external shunt?
a. Avoid taking BP or blood sample from the arm with
shunt
b. Instruct the client not to exercise the arm with the
shunt
c. Heparinize the shunt daily
d. Change dressing of the shunt daily
87. Diet therapy for Rudy, who has acute renal failure,
is tow-protein, low potassium and sodium. The
nutrition instruction should include:
a. Recommend protein of high biologic value like eggs,
poultry and lean meat
b. Encourage client to include raw cucumbers, carrot,
cabbage, and tomatoes
c. Allowing the client cheese, canned foods, and other
processed food
d. Bananas, cantaloupe, orange and other fresh fruits
can be included in the diet
88. Rudy undergoes hemodialysis for the first time and
was scared of disequilibrium syndrome. He asked you
how this can be prevented. Your response is:
a. maintain a conducive comfortable and cool
environment
b. maintain fluid and electrolyte balance
c. initial hemodialysis shall be done for 30 minutes only
so as not to rapidly remove the waste from the blood
than from the brain
d. maintain aseptic technique throughout the
hemodialysis
89. You are assisted by a nursing aide with the care of
the client with renal failure. Which delegated function
to the aide would you particularly check?
a. Monitoring and recording I and O
b. Checking bowel movement
c. Obtaining vital signs
d. Monitoring diet
90. A renal failure patient was ordered for creatinine
clearance. As the nurse you will collect
a. 48 jour urine specimen
b. first morning urine
c. 24 hour urine specimen
d. random urine specimen
Situation 19 - Fe is experiencing left sharp pain and
occasional hematuria. She was advised to undergo IVP
by her physician.
91. Fe was so anxious about the procedure and
particularly expressed her low pain threshold. Nursing
health instruction will include:
a. assure the client that the pain is associated with the
warm sensation during the administration of the
Hypaque by IV
b. assure the client that the procedure painless
c. assure the client that contrast medium will be given
orally
d. assure the client that x-ray procedure like IVP is only
done by experts
92. What will the nurse monitor and instruct the client
and significant others, post IVP?
a. Report signs and symptoms for delayed allergic
reactions
b. Observe NPO for 6 hours
c. Increase fluid intake
d. Monitor intake and output
93. Post IVP, Fe should excrete the contrast medium.
You instructed the family to include more vegetables in
the diet and
a. increase fluid intake
b. barium enema
c. cleansing enema
d. gastric lavage
94. The IVP reveals that Fe has small renal calculus that
can be passed out spontaneously. To increase the
chance of passing the stones, you instructed her to
force fluids and do which of the following?
a. Balanced diet
b. Ambulance more
c. Strain all urine
d. Bed rest
95. The presence of calculi in the urinary tract is called:
a. Colelithiasis
b. Nephrolithiasis
c. Ureterolithiasis
d. Urolithiasis
Situation 20 - At the medical-surgical ward, the nurse
must also be concerned about drug interactions.
96. You have a client with TPN. You know that in TPN,
like blood transfusion, there should be no drug
incorporation. However, the MD's order read;
incorporate insulin to present TPN. Will you follow the
order?
a. No, because insulin will induce hyperglycemia in
patients with TPN
b. Yes, because insulin is chemically stable with TPN and
can enhance blood glucose level
c. No, because insulin is not compatible with TPN
d. Yes, because it was ordered by the MD
97. The RN should also know that some drugs have
increased absorption when infused in PVC container.
How will you administer drugs such as insulin,
nitroglycerine hydralazine to promote better
therapeutic drug effects?
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a. Administer by fast drip
b. Inject the drugs as close to the IV injection site
c. Incorporate to the IV solution
d. Use volumetric chamber
98. One patient has a 'runaway' IV of 50% dextrose. To
prevent temporary excess of insulin transient
hyperinsulin reaction, what solution should you
prepare in anticipation of the doctors order?
a. Any IV solution available to KVO
b. Isotonic solution
c. Hypertonic solution
d. Hypotonic solution
99. How can nurse prevent drug interaction including
absorption?
a. Always flush with NSS after IV administration
b. Administering drugs with more diluents
c. Improving on preparation techniques
d. Referring to manufacturer's guidelines
100. In insulin administration, it should be understood
that our body normally releases insulin according to our
blood glucose level. When is insulin and glucose level
highest?
a. After excitement
b. After a good night's rest
c. After an exercise
d. After ingestion of food
CARE OF CLIENTS WITH PHYSIOLOGIC AND
PSYCHOSOCIAL ALTERATIONS
Situation 1 - Because of the serious consequences of
severe burns management requires a multi disciplinary
approach. You have important responsibilities as a
nurse.
1. While Sergio was lighting a barbecue grill with a
lighter fluid, his shirt burst into flames. The most
effective way to extinguish the flames with as little
further damage as possible is to:
a. log roll on the grass/ground
b. slap the flames with his hands
c. remove the burning clothes
d. pour cold liquid over the flames
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2. Once the flames are extinguished, it is most
important to:
a. cover Sergio with a warm blanket
b. give him sips of water
c. calculate the extent of his burns
d. assess the Sergio's breathing
3. Sergio is brought to the Emergency Room after the
barbecue grill accident. Based on the assessment of the
physician, Sergio sustained superficial partial thickness
bums on his trunk, right upper extremities ad right
lower extremities. His wife asks what that means. Your
most accurate response would be:
a. Structures beneath the skin are damaged
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged
4. During the first 24 hours after thermal injury, you
should assess Sergio for
b. Call security officer and report the incident
c. Call your nurse supervisor and report the incident :
d. Call the physician on duty
7. You are on morning duty in the medical ward. You
have 10 patients assigned to you. During your
endorsement rounds, you found out that one of your
patients was not in bed. The patient next to him
informed you that he went home without notifying the
nurses. Which among the following will you do first?
a. Make and incident report
b. Call security to report the incident
c. Wait for 2 hours before reporting
d. Report the incident to your supervisor
8. You are on duty in the medical ward. You were asked
to check the narcotics cabinet. You found out that what
is on record does not tally with the drugs used. Which
among the following will you do first?
a. hypokalemia and hypernatremia
b. hypokalemia and hyponatremia
c. hyperkalemia and hyponatremia
d. hyperkalemia and hypernatremia
a. Write an incident report and refer the matter to the
nursing director
b. Keep your findings to yourself
c. Report the matter to your supervisor
d. Find out from the endorsement any patient who
might have been given narcotics
5. Teddy, who sustained deep partial thickness and full
thickness burns of the face, whole anterior chest and
both upper extremities two days ago, begins to exhibit
extreme restlessness. You recognize that this most
likely indicates that Teddy is developing:
9. You are on duty in the medical ward. The mother of
your patient who is also a nurse came running to the
nurse station and informed you that Fiolo went into
cardiopulmonary arrest. Which among the following
will you do first?
a. Cerebral hypoxia
b. Hypervolemia
c. Metabolic acidosis
d. Renal failure .
a. Start basic life support measures
b. Call for the Code
c. Bring the crush cart to the room
d. Go to see Fiolo and assess for airway patency and
breathing problems
Situation 2 - You are now working as a staff nurse in a
general hospital. You have to be prepared to handle
situations with ethico-legal and moral implications.
6. You are on night duty in the surgical ward. One of
our patients Martin is prisoner who sustained an
abdominal gunshot wound. He is being guarded by
policemen from the local police unit. During your
rounds you heard a commotion. You saw the policeman
trying to hit Martin. You asked why he was trying to
hurt Martin. He denied the matter. Which among the
following activities will you do first?
a. Write an incident report
10. You are admitting Jorge to the ward and you found
out that he is positive for HIV. Which among the
following will you do first?
a. Take note of it and plan to endorse this to next shift
b. Keep this matter to your self
c. Write an incident report
d. Report the matter to your head nurse
Situation 3 - Colorectal cancer can affect old and
younger people. Surgical procedures and other modes of
treatment are done to ensure quality of life. You are
assigned in the Cancer institute to care of patients with
this type of cancer.
11. Larry, 55 years old, who is suspected of having
colorectal cancer, is admitted to the CI. After taking the
history and vital signs the physician does which test as
a screening test for colorectal cancer.
a. Barium enema
b. Carcinoembryonig antigen
c. Annual digital rectal examination
d. Proctosigmoidoscopy
12. To confirm his impression of colorectal cancer, Larry
will require which diagnostic study?
a. carcinoembryonic antigen
b. proctosigmoidbscopy
c. stool hematologic test
d. abdominal computed tomography (CT) test
13. The following are risk factors for colorectal cancer,
EXCEPT:
a. inflammatory bowels
b. high fat, high fiver diet
c. smoking
d. genetic factors-familial adenomatous polyposis
14. Symptoms associated with cancer of the colon
include:
a. constipation, ascites and mucus in the stool
b. diarrhea, heartburn and eructation
c. blood in the stools, anemia, and pencil-shaped, stools
d. anorexia, hematemesis, and increased peristalsis
15. Several days prior to bowel surgery, Larry may be
given sulfasuxidine and neomycin primarily to:
a. promote rest of the bowel by minimizing peristalsis
b. reduce the bacterial content of the colon
c. empty the bowel of solid waste
d. soften the stool by retaining water in the colon
Situation 4 - ENTEROSTOMAL THERAPY is now
considered especially in nursing. You are participating in
the OSTOMY CARE CLASS.
16. You plan to teach Fermin how to irrigate the
colostomy when:
a. The perineal wound heals and Fermin can sit
comfortably on the commode
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b. Fermin can lie on the side comfortably, about the 3rd
postoperative day
c. The abdominal incision is close and contamination is
no longer a danger
d. The stool starts to become formed, around the 7th
postoperative day
17. When preparing to teach Fermin how to irrigate his
colostomy, you should plan to do the procedure:
a. When Fermin would have normal bowel movement
b. At least 2 hours before visiting hours
c. Prior to breakfast and morning care
d. After Fermin accepts alteration in body image
18. When observing a rectum demonstration of
colostomy irrigation, you know that more teaching is
required if Fermin:
a. Lubricates the tip of the catheter prior to inserting
into the stoma
b. Hands the irrigating bag on the bathroom door doth
hook during fluid insertion
c. Discontinues the insertion of fluid after only 500 ml of
fluid had been insertion
d. Clamps off the flow of fluid when feeling
uncomfortable
19. You are aware that teaching about colostomy care
is understood when Fermin states, "I will contact my
physician and report:
a. If I have any difficulty inserting the irrigating tub into
the stoma.”
b. If I notice a loss of sensation to touch in the stoma
tissue."
c. The expulsion of flatus while the irrigating fluid is
running out."
d. When mucus is passed from the stoma between
irrigation."
20. You would know after teaching. Fermin that dietary
instruction for him is effective when he states, "It is
important that I eat:
a. Soft foods that are easily digested and absorbed by my
large intestine."
b. Bland food so that my intestines do not become
irritate."
c. Food low in fiber so that there is less stool."
d. Everything that I ate before the operation, while
avoiding foods that cause gas."
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Situation 5 - Ensuring safety is one of your most
important responsibilities. You will need to provide
instructions and information to your clients to prevent
complications.
21. Randy has chest tubes attached to a pleural
drainage system. When caring for him you should:
a. empty the drainage system at the end of the shift
b. clamp the chest tube when auctioning
c. palpate the surrounding areas for crepitus
d. change the dressing daily using aseptic techniques
22. Fanny came in from PACU after pelvic surgery. As
Fanny's nurse you know that the sign that would be
indicative of a developing thrombophlebitis would be:
a. a tender, painful area on the leg
b. a pitting edema of the ankle
c. a reddened area at the ankle
d. pruritus on the calf and ankle
23. To prevent recurrent attacks on Terry who has
acute glumerulonephritis, you should instruct her to:
a. seek early treatment for respiratory infections
b. take showers instead of tub bath
c. continue to take the same restrictions on fluid intake
d. avoid situations that involve physical activity
24. Herbert has a laryngectomy and he is now for
discharge. Re verbalized his concern regarding his
laryngectomy tube being dislodged. What should you
teach him first?
a. Recognize that prompt closure of the tracheal opening
may occur
b. Keep calm because there is no immediate emergency
c. Reinsert another tubing immediately
d. Notify the physician at once
25. When caring for Larry after an exploratory chest
surgery and pneumonectomy, your priority would be to
maintain:
a. supplementary oxygen
b. ventilation exchange
c. chest tube drainage
d. blood replacement
Situation 6 - Infection can cause debilitating
consequences when host resistance is compromised and
virulence of microorganisms and environmental factors
are favorable. Infection control is one important
responsibility of the nurse to ensure quality of care.
26. Honrad, who has been complaining of anorexia and
feeling tired, develops jaundice. After a workup he is
diagnosed of having Hepatitis A. His wife asks you
about gamma globulin for herself and her household
help. Your most appropriate response would be:
a. "Don't worry your husband's type of hepatitis is no
longer communicable"
b. "Gamma globulin provides passive immunity for
Hepatitis B"
c. "You should contact your physician immediately about
getting gamma globulin."
d. "A vaccine has been developed for this type of
hepatitis"
27. Voltaire develops a nosocomial respiratory tract
infection. He asks you what that means.
a. "You acquired the infection after you have been
admitted to the hospital."
b. "This is a highly contagious infection requiring
complete isolation."
c. "The infection you had prior to hospitalization flared
up."
d. "As a result of medical treatment, you have acquired a
secondary infection.''
28. As a nurse you know that one of the complications
that you have to watch out for when caring for Omar
who is receiving total parenteral nutrition is:
a. stomatitis
b. hepatitis
c. dysrhythmia
d. infection
29. A solution used to treat Pseudomonas would
infection is:
a. Dakin's solution
b. Half-strength hydrogen peroxide
b. Acetic acid
d. Betadine
30. Which of the following is most reliable in diagnosing
a wound infection?
a. Culture and sensitivity
b. Purulent drainage from a wound
c. WBC count of 20,000/pL
d. Gram stain testing
Situation 7 - As a nurse you need to anticipate the
occurrence of complications of stroke so that life
threatening situations can be prevented.
31. Wendy is admitted to the hospital with signs and
symptoms of stroke. Her Glasgow Coma Scale is 6 on
admission. A central venous catheter was inserted and
an I.V. infusion was started. As a nurse assigned to
Wendy what will he your priority goal?
a. Prevent skin breakdown
b. Preserve muscle function
c. Promote urinary elimination
d. Maintain a patent airway
c. is permanently paralyzed
d. has received a significant brain injury
Situation 8 - With the improvement in life expectancies
and the emphasis in the quality of life it is important to
provide quality care to our older patients. There are
frequently encountered situations and issues relevant to
the older, patients.
36. Hypoxia may occur in the older patients because of
which of the following physiologic changer associated
with aging.
a Ineffective airway clearance
b. Decreased alveolar surface area
c. Decreased anterior-posterior chest diameter
d. Hyperventilation
32. Knowing that for a comatose patient hearing is the
best last sense to be lost, as Judy's nurse, what should
you do?
37. The older patient is at higher risk for in
inconvenience because of:
a. Tell her family that probably she can't hear them
b. Talk loudly so that Wendy can hear you
c. Tell her family who are in the room not to talk
d. Speak softly then hold her hands gently
a. dilated urethra
b. increased glomerular filtration rate
c. diuretic use
d. decreased bladder capacity
33. Which among the following interventions should
you consider as the highest priority when caring for
June who has hemiparersis secondary to stroke?
38. Merle, age 86, is complaining of dizziness when she
stands up. This may indicate:
a. Place June on an upright lateral position
b. Perform range of motion exercises
c. Apply antiembolic stocking
d. Use hand rolls or pillows for support
34. Ivy, age 40, was admitted to the hospital with a
severe headache, stiff neck and photophobia. She was
diagnosed with a subarachnoid hemorrhage secondary
to ruptured aneurysm. While waiting for surgery, you
can provide a therapeutic by doing which of the
following?
a. honoring her request for a television
b. placing her bed near the window
c. dimming the light in her room
d. allowing the family unrestricted visiting privileges
35. When performing a neurological assessment on
Walter, you find that his pupils are fixed and dilated.
This indicated that he:
a. probably has meningitis
b. is going to be blind because of trauma
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a. dementia
b. a visual problem
c. functional decline
d. drug toxicity
39. Cardiac ischemia in an older patient usually
produces:
a. ST-T wave changes
b. Very high creatinine kinase level
c. chest pain radiating to the left arm
d. acute confusion
40. The most dependable sign of infection in the older
patient is:
a. change in mental status pain
b. fever
c. pain
d. decreased breath sound with crackles
Situation 9 - A "disaster" is a large-scale emergency—
even a small emergency left unmanaged may turn into a
disaster. Disaster preparedness is crucial and is
227
everybody's business. There are agencies that are in
charge of ensuring prompt response. Comprehensive
Emergency Management (CEM) is an integrated
approach to the management of emergency program
and activities for all four emergency phases (mitigation,
preparedness, response, and recovery), for all type of
emergencies and disasters (natural, man-made, and
attack) and for all levels of government and the private
sector.
41. Which of the four phases of emergency
management is defined as "sustained action that
reduces or eliminates long-term risk to people and
properly from natural hazards and the effect"?
a. Recovery
b. Mitigation
c. Response
d. Preparedness
42. You are a community health nurse collaborating
with the Red Cross and working with disaster relief
following a typhoon which flooded and devastated the
whole province. Finding safe housing for survivors,
organizing support for the family, organizing counseling
debriefing sessions and securing physical care are the
services you are involved with. To which type of
prevention are these activities included.
a. Tertiary prevention
b. Primary prevention
c. Aggregate care prevention
d. Secondary prevention
43. During the disaster you see a victim with a green
tag, you know that the person:
a. has injuries that are significant and require medical
care but can wait hours will threat to life or limb
b. has injuries that are life threatening but survival is
good with minimal intervention
c. indicates injuries that are extensive and chances of
survival are unlikely even with definitive care
d. has injuries that are minor and treatment can be
delayed from hours to days
d. Urgent
45. Which of the following terms refer to a process by
which the individual receives education about
recognition of stress reactions and management
strategies for handling stress which may be instituted
after a disaster?
a. Critical incident stress management
b. Follow-up
c. Defriefing
d. Defusion
Situation 10 - As a member of the health and nursing
team you have a crucial role to play in ensuring that all
the members participate actively is the various tasks
agreed upon,
46. While eating his meal, Matthew accidentally
dislodges his IV line and bleeds. Blood oozes on the
surface of the over-bed table. It is most appropriate
that you instruct the housekeeper to clean the table
with:
a. Acetone
b. Alcohol
c. Ammonia
d. Bleach
47. You are a member of the infection control team, of
the hospital. Based on a feedback during the meeting of
the committee there is an increased incidence of
pseudomonas infection in the Burn Unit (3 out of 10
patients had positive blood and wound culture). What
is your priority activity?
a. Establish policies for surveillance and monitoring
b. Do data gathering about the possible sources of
infection (observation, chart review, interview)
c. Assign point persons who can implement policies
d. Meet with the nursing group working in the burn unit
and discuss problem with them feel
44. The term given to a category of triage that refers to
life threatening or potentially life threatening injury or
illness requiring immediate treatment:
48. Part of your responsibility as a member of the
diabetes core group is to get referrals from the various
wards regarding diabetic patients needing diabetes
education. Prior to discharge today 4 patients are
referred to you. How would you start prioritizing your
activities?
a. Immediate
b. Emergent
c. Non-acute
a. Bring your diabetes teaching kit and start your session
taking into consideration their distance from your office
b. Contact the nurse-in-charge and find out from her the
reason for the referral
c. Determine their learning needs then prioritize
d. involve the whole family in the teaching class
49. You have been designated as a member of the task
force to plan activities for the Cancer Consciousness
Week. Your committee has 4 months to plan and
implement the plan. You are assigned to contact the
various cancer support groups in your hospital. What
will be your priority activity?
a. Find out if there is a budget for this activity
b. Clarify objectives of the activity with the task force
before contacting the support groups
c. Determine the VIPs and Celebrities who will be invited
d. Find out how many support groups there are in the
hospital and get the contact number of their president
50. You are invited to participate in the medical mission
activity of your alumni association. In the planning
stage everybody is expected to identify what they can
do during the medical mission and what resources are
needed. You though it is also your chance to share what
you can do for others. What will be your most
important role where you can demonstrate the impact
of nursing health?
a. Conduct health education on healthy lifestyle
b. Be a triage nurse
c. Take the initial history and document findings
d. Act as a coordinator
help her by:
a. Coming back periodically and indicating your
availability if she would like you to sit with her
b. Insisting that Ruby should talk with you because it is
not good to Keep everything inside
c. Leaving her atone because she is uncooperative and
unpleasant to be with
d. Encouraging her to be physically active as possible
53. Leo who is terminally ill and recognizes that he is in
the process of losing, everything and everybody he
loves, is depressed. Which of the following would best
help him during depression?
a. Arrange for visitors who might cheer him
b. Sit down and talk with him for a while
c. Encourage him to look at the brighter side of things
d. Sit silently with him
54. Which of the following statements would best
indicate that Ruffy; who is dying has accepted this
impending death?
a. "I'm ready to do."
b. "I have resigned myself to dying"
c. "What's the use"?
d: "I'm giving up"
55. Maria, 90 years old has planned ahead for herdeath-philosophically, socially, financially and
emotionally. This is recognized as:
Situation 11 - One of the realities that we are confronted
with is'6w mortality. It is important for us nurses to be
aware of how we view suffering, pain, illness, and even
our death as well as its meaning. That way we can help
our patients cope with death and dying.
a. Acceptance that death is inevitable
b Avoidance of the true sedation
c. Denial with planning for continued life
d. Awareness that death will soon occur
51. Irma is terminally ill she speaks to you in
confidence. You now feel that Irma's family could be
helpful if they knew what Irma has told you. What
should you do first?
Situation 12 - Brain tumor, whether malignant or benign,
has serious management implications nurse, you should
be able to understand the consequences of the disease
and the treatment.
a. Tell the physician who in turn could tell the family
b. Obtain Irma's permission to share the information
with the family
c. Tell Irma that she has to tell her family what she told
you
d. Make an appointment to discuss the situation with
the family
56. You are caring for Conrad who has a brain tumor
and increased intracranial Pressure (ICP). Which
intervention should you include in your plan to reduce
ICP?
52. Ruby who has been told she has terminal cancer
turns away aha refuses to respond to you. You can best
228
a. Administer bowel! Softener
b. Position Conrad with his head turned toward the side
of the tumor
c. Provide sensory stimulation
d. Encourage coughing and deep breathing
229
57. Keeping Conrad's head and neck in alignment
results in:
a. increased intrathoracic pressure
b. increased venous outflow
c. decreased venous outflow
d. increased intra abdominal pressure
58. Which of the following activities may increase
intracranial pressure (ICP)?
a. Raising the head of the bed
b. Manual hyperventilation
c. Use of osmotic Diuretics
d. Valsava's maneuver
59. After you assessed Conrad, you suspected increased
ICP! Your most appropriate respiratory goal is to:
a. maintain partial pressure of arterial 02 (PaO2) above
80 mmHg
b. lower arterial pH
c. prevent respiratory alkalosis
d. promote CO2 elimination
60. Conrad underwent craniotomy. As his nurse; you
know that drainage on a craniotomy dressing must be
measured and marked. Which findings should you
report immediately to the surgeon?
a. Foul-smelling drainage
b. yellowish drainage
c. Greenish drainage
d. Bloody drainage
Situation 13 -As a Nurse, you have specific
responsibilities as professional. You have to demonstrate
specific competencies.
61. The essential components of professional nursing
practice are all the following EXCEPT:
a. Culture
b. Care
c. Cure
d. Coordination
c. Aris, who is newly admitted and is scheduled for an
executive check-up
d. Claire, who has cholelithiasis and is for operation on
call
63. Brenda, the Nursing Supervisor of the intensive care
unit (ICU) is not on duty when a staff nurse committed
a serious medication error. Which statement accurately
reflects the accountability of the nursing supervisor?
a. Brenda should be informed when she goes back on
duty
b. Although Brenda is not on duty, the nursing supervisor
on duty decides to call her if time permits
c. The nursing supervisor on duty will notify Brenda at
home
d. Brenda is not duty therefore it is not necessary to
inform her
64. Which barrier should you avoid, to manage your
time wisely?
a. Practical planning
b. Procrastination
c. Setting limits
d. Realistic personal expectation
65. You are caring for Vincent who has just been
transferred to the private room. He is anxious because
he fears he won't be monitored as closely as he was in
the Coronary Care Unit. How can you allay his fear?
a. Move his bed to a room far from nurse's station to
reduce
b. Assign the same nurse to him when possible
c. Allow Vincent uninterrupted period of time
d. Limit Vincent's visitors to coincide with CCU policies
Situation 14 - As a nurse in the Oncology Unit, you have
to be prepared to provide efficient and effective care to
your patients.
66. Which one of the following nursing interventions
would be most helpful in preparing the patient for
radiation therapy?
62. You are assigned to care for four (4) patients. Which
of the following patients should you give first priority?
a. Offer tranquilizers and antiemetics
b. Instruct the patient of the possibility of radiation burn
c. Emphasis on the therapeutic value of the treatment
d. Map out the precise course of treatment
a. Grace, who is terminally ill with breast cancer
b. Emy, who was previously lucid but is now unarousable
67. What side effects are most apt to occur to patient
during radiation therapy to the pelvis?
a. Urinary retention
b. Abnormal vaginal or perineal discharge
c. Paresthesia of the lower extremities
d. Nausea and vomiting and diarrhea
c. training on disaster is not important to the response in
the event of a real disaster because each disaster is
unique in itself
d. do the greatest good for the greatest number of
casualties
68. Which of the following can be used on the
irradiated skin during a course of radiation therapy?
73. Which of the following categories of conditions
should be considered first priority in a disaster?
a. Adhesive tape
b. Mineral oil
c. Talcum powder
d. Zinc oxide ointment
a. Intracranial pressure and mental status
b. Lower gastrointestinal problems
c. Respiratory infection
d. Trauma
69. Earliest sign of skin reaction to radiation therapy is:
74. A guideline that is utilized in determining priorities
is to assess the status of the following, EXCEPT?
a. desquamation
b. erythema
c. atrophy
d. pigmentation
70. What is the purpose of wearing a film badge while
caring for the patient who is radioactive?
a. Identify the nurse who is assigned to care for such a
patient
b. Prevent radiation-induced sterility
c. Protect the nurse from radiation effects
d. Measure the amount of exposure to radiation
Situation 15 - In a disaster there must be a chain of
command in place that defines the roles of each
member of the response team. Within the health care
group there are pre-assigned roles based on education,
experience and training on disaster.
71. As a nurse to which of the following groups are you
best prepared to join?
a. Treatment group
b. Triage group
c. Morgue management
d. Transport group
72. There are important principles that should guide
the triage team in disaster management that you have
to know if you were to volunteer as part of the triage
team. The following principles should be observed in
disaster triage, EXCEPT:
a. any disaster plan should have resource available to
triage at each facility and at the disaster site if possible
b. make the most efficient use of available resources
230
a. perfusion
b. locomotion
c. respiration
d. mentation
75. The most important component of neurologic
assessment is:
a. pupil reactivity
b. vital sign assessment
c. cranial nerve assessment
d. level of consciousness/responsiveness
Situation 16 - You are going to participate in a Cancer
Consciousness Week. You are assigned to take charge of
the women to make them aware of cervical cancer. You
reviewed its manifestations and management.
76. The following are risk factors for cervical Cancer
EXCEPT:
a. immunisuppressive therapy
b. sex at an early age, multiple partners, exposure to
socially transmitted diseases, male partner's sexual
habits
c. viral agents like the Human Papilloma Virus
d. smoking
77. Late signs and symptoms of cervical cancer include
the following EXCEPT:
a. urinary/bowel changes
b. pain in pelvis, leg of flank
c. uterine bleeding
d. lymph edema of lower extremities
231
78. When a panhysterectomy is performed due to
cancer of the cervix, which of the following organs are
moved?
a. the uterus, cervix, and one ovary
b. the uterus, cervix, and two-thirds of the vagina
c. the uterus, cervix, tubes and ovaries
d. the uterus and cervix
79. The primary modalities of treatment for Stage 1 and
IIA cervical cancer include the following:
a. surgery, radiation therapy and hormone therapy
b. surgery
c. radiation therapy
d. surgery and radiation therapy
80. A common complication of hysterectomy is:
a. thrombophlebitis of the pelvic and thigh vessels
b. diarrhea due to over stimulating
c. atelectasis
d. wound dehiscence
Situation 17 - The body has regulatory mechanism to
maintain the needed electrolytes. However there are
conditions/surgical interventions that could compromise
life. You have to understand how management of these
conditions are done.
a. Place pillows under your patient's shoulders
b. Raise the knee-gatch to 30 degrees
c. Keep your patient in a high-fowler's position
d. Support the patient's head and neck with pillows and
sandbags
84. If there is an accidental injury to the parathyroid
gland during a thyroidectomy which of the following
might Leda develops postoperative?
a. Cardiac arrest
b. Dyspnea
c. Respiratory failure
d. Tetany
85. After surgery Leda develops peripheral numbness,
tingling and muscle twitching and spasm. What would
you anticipate to administer?
a. Magnesium sulfate
b. Calcium gluconate
c. Potassium iodine
d. Potassium chloride
Situation 18 - NURSES are involved in maintaining a safe
and health environment. This is part of quality care
management.
86. The first step in decontamination is:
81. You are caring for Leda who is scheduled to undergo
total thyroidectomy because of a diagnosis of thyroid
cancer. Prior to total thyroidectomy, you should
instruct Leda to:
a. Perform range and motion exercises on the head and
neck
b. Apply gentle pressure against the incision when
swallowing
c. Cough and deep breath every 2 hours
d. Support head with the hands when changing position
82. As Leda's nurse, you plan to set up an emergency
equipment at her beside following thyroidectomy. You
should include:
a An airway and rebreathing tube
b. A tracheostomy set and oxygen
c. A crush cart .with bed board
d. Two ampules of sodium bicarbonate
83. Which of the following nursing interventions is
appropriate after a total thyroidectomy?
a. to immediately apply a chemical decontamination
foam to the area of contamination
b. a thorough soap and water was and rinse of the
patient
c. to immediately apply personal protective equipment
d. removal of the patients clothing and jewelry and then
rinsing the patient with water
87. For a patient experiencing pruritus, you recommend
which type of bath:
a. Water
b. colloidal (oatmeal)
c. saline
d. sodium bicarbonate
88. Induction of vomiting is indicated for the accidental
poisoning patient who has ingested.
a. rust remover
b. gasoline
c. toilet bowl cleaner
d. aspirin
89. Which of the following term most precisely refer to
an infection acquired in the hospital that was not
present or incubating at the time of hospital
admission?
a. Secondary bloodstream infection
b. Nosocomial infection
c. Emerging infectious disease
d. Primary bloodstream infection
90. Which of the following guidelines is not appropriate
to helping family members cope with sudden death?
a. Obtain orders for sedation of family members
b. Provide details of the factors attendant to the sudden
death
c. Show acceptance of the body by touching it and giving
the family permission to touch
d. Inform the family that the patient has passed on
Situation 19 - As a nurse you are expected to participate
in initiating or participating in the conduct of research
studies to improve nursing practice. You have to be
updated on the latest trends and issues affecting
profession and the best practices arrived at by the
profession
91. You are interested to study the effects of
meditation and relaxation on the pain experienced by
cancer patients. What type of variable is pain?
a. Dependant
b. Correlational
c. Independent
d. Demographic
92. You would like to compare the support system of
patients with chronic illness to those with acute illness.
How will you best state your problem?
a. A descriptive study to compare the support system of
patients with chronic illness and those with acute illness
in terms of demographic data and knowledge about
interventions
b. The effect of the Type of Support system of patients
with chronic illness and those with acute illness
c. A comparative analysis of the support: system of
patients with chronic illness and those with acute illness
d. A study to compare the support system of patients
with chronic illness and those with acute illness
232
93. You would like to compare the support, system of
patients with chronic illness to those with acute illness.
What type of research it this?
a. Correlational
b. Descriptive
c. Experimental
d. Quasi-experimental
94. You are shown a Likert Scale that will be used in
evaluating your performance in the clinical area. Which
of the following questions will you not use in critiquing
the Likert Scale?
a. Are the techniques to complete and score the scale
provided?
b. Are the reliability and validity information on the scale
described?
c. If the Likert Scale is to be used for a study, was the
development process described?
d. Is the instrument clearly described?
95. In any research study where individual persons are
involves, it is important that an informed consent for
the Study is obtained. The following are essential
information about the consent that you should disclose
to the prospective subjects EXCEPT:
a. Consent to incomplete disclosure
b. Description of benefits, risks and discomforts
c. Explanation of procedure
d. Assurance of anonymity and confidentiality,
Situation 20 - Because severe burn can affect the
person's totality it is important that you apply
interventions focusing on the various dimensions of
man. You also have to understand the rationale of the
treatment.
96. What type of debribement involves proteolytic
enzymes?
a. Interventional
b. Mechanical
c. Surgical
d Chemical
97. Which topical antimicrobial is most frequently used
in burn wound care?
a. Neosporin
b. Silver nitrate
c. Silver sulfadiazine
233
d. Sulfamylon
98. Hypertrophic burns scars are caused by:
a. exaggerated contraction
b. random layering of collagen
c. wound ischemia
d. delayed epithelialization
99. The major disadvantage of whirlpool cleansing of
burn wounds is:
a. patient hypothermia
b. cross contamination of wound
c. patient discomfort
d. excessive manpower requirement
100. Oral analgecis are most frequently used to control
burn injury pain:
a. upon patient request
b. during the emergent phase
c. after hospital discharge
d. during the cute phase
ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC
AND PSYCHOSOCIAL ALTERATIONS
1. A
2. D
3. D
4. B
5. D
6. A
7. B
8. A
9. D
10. A
11. B
12. B
13. B
14. C
15. B
16. C
17. C
18. C
19. A
20. C
21. C
22. A
23. A
24. D
25. A
26. D
27. A
28 D
29. C
30. D
31. D
32. D
33. B
34. C
35. D
36. B
37. D
38. B
39. C
40. C
41. B
42. C
43. D
44. D
45. A
46. D
47. A
48. C
49. B
50. A
234
51. C
52. A
53. D
54. A
55. D
56. A
57. B
58. B
59. D
60. A
61. A
62. B
63. A
64. B
65. B
66. C
67. A
68. D
69. B
70. C
71. B
72. C
73. D
74. B
75. D
76. A
77. B
78. C
79. D
80. A
81. C
82. B
83. C
84. D
85. B
86. C
87. B
88. D
89. B
90. A
91. A
92. C
93. A
94. A
95. A
96. D
97. B
98. A
99. A
100. C
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Nursing Practice Test V
Situation: The nurse is interviewing a handsome man. He
is intelligent and very charming. When asked about his
family, he states he has been married four times. He says
three of those marriages were "shotgun" weddings. He
states he never really loved any of his wives. He doesn't
know much about his three children. "I've lost track," he
states.
personalities may marry repeatedly or get into trouble
with legal authorities is:
a. They usually just don't care
b. They are borderline mentally retarded
c. They are too psychotic to see what’s going on
d. They do not learn from past mistakes
7. The nurse recognizes that these are traits of:
1. If a patient is very resistant in taking responsibility of
his action and asks, "Can you just give me some
medication?" the best response is:
a. Bipolar disorder
b. Alcoholic personality
c. Antisocial personality
d. Borderline personality
a. "The medication has too many side effects."
b. You don't want to take medication, do you?"
c. Medication is given only as a East resort."
d. "There is no medication specific for your condition."
Situation: The patient with bipolar disorder is pacing
continuously and is skipping meals.
2. The patient asks the nurse, "What is this therapy for
anyway. I just don't understand it." the best reply is:
8. Blood levels are drawn on the patient who has been
taking Lithium for about six months. The present level
is 2.1 meq/L. The nurse evaluates this level as:
a. "It keeps you from being put on medications."
b. "It helps you to change others in the family."
c. "The purpose of therapy is to help you change."
d. "No one but professionals can really understand
a. Therapeutic
b. Below therapeutic
c. Potentially dangerous
d. Fatally toxic
3. For patient in group therapy, the goal is:
9. The priority in working with patient a thought
disorder is:
a. Exchanging information and ideas
b. Developing insight by relating to others
c. Learning that everyone has problems
d. All of the above
4. In planning care for the patient with a personality
disorder, the nurse realizes that this patient will most
likely:
a. Not need long-term therapy
b. Not require medication
c. Require anti-anxiety medication
d. Resist any change in behavior
5. The person with an antisocial personality is
participating in therapy while a patient at a psychiatric
hospital. The nurse’s expectations are that he will:
a. Make a complete recovery
b. Make significant changes
c. Begin the slow process of change
d. Make few changes, if any
6. One of the reasons that persons with antisocial
a. Get him to understand what you're saying
b. Get him to do his ADLs
c. Reorient him to reality
d. Administer antipsychotic medications
10. The most recent Lithium level on bipolar patient
indicates a drop non-therapeutic level. What associated
behavior does the nurse assess?
a. Ataxia
b. Confusion
c. Hyperactivity
d. Lethargy
11. Adequate fluid intake for a patient on Lithium is:
a. 1,000 ml per day
b. 1,500 ml per day
c. 2,000 ml per day
d. 3,600 ml per day
12. The physician orders Lithium carbonate for the
bipolar patient. The nurse is aware that:
a. The patient should be put on a special diet
b. The medication should be given only at night
c. A salt-free should be provided for the patient
d. The drug level should be monitored regularly
a. Secretaries
b. Elderly
c. Students
d. Professionals
13. The nursing plan should emphasize:
19. The best intervention is:
a. Offering him finger foods
b. Telling him he must sit down and eat
c. Serving food in his room and staying with him
d. Telling him to order fast food of he wants to eat
a. Tell her it just takes a long time
b. Ask her if her husband is angry
c. Refer her and her husband to sex therapy
d. Tell her she is suffering PTSD
Situation: Anna, 25 years old was raped six months ago
states, "I just can't seem to get over this. My husband
and I don't even have sex anymore. What can I do?"
Situation: Obsessions are recurring thoughts that
become prevalent in the consciousness and may be
considered as senseless or repulsive white compulsion
are the repetitive acts that follow obsessive thoughts.
14. Supportive therapy to the rape victim is directed at
overwhelming feeling that the victim experiences just
after the rape has occurred?
20. To understand the meaning of the cleaning rituals,
the nurse must realize:
a. Guilt
b. Rage
c. Damaged
d. Despair
a. The patient cannot help herself
b. The patient cannot change
c. Rituals relieve intense anxiety
d. Medications cannot help
15. Anna asks, "Why do I need to have pelvic exam?"
The nurse explains:
21. Upon admission to the hospital the patient
increases the ritual behavior at bedtime. She cannot
sleep. The treatment plan should include:
a. "To make sure you're not pregnant."
b. "To see if you got an infection."
c. "To make sure you were really raped."
d. "To gather legal evidence that is required."
16. In providing support therapy, the nurse explains
that rape has nothing to do with sexual desires or
heeds. The two most common elements in rape are:
a. Guilt and shame
b. Shame and jealousy
c. Embarrassment and envy
d. Power and anger
17. The rape victim will not talk, is withdrawn and
depressed. The defensive mechanism being used is:
a. Rationalization
b. Denial
c. Repression
d. Regression
18. The composite picture of rape victim reveals that
most victimized women are:
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a. Recommending a sedative medication
b. Modifying the routine to diminish her bedtime anxiety
c. Reminding her to perform rituals early in the evening
d. Limit the amount of time she spends washing her
hands
22. A patient has been diagnosed with a personality
disorder with .compulsive traits. Of the following
behavior's, which one would you expect the patient to
exhibit?
a. Inability to make decisions
b. Spontaneous playfulness
c. Inability to alter plans
d. Insistence that things be done his way
23. The patient will not be able to stop her compulsive
washing routines until she:
a. Acquires more superego
b. Recognizes the behavior is unrealistic
c. No longer needs them to manage her feelings of
anxiety
237
d. Regains contact with reality
problem in this country.
24. A 48-year-old female patient is brought to the
hospital by her husband because her behavior is
blocking her ability to meet her family's needs. She has
uncontrollable and constant desire to scrub her hands,
the walls, floors and sofa. She keeps repeating,"
Everything is dirty." This is an example of:
29. The nurse is monitoring a drug abuser who states
he was given cocaine and heroine that war cut with
cornstarch or some other kind of powder. He states, "It
was really bad stuff." Which complication is most
threatening to this patient?
a. Compulsion
b. Obsession
c. Delusion
d. Hallucination
a. Endocarditis
b. Gangrene
c. Pulmonary abscess
d. Pulmonary embolism
25. The female patient is preoccupied with rules and
regulations. She becomes upset if others do not follow
her lead and adhere to the rules exactly. This is a
characteristic of which of the following personality?
30. The chronic drug abuser is suffering lymphedema in
all extremities, but particularly in the arm where the
drug was obviously injected. There is severe
obstruction of veins and lymphatics. The nurse suspects
the patient used:
a. Compulsive
b. Borderline
c. Antisocial
d. Schizoid
a. A dull, contaminated needle
b. A needle contaminated with AIDS
c. Contaminated drugs
d. Cocaine mixed with uncut heroin
26. In planning care focused on decreasing the patient's
anxiety, what plan should the nurse have in regards to
the rituals?
31. The nurse is assessing a heroin user who injected
the drug into an artery instead of a vein. Which
complication is the nurse most likely to expect?
a. Encourage the routines
b. Ignore rituals
c. Work with her to develop limits of behavior
d. Restrain her from the rituals
a. Infection
b. Cardiac dysrhythmias
c. Gangrene
d. Thrombophlebitis
27. After the patient entered the hospital she began to
increase her ritualistic hand washing at bedtime and
could; not sleep. The nurse plans care around the fact
that this patient needs:
32. The nurse is assessing a 16-year-old patient for drug
abuse. The patient is incoherent. Because she notes
irritation of eyes, nose and mouth, she suspects
inhalants. Which sign is most indicative of inhalant
abuse?
a. A substitute activity to relieve anxiety
b. Medication for sleeping
c. Anti-anxiety medication such as Xanax
d. More scheduled activities during the day
28. The patient states, "I know all this scrubbing is silly
but I can’t help it:'', this statement indicates that the
patient does not recognize:
a. What she is doing
b. Why she is cleaning
c. Her level of anxiety
d. Need for medication
Situation: Substance, abuse is a common, growing health
a. Vomiting
b. Bad breath
c. Bad trip
d. Sudden fear
33. An impaired nurse has been admitted for treatment
of Demerol addiction. She asks, "When will the
withdrawal begin?" the best response is:
a. "It varies, with each individual."
b. "There is no way to tell."
c. "Withdrawal begins soon after the last dose."
d. "It depends upon how well the Demerol works."
34. The patient has a blood pressure of 180/100, heart
rate of 120, associated with extreme restlessness. He is
very suspicious of the hospital environment and actions
of healthcare workers. The nurse should confront this
patient on abuse of;
a. Marijuana
b. Cocaine
c. Barbiturates
d. Tranquilizers
a. Rationalization
b. Projection
c. Compensation
d. Substitution
40. An unattractive girl becomes a very good student.
This is an example of:
35. The nursing interventions most effective in working
with substance dependent patients are:
a. displacement
b. Regression
c. Compensation
d. Projection
a. Firm and directive
b. Instillation of values
c. Helpful and advisory
d Subjective and non-judgmental
41. A patient has been sharing a painful experience of
sexual abuse during his childhood. Suddenly he stops
and says, “l can't remember any more." The nurse
assesses his behavior as:
36. An adolescent patient has bloodshot eyes, a
voracious appetite (especially for junk foods), and a dry
mouth. Which drug of abuse would the nurse most
likely suspect?
a. Stubbornness
b. Forgetfulness
c. Blocking
d. Transference
a. Marijuana
b. Amphetamines
c. Barbiturates
d. Anxiolytics
42. The patient has a phobia about walking down in
dark halls. The nurse recognizes that the coping
mechanism usually associated with phobia is:
Situation: Defense mechanisms are unconscious
intrapsychic process implemented to cope with anxiety.
The use of some of these mechanisms is healthy, while
she use of others is unhealthy.
a. Compensation
b. Denial
c. Conversion
d. Displacement
37. A patient cries and curls in a fetal position refusing
to move or talk. This is an example of:
43. The patient is denying that he is an alcoholic He
states that his wife is an alcoholic. The defense
mechanism he is utilizing is: v
a. Regression
b. Suppression
c. Conversion
d. Sublimation
a. Sublimation
b. Projection
c. Suppression
d. Displacement
38. A person who expands sexual energy in a
nonsexual, socially accepted way is using the coping
mechanism of.
Situation: Ms. Dwane, 17 years old, is admitted with
anorexia nervosa. You have been assigned to sit with her
while she eats her dinner. Ms. Dwane says "My primary
nurse trusts me. I don't see why you don't."
a. Projection
b. Conversion
c. Sublimation
d. Compensation
39. "The reason I did not do well on the exam is that I
was tired." This is an example of:
238
44. Which observation of the client with anorexia
nervosa indicates the client is improving?
a. The client eats meats in the dining room
b. The client gains one pound per week
c. The client attends group therapy sessions
239
d. The client has a more realistic self-concept
45. The nurse is caring for a client with anorexia
nervosa who is to be placed on behavioral
modification. Which is appropriate to include in (he
nursing care plan?
a. Remind the client frequently to eat all the food served
on the tray
b. Increased phone calls allowed for client by one per day
for each pound gained
c. Include the family of the client in therapy sessions two
times per week
d. Weigh the client each day at 6:00 am in hospital gown
and slippers after she voids
Situation: The nurse suspects a client is denying his
feelings of anxiety
50. The nurse is monitoring a patient who is
experiencing increasing anxiety related to recent
accident. She notes an increase in vital signs from
130/70 to 160/30, pulse rate of 120, respiration 36. He
is having difficulty communicating. His level of anxiety
is:
a. Mild
b. Moderate
c. Severe
d. Panic
46. A nursing intervention based on the behavior
modification model of treatment for anorexia nervosa
would be:
51. The patient who suffers panic attacks is prescribed
a medication for short-term therapy. The nurse
prepares to administer.
a. Role playing the client's interaction with her parents
b. Encouraging the client to vent her feelings through
exercise
c. Providing a high-calorie, high protein diet with
between meals snacks
d. Restricting the client's privileges until she gains three
pounds
a. Elavil
b. Librium
c. Xanax
d. Mellaril
47. While admitting Ms. Dwane, the nurse discovers a
bottle of pills that Ms. Dwane calls antacids. She takes
them because her stomach hurts. The nurse's best
initial response is:
a. Provide safely
b. Hold the patient
c. Describe crisis in detail
d. Demonstrate ADLs frequently
a. Tell me more about your stomach pain
b. These do not look like antacids. I need to get an order
for you to have them
c. Tell me more about you drug use
d. Some girls take pills to help them lose weight
53. Which assessment would the nurse most likely find
in a person who is suffering increased anxiety?
48. The primary objective in the treatment of the
hospitalized anorexic client is to:
a. Decrease the client's anxiety
b. Increase the insight into the disorder
c. Help the mother to gain control
d. Get the client to ea and gain weight
49. Your best response for Ms. Dwane is:
a. I do trust you, but I was assigned to be with you
b. It sounds as if you are manipulating me
c. Ok, when I return, you should have eaten everything
d. Who is your primary nurse?
52. In attempting to control a patient who is suffering
panic attack, the nursing priority is:
a. Increasing BP, increasing heart rate and respirations
b. Decreasing BP, heart rate and respirations
c. Increased BP and decreased respirations
d. Increased respirations and decreased heart rate
54. A patient who suffers an acute anxiety disorder
approaches the nurse and while clutching at his shirt
states "I think I'm having a heart attack." The priority
nursing action is:
a. Reassure him he is OK
b. Take vital signs stat
c. Administer Valium IM
d. Administer Xanax PO
55. In teaching stress management, the goal of therapy
is to:
a. Get rid of the major stressor
b. Change lifestyle completely
c. Modify responses to stress
d. Learn new ways of thinking
56. Another client walks in to the mental health
outpatient center and States, "I've had it. I can't go on
any longer. You've got to help me. "The nurse asks the
client to be seated in a private interview room. Which
action should the nurse take next?
a. Reassure the client that someone will help him soon
b. Assess the client's insurance coverage
c. Find out more about what is happening to the client
d. Call the client's family to come and provide support
57. Mr. Juan is admitted for panic attack. He frequently
experiences shortness of breath, palpitations, nausea,
diaphoresis, and terror. What should the nurse include
in the care plan for Mr. Juan? When he is shaving a
panic attack?
a. Calm reassurance, deep breathing and medications as
ordered
b. Teach Mr. Juan problem solving in relation to his
anxiety
c. Explain the physiologic responses of anxiety
d. Explore alternate methods for dealing with the cause
of his anxiety
58. Ms. Wendy is pacing about the unit and wringing
his hands. She is breathing rapidly and complains of
palpitations and nausea, and she has difficulty focusing
on what the nurse is saying. She says she is having a
heart attack but refuses to rest. The nurse would
interpret her level of anxiety as:
a. Mild
b. Moderate
c. Severe
d. Panic
59. When assessing this client, the nurse must be
particularly alert to:
a. Restlessness
b. Tapping of the feet
c. Wringing of the hands
d. His or her own anxiety level
Situation: Raul aged 70 was recently admitted to a
nursing home because of confusion, disorientation, and
240
negativistic behavior. Her family states that Raul is in
good health. Raul asks you, "Where am I?"
60. Another patient, Mr. Pat, has been brought to the
psychiatric unit and is pacing up and down the hall. The
nurse is to admit him to the hospital. To establish a
nurse-client relationship, which approach should the
nurse try first?
a. Assign someone to watch Mr. Pat until he is calm
b. Ask Mr. Pat to sit down and orient him to the nurse's
name and the need for information
c. Check Mr. Pat's vital signs, ask him about allergies, and
call the physician for sedation
d. Explain the importance of accurate assessment data
to Mr. Pat .
61. If Raul will say "I'm so afraid! Where I am? Where is
my family'?" How should the nurse respond?
a. "You are in the hospital and you're safe here. Your
family will return at 10 o'clock, which is one hour from
now"
b. "You know were you are. You were admitted here 2
weeks ago. Don’t worry your family will be back soon."
c. "I just told you that you're in the hospital and your
family will be here soon."
d. "The name of the hospital is on the sigh over the door.
Let's go read it again."
62. Raul has had difficulty sleeping since admission.
Which of the following would be the best intervention?
a. Provide him with glass of warm milk
b. Ask the physician for a mild sedative
c. Do not allow Raul to take naps during the day
d. Ask him family what they prefer
63. Which activity would you engage in Raul at the
nursing home?
a. Reminiscence groups
b. Sing-along
d. Discussion groups
c. Exercise class
64. Which of the following would be an appropriate
strategy in reorienting a confused client to where her
room is?
a. Place pictures of her family on the bedside stand
b. Put her name in large letters on her forehead
c. Remind the client where her room is
241
d. Let the other residents know where the client’s room
is
65. The best response for the nurse to make is:
a. Don't worry, Raul. You're safe here
b. Where do you think you are?
c. What did your family tell you?
d. You're at the community nursing home
d. "What caused you to think you were God?"
70. The nurse is caring for a client who is experiencing
auditory hallucination. What would be most crucial for
the nurse to assess?
a. Possible hearing impairment
b. Family history of psychosis
c. Content of the hallucination
d. Otitis media
Situation: The police bring a patient to the emergency
department. He has been locked in his apartment for the
past 3 days, making frequent calls to the police and
emergency services and stating that people are trying to
kill him.
71. A patient with schizophrenia reports that the
newscaster on the radio has a divine message
especially for her. You would interpret this as
indicating.
66. A client on an inpatient psychiatric unit refuses to
eat and states that the staff is poisoning her food.
Which action should the nurse include in the client's
care plan?
a. Loose of associations
b. Delusion of reference
c. Paranoid speech
d. Flight of ideas
a. Explain to the client that the staff can be trusted
b. Show the client that others eat the food without harm
c. Offer the client factory-sealed foods and beverages
d. Institute behavioral modification with privileges
dependent on intake
72. What type of delusions is the patient experiencing?
67. The client tells the nurse that he can't eat because
his food has been poisoned. This statement is an
indication of which of the following?
a. Paranoia
b. Delusion of persecution
c. Hallucination
d. Illusion
68. The client on antipsychotic drugs begins to exhibit
signs and symptoms of which disorder?
a. Akinesia
b. Pseudoparkinsonism
c. Tardive dyskinesia
d. Oculogyric crisis
69. During a patient history, a patient state that she
used to believe she was God. But she knows this isn't
true. Which of the following would be your best
response?"
a. "Does it bother you that you used to believe that
about yourself?"
b. "Your thoughts are now more appropriate"
c. "Many people have these delusions."
a. Persecutory
b. Grandiose
c. Jealous
d. Somatic
Situation: Helen, with a diagnosis of disorganized
schizophrenia is creating a disturbance in the day room.
She is yelling and pointing at another patient, accusing
him to stealing her purse. Several patients are in the day
room when this incident starts.
73. The nurse is preparing to care for a client diagnosed
with catatonic schizophrenia. In anticipation of this
client's arrival, what should the nurse do?
a. Notify security
b. Prepare a magnesium sulfate drip
c. Place a specialty mattress overlay on the bed
d. Communicable the client's nothing-by-mouth status to
the dietary department
74. The nurse is caring for a client whom she suspects is
paranoid. How would the nurse confirm this
assessment?
a. indirect questioning
b. Direct questioning
c. Les-ad-in-sentences
d. Open-ended sentences
75. Which of the following is an example of a negative
symptom of schizophrenia?
c. Affect more women than men
d. May be related to certain medical conditionsa
a. Delusions
b. Disorganized speech
c. Flat affect
d. Catatonic behavior
80. A patient with schizophrenia (catatonic type) is
mute and can't perform activities of daily living. The
patient stares out the window for hours. What is your
first priority in this situation?
76. The patient tells you that a "voice" keeps laughing
at him and tells him he must crawl on his hands and
knees like a dog. Which of the following would be the
most appropriate response?
a. Assist the patient with feeding
b. Assist the patient with showering and tasks for
hygiene
c. Reassure the patient about safely, and try to orient
him to his surroundings
d. Encourage, socialization with peers, and provide a
stimulating environment
a. "They are imaginary voices and we're here to make
them go, away."
b. "If it makes you feel better, do what the voices tell
you."
c. "The voices can't hurt you here in the hospital"
d. "Even though I don't hear the voices, I understand that
you do."
77. A 23-year-old patient is receiving antipsychotic
medication to treat his schizophrenia. He's
experiencing some motor abnormalities called
extrapyramidal effects. Which of the following
extrapyramidal effects occurs most frequently in
younger make patients?
a. Akathisia
b. Akinesia
c. Dystonia
d. Pseudoparkinsonism
78. Which of the following should you do next?
a. Firmly redirect the patient to her room to discuss the
incident
b. Call the assistance and place the patient in locked
seclusion
c. Help the patient look for her purse
d. Don't intervene - the patients need a little bit of room
in which to work out differences
Situation: John is admitted with a diagnosis of paranoid
schizophrenia.
81. Which of the following would you suspect in a
patient receiving Chlorpromazine (Thorazine) who
complains of a sore throat and has a fever?
a. An allergic reaction
b. Jaundice
c. Dyskinesia
d. Agranulocytosis
82. While providing information for the family of a
patient with schizophrenia, you should be sure to
inform them about which of the following
characteristics of the disorder?
a. Relapse can be prevented if the patient takes
medication
b. Support is available to help family members meet their
own needs
c. Improvement should occur if the patient's
environment is carefully maintained
d. Stressful situations in the family in the family can
precipitate a relapse in the patient
83. While caring for John, the nurse knows that John
may have trouble with:
a. Staff who are cheerful
b. Simple direct sentences
c. Multiple commands
d. Violent behaviors
79. You're reaching a community group about
schizophrenia disorders. You explain the different types
of schizophrenia and delusional disorders. You also
explain that, unlike schizophrenia, delusional disorders:
84 Which nursing diagnosis is most likely to be
associated with a person who has a medical diagnosis
of schizophrenia, paranoid type?
a. Tend to begin in early childhood
b. Affect more men than women
a. Fear of being along
b. Perceptual disturbance related to delusion of
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243
persecution
c. Social isolation related to impaired ability to trust
d. Impaired social skills related to inadequate developed
superego
hospital
b. Provide nutritious food and a quite place to rest
c. Protect the client and others from harm
d. Create a structured environment
85. Which of the following behaviors can the nurse
anticipate with this client?
Situation: Wendell, 24 year-old student with a primary
sleep disorder, is unable to initiate maintenance of
sleep. Primary sleep disorders may be categorized as
dyssomnias or parasomnias.
a. Negative cognitive distortions
b. Impaired psychomotor development
c. Delusions of grandeur and hyperactivity
d. Alteration of appetite and sleep pattern
Situation: A client is admitted to the hospital. During the
assessment the nurse notes that the client has not slept
for a week. The client is talking rapidly, and throwing his
arms around randomly.
86. When writing an assessment of a client with mood
disorder, the nurse should specify:
a. How flat the client's affect
b. How suicidal the client is
c. How grandiose the client is
d. How the client is behaving
87. It is an apprehensive anticipation of an unknown
danger:
a. Fear
b. Anxiety
c. Antisocial
d. Schizoid
88. It is an, emotional response to a consciously
recognized threat.
a. Fear
b. Anxiety
c. Antisocial
d. Schizoid
89. All but one is an example of situational crisis:
a. Menstruation
b. Role changes
c. Rape
d. Divorce
90. What would be the highest priority in formulating a
nursing care plan for this client?
a. Isolate the client until he or she adjusts to 'the
91. The nurse is caring for a client who complains; of
fat?gue, inability to concentrate, and palpitations. The
client stales that she has been experiencing these
symptoms for the past 6 months. Which factor in the
client’s history has most likely contributed to.these
symptoms?
a. History of recent fever
b. Shift work
c. Hyperthyroidism
d. Fear
92. If Wendell complains of experiencing an
overwhelming urge to sleep and states that he's been
falling asleep while studying and reports that these
episodes occur about 5 times daily Wendell is most
likely experiencing which sleep disorder?
a. Breathing-related sleep disorder
b. Narcolepsy
c. Primary hypersomnia
d. Circadian rhythm disorder
93. The nurse is preparing a teaching plan for a client
diagnosed with primary insomnia. Which of the
following teaching topics should be included in the
plan?
a. Eating unlimited spicy foods, and limiting caffeine and
alcohol
b. Exercising 1 hour before bedtime to promote sleep
c. Importance of steeping whenever the client tires
d. Drinking warm milk before bed to induce sleep
94. Examples of dyssomnia includes:
a. Insomnia, hypersomnia, narcolepsy
b. Sleepwalking, nightmare
c. Snoring while sleeping
d. Non-rapid eye movement
Situation: The following questions refer to therapeutic
communication.
95. When preparing to conduct group therapy, the
nurse keeps in mind that the optimal number of clients
in a group would be:
a. 6 to 8
b. 10 to 12
c. 3 to 5
d. Unlimited
96. What occurs during the working phase of the-nurseclient relationship?
a. The nurse assesses the client's needs and develops a
plan of care
b. The nurse and client together evaluate and modify the
goals of the relationship
c. The nurse and client discuss their feelings about
terminating the relationship
d. The nurse and client explore each other's expectations
of-the relationship
97. A 42 year-old homemaker arrives at the emergency
department with uncomfortable crying and anxiety.
Her husband of 17 years has recently asked her for a
divorce. The patient is sitting in a chair, rocking back
and forth. Which is the best response for the nurse to
make?
a. "You must stop crying so that we can discuss your
feelings about the divorce."
b. "Once you find a job, you will feel much better and
more secure."
c. "I can see how upset you are. Let's sit in the office so
that we can talk about how you're feeling."
d. "Once you have a lawyer looking out for your
interests, you will feel better."
98. A client on the unit tells the nurse that his wife's
nagging really gets on his nerves. He asks the nurse if
she will talk with his wife about nagging during their
family session tomorrow afternoon. Which of the
following would be most therapeutic response to
client?
a. "Tell me more specifically about her complaints"
b. "Can you think why she might nag you so much?"
c. "I'll help you think about how to bring this up yourself
tomorrow."
d. "Why do you want me to initiate this discussion in
tomorrow's session rather than you?"
99. The nurse is working with a client who has just
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stimulated her anger by using a condescending tone of
voice. Which of the following responses by the nurse
would be the most therapeutic?
a. "I feel angry when I hear that tone of voice"
b. "You make me so angry when you talked to me that
way."
c. "Are you trying to make me angry?"
d. "Why do you use that condescending tone of voice
with me?"
100. A 35 year-old client tells the nurse that he never
disagrees with anyone and that he has loved everyone
he's ever known. What would be the nurse's best
response to this client?
a. "How do you manage to do that?"
b. "That's hard to believe. Most people couldn't to that."
c. "What do you do with your feelings of dissatisfaction
or anger?"
d. "How did you come to adopt such a way of life?"
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Nursing Practice Test V
Situation: The nurse is interviewing a handsome man. He
is intelligent and very charming. When asked about his
family, he states he has been married four times. He says
three of those marriages were "shotgun" weddings. He
states he never really loved any of his wives. He doesn't
know much about his three children. "I've lost track," he
states.
personalities may marry repeatedly or get into trouble
with legal authorities is:
a. They usually just don't care
b. They are borderline mentally retarded
c. They are too psychotic to see what’s going on
d. They do not learn from past mistakes
7. The nurse recognizes that these are traits of:
1. If a patient is very resistant in taking responsibility of
his action and asks, "Can you just give me some
medication?" the best response is:
a. Bipolar disorder
b. Alcoholic personality
c. Antisocial personality
d. Borderline personality
a. "The medication has too many side effects."
b. You don't want to take medication, do you?"
c. Medication is given only as a East resort."
d. "There is no medication specific for your condition."
Situation: The patient with bipolar disorder is pacing
continuously and is skipping meals.
2. The patient asks the nurse, "What is this therapy for
anyway. I just don't understand it." the best reply is:
8. Blood levels are drawn on the patient who has been
taking Lithium for about six months. The present level
is 2.1 meq/L. The nurse evaluates this level as:
a. "It keeps you from being put on medications."
b. "It helps you to change others in the family."
c. "The purpose of therapy is to help you change."
d. "No one but professionals can really understand
a. Therapeutic
b. Below therapeutic
c. Potentially dangerous
d. Fatally toxic
3. For patient in group therapy, the goal is:
9. The priority in working with patient a thought
disorder is:
a. Exchanging information and ideas
b. Developing insight by relating to others
c. Learning that everyone has problems
d. All of the above
4. In planning care for the patient with a personality
disorder, the nurse realizes that this patient will most
likely:
a. Not need long-term therapy
b. Not require medication
c. Require anti-anxiety medication
d. Resist any change in behavior
5. The person with an antisocial personality is
participating in therapy while a patient at a psychiatric
hospital. The nurse’s expectations are that he will:
a. Make a complete recovery
b. Make significant changes
c. Begin the slow process of change
d. Make few changes, if any
6. One of the reasons that persons with antisocial
a. Get him to understand what you're saying
b. Get him to do his ADLs
c. Reorient him to reality
d. Administer antipsychotic medications
10. The most recent Lithium level on bipolar patient
indicates a drop non-therapeutic level. What associated
behavior does the nurse assess?
a. Ataxia
b. Confusion
c. Hyperactivity
d. Lethargy
11. Adequate fluid intake for a patient on Lithium is:
a. 1,000 ml per day
b. 1,500 ml per day
c. 2,000 ml per day
d. 3,600 ml per day
12. The physician orders Lithium carbonate for the
bipolar patient. The nurse is aware that:
a. The patient should be put on a special diet
b. The medication should be given only at night
c. A salt-free should be provided for the patient
d. The drug level should be monitored regularly
a. Secretaries
b. Elderly
c. Students
d. Professionals
13. The nursing plan should emphasize:
19. The best intervention is:
a. Offering him finger foods
b. Telling him he must sit down and eat
c. Serving food in his room and staying with him
d. Telling him to order fast food of he wants to eat
a. Tell her it just takes a long time
b. Ask her if her husband is angry
c. Refer her and her husband to sex therapy
d. Tell her she is suffering PTSD
Situation: Anna, 25 years old was raped six months ago
states, "I just can't seem to get over this. My husband
and I don't even have sex anymore. What can I do?"
Situation: Obsessions are recurring thoughts that
become prevalent in the consciousness and may be
considered as senseless or repulsive white compulsion
are the repetitive acts that follow obsessive thoughts.
14. Supportive therapy to the rape victim is directed at
overwhelming feeling that the victim experiences just
after the rape has occurred?
20. To understand the meaning of the cleaning rituals,
the nurse must realize:
a. Guilt
b. Rage
c. Damaged
d. Despair
a. The patient cannot help herself
b. The patient cannot change
c. Rituals relieve intense anxiety
d. Medications cannot help
15. Anna asks, "Why do I need to have pelvic exam?"
The nurse explains:
21. Upon admission to the hospital the patient
increases the ritual behavior at bedtime. She cannot
sleep. The treatment plan should include:
a. "To make sure you're not pregnant."
b. "To see if you got an infection."
c. "To make sure you were really raped."
d. "To gather legal evidence that is required."
16. In providing support therapy, the nurse explains
that rape has nothing to do with sexual desires or
heeds. The two most common elements in rape are:
a. Guilt and shame
b. Shame and jealousy
c. Embarrassment and envy
d. Power and anger
17. The rape victim will not talk, is withdrawn and
depressed. The defensive mechanism being used is:
a. Rationalization
b. Denial
c. Repression
d. Regression
18. The composite picture of rape victim reveals that
most victimized women are:
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a. Recommending a sedative medication
b. Modifying the routine to diminish her bedtime anxiety
c. Reminding her to perform rituals early in the evening
d. Limit the amount of time she spends washing her
hands
22. A patient has been diagnosed with a personality
disorder with .compulsive traits. Of the following
behavior's, which one would you expect the patient to
exhibit?
a. Inability to make decisions
b. Spontaneous playfulness
c. Inability to alter plans
d. Insistence that things be done his way
23. The patient will not be able to stop her compulsive
washing routines until she:
a. Acquires more superego
b. Recognizes the behavior is unrealistic
c. No longer needs them to manage her feelings of
anxiety
247
d. Regains contact with reality
problem in this country.
24. A 48-year-old female patient is brought to the
hospital by her husband because her behavior is
blocking her ability to meet her family's needs. She has
uncontrollable and constant desire to scrub her hands,
the walls, floors and sofa. She keeps repeating,"
Everything is dirty." This is an example of:
29. The nurse is monitoring a drug abuser who states
he was given cocaine and heroine that war cut with
cornstarch or some other kind of powder. He states, "It
was really bad stuff." Which complication is most
threatening to this patient?
a. Compulsion
b. Obsession
c. Delusion
d. Hallucination
a. Endocarditis
b. Gangrene
c. Pulmonary abscess
d. Pulmonary embolism
25. The female patient is preoccupied with rules and
regulations. She becomes upset if others do not follow
her lead and adhere to the rules exactly. This is a
characteristic of which of the following personality?
30. The chronic drug abuser is suffering lymphedema in
all extremities, but particularly in the arm where the
drug was obviously injected. There is severe
obstruction of veins and lymphatics. The nurse suspects
the patient used:
a. Compulsive
b. Borderline
c. Antisocial
d. Schizoid
a. A dull, contaminated needle
b. A needle contaminated with AIDS
c. Contaminated drugs
d. Cocaine mixed with uncut heroin
26. In planning care focused on decreasing the patient's
anxiety, what plan should the nurse have in regards to
the rituals?
31. The nurse is assessing a heroin user who injected
the drug into an artery instead of a vein. Which
complication is the nurse most likely to expect?
a. Encourage the routines
b. Ignore rituals
c. Work with her to develop limits of behavior
d. Restrain her from the rituals
a. Infection
b. Cardiac dysrhythmias
c. Gangrene
d. Thrombophlebitis
27. After the patient entered the hospital she began to
increase her ritualistic hand washing at bedtime and
could; not sleep. The nurse plans care around the fact
that this patient needs:
32. The nurse is assessing a 16-year-old patient for drug
abuse. The patient is incoherent. Because she notes
irritation of eyes, nose and mouth, she suspects
inhalants. Which sign is most indicative of inhalant
abuse?
a. A substitute activity to relieve anxiety
b. Medication for sleeping
c. Anti-anxiety medication such as Xanax
d. More scheduled activities during the day
28. The patient states, "I know all this scrubbing is silly
but I can’t help it:'', this statement indicates that the
patient does not recognize:
a. What she is doing
b. Why she is cleaning
c. Her level of anxiety
d. Need for medication
Situation: Substance, abuse is a common, growing health
a. Vomiting
b. Bad breath
c. Bad trip
d. Sudden fear
33. An impaired nurse has been admitted for treatment
of Demerol addiction. She asks, "When will the
withdrawal begin?" the best response is:
a. "It varies, with each individual."
b. "There is no way to tell."
c. "Withdrawal begins soon after the last dose."
d. "It depends upon how well the Demerol works."
34. The patient has a blood pressure of 180/100, heart
rate of 120, associated with extreme restlessness. He is
very suspicious of the hospital environment and actions
of healthcare workers. The nurse should confront this
patient on abuse of;
a. Marijuana
b. Cocaine
c. Barbiturates
d. Tranquilizers
a. Rationalization
b. Projection
c. Compensation
d. Substitution
40. An unattractive girl becomes a very good student.
This is an example of:
35. The nursing interventions most effective in working
with substance dependent patients are:
a. displacement
b. Regression
c. Compensation
d. Projection
a. Firm and directive
b. Instillation of values
c. Helpful and advisory
d Subjective and non-judgmental
41. A patient has been sharing a painful experience of
sexual abuse during his childhood. Suddenly he stops
and says, “l can't remember any more." The nurse
assesses his behavior as:
36. An adolescent patient has bloodshot eyes, a
voracious appetite (especially for junk foods), and a dry
mouth. Which drug of abuse would the nurse most
likely suspect?
a. Stubbornness
b. Forgetfulness
c. Blocking
d. Transference
a. Marijuana
b. Amphetamines
c. Barbiturates
d. Anxiolytics
42. The patient has a phobia about walking down in
dark halls. The nurse recognizes that the coping
mechanism usually associated with phobia is:
Situation: Defense mechanisms are unconscious
intrapsychic process implemented to cope with anxiety.
The use of some of these mechanisms is healthy, while
she use of others is unhealthy.
a. Compensation
b. Denial
c. Conversion
d. Displacement
37. A patient cries and curls in a fetal position refusing
to move or talk. This is an example of:
43. The patient is denying that he is an alcoholic He
states that his wife is an alcoholic. The defense
mechanism he is utilizing is: v
a. Regression
b. Suppression
c. Conversion
d. Sublimation
a. Sublimation
b. Projection
c. Suppression
d. Displacement
38. A person who expands sexual energy in a
nonsexual, socially accepted way is using the coping
mechanism of.
Situation: Ms. Dwane, 17 years old, is admitted with
anorexia nervosa. You have been assigned to sit with her
while she eats her dinner. Ms. Dwane says "My primary
nurse trusts me. I don't see why you don't."
a. Projection
b. Conversion
c. Sublimation
d. Compensation
39. "The reason I did not do well on the exam is that I
was tired." This is an example of:
248
44. Which observation of the client with anorexia
nervosa indicates the client is improving?
a. The client eats meats in the dining room
b. The client gains one pound per week
c. The client attends group therapy sessions
249
d. The client has a more realistic self-concept
45. The nurse is caring for a client with anorexia
nervosa who is to be placed on behavioral
modification. Which is appropriate to include in (he
nursing care plan?
a. Remind the client frequently to eat all the food served
on the tray
b. Increased phone calls allowed for client by one per day
for each pound gained
c. Include the family of the client in therapy sessions two
times per week
d. Weigh the client each day at 6:00 am in hospital gown
and slippers after she voids
Situation: The nurse suspects a client is denying his
feelings of anxiety
50. The nurse is monitoring a patient who is
experiencing increasing anxiety related to recent
accident. She notes an increase in vital signs from
130/70 to 160/30, pulse rate of 120, respiration 36. He
is having difficulty communicating. His level of anxiety
is:
a. Mild
b. Moderate
c. Severe
d. Panic
46. A nursing intervention based on the behavior
modification model of treatment for anorexia nervosa
would be:
51. The patient who suffers panic attacks is prescribed
a medication for short-term therapy. The nurse
prepares to administer.
a. Role playing the client's interaction with her parents
b. Encouraging the client to vent her feelings through
exercise
c. Providing a high-calorie, high protein diet with
between meals snacks
d. Restricting the client's privileges until she gains three
pounds
a. Elavil
b. Librium
c. Xanax
d. Mellaril
47. While admitting Ms. Dwane, the nurse discovers a
bottle of pills that Ms. Dwane calls antacids. She takes
them because her stomach hurts. The nurse's best
initial response is:
a. Provide safely
b. Hold the patient
c. Describe crisis in detail
d. Demonstrate ADLs frequently
a. Tell me more about your stomach pain
b. These do not look like antacids. I need to get an order
for you to have them
c. Tell me more about you drug use
d. Some girls take pills to help them lose weight
53. Which assessment would the nurse most likely find
in a person who is suffering increased anxiety?
48. The primary objective in the treatment of the
hospitalized anorexic client is to:
a. Decrease the client's anxiety
b. Increase the insight into the disorder
c. Help the mother to gain control
d. Get the client to ea and gain weight
49. Your best response for Ms. Dwane is:
a. I do trust you, but I was assigned to be with you
b. It sounds as if you are manipulating me
c. Ok, when I return, you should have eaten everything
d. Who is your primary nurse?
52. In attempting to control a patient who is suffering
panic attack, the nursing priority is:
a. Increasing BP, increasing heart rate and respirations
b. Decreasing BP, heart rate and respirations
c. Increased BP and decreased respirations
d. Increased respirations and decreased heart rate
54. A patient who suffers an acute anxiety disorder
approaches the nurse and while clutching at his shirt
states "I think I'm having a heart attack." The priority
nursing action is:
a. Reassure him he is OK
b. Take vital signs stat
c. Administer Valium IM
d. Administer Xanax PO
55. In teaching stress management, the goal of therapy
is to:
a. Get rid of the major stressor
b. Change lifestyle completely
c. Modify responses to stress
d. Learn new ways of thinking
56. Another client walks in to the mental health
outpatient center and States, "I've had it. I can't go on
any longer. You've got to help me. "The nurse asks the
client to be seated in a private interview room. Which
action should the nurse take next?
a. Reassure the client that someone will help him soon
b. Assess the client's insurance coverage
c. Find out more about what is happening to the client
d. Call the client's family to come and provide support
57. Mr. Juan is admitted for panic attack. He frequently
experiences shortness of breath, palpitations, nausea,
diaphoresis, and terror. What should the nurse include
in the care plan for Mr. Juan? When he is shaving a
panic attack?
a. Calm reassurance, deep breathing and medications as
ordered
b. Teach Mr. Juan problem solving in relation to his
anxiety
c. Explain the physiologic responses of anxiety
d. Explore alternate methods for dealing with the cause
of his anxiety
58. Ms. Wendy is pacing about the unit and wringing
his hands. She is breathing rapidly and complains of
palpitations and nausea, and she has difficulty focusing
on what the nurse is saying. She says she is having a
heart attack but refuses to rest. The nurse would
interpret her level of anxiety as:
a. Mild
b. Moderate
c. Severe
d. Panic
59. When assessing this client, the nurse must be
particularly alert to:
a. Restlessness
b. Tapping of the feet
c. Wringing of the hands
d. His or her own anxiety level
Situation: Raul aged 70 was recently admitted to a
nursing home because of confusion, disorientation, and
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negativistic behavior. Her family states that Raul is in
good health. Raul asks you, "Where am I?"
60. Another patient, Mr. Pat, has been brought to the
psychiatric unit and is pacing up and down the hall. The
nurse is to admit him to the hospital. To establish a
nurse-client relationship, which approach should the
nurse try first?
a. Assign someone to watch Mr. Pat until he is calm
b. Ask Mr. Pat to sit down and orient him to the nurse's
name and the need for information
c. Check Mr. Pat's vital signs, ask him about allergies, and
call the physician for sedation
d. Explain the importance of accurate assessment data
to Mr. Pat .
61. If Raul will say "I'm so afraid! Where I am? Where is
my family'?" How should the nurse respond?
a. "You are in the hospital and you're safe here. Your
family will return at 10 o'clock, which is one hour from
now"
b. "You know were you are. You were admitted here 2
weeks ago. Don’t worry your family will be back soon."
c. "I just told you that you're in the hospital and your
family will be here soon."
d. "The name of the hospital is on the sigh over the door.
Let's go read it again."
62. Raul has had difficulty sleeping since admission.
Which of the following would be the best intervention?
a. Provide him with glass of warm milk
b. Ask the physician for a mild sedative
c. Do not allow Raul to take naps during the day
d. Ask him family what they prefer
63. Which activity would you engage in Raul at the
nursing home?
a. Reminiscence groups
b. Sing-along
d. Discussion groups
c. Exercise class
64. Which of the following would be an appropriate
strategy in reorienting a confused client to where her
room is?
a. Place pictures of her family on the bedside stand
b. Put her name in large letters on her forehead
c. Remind the client where her room is
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d. Let the other residents know where the client’s room
is
65. The best response for the nurse to make is:
a. Don't worry, Raul. You're safe here
b. Where do you think you are?
c. What did your family tell you?
d. You're at the community nursing home
d. "What caused you to think you were God?"
70. The nurse is caring for a client who is experiencing
auditory hallucination. What would be most crucial for
the nurse to assess?
a. Possible hearing impairment
b. Family history of psychosis
c. Content of the hallucination
d. Otitis media
Situation: The police bring a patient to the emergency
department. He has been locked in his apartment for the
past 3 days, making frequent calls to the police and
emergency services and stating that people are trying to
kill him.
71. A patient with schizophrenia reports that the
newscaster on the radio has a divine message
especially for her. You would interpret this as
indicating.
66. A client on an inpatient psychiatric unit refuses to
eat and states that the staff is poisoning her food.
Which action should the nurse include in the client's
care plan?
a. Loose of associations
b. Delusion of reference
c. Paranoid speech
d. Flight of ideas
a. Explain to the client that the staff can be trusted
b. Show the client that others eat the food without harm
c. Offer the client factory-sealed foods and beverages
d. Institute behavioral modification with privileges
dependent on intake
72. What type of delusions is the patient experiencing?
67. The client tells the nurse that he can't eat because
his food has been poisoned. This statement is an
indication of which of the following?
a. Paranoia
b. Delusion of persecution
c. Hallucination
d. Illusion
68. The client on antipsychotic drugs begins to exhibit
signs and symptoms of which disorder?
a. Akinesia
b. Pseudoparkinsonism
c. Tardive dyskinesia
d. Oculogyric crisis
69. During a patient history, a patient state that she
used to believe she was God. But she knows this isn't
true. Which of the following would be your best
response?"
a. "Does it bother you that you used to believe that
about yourself?"
b. "Your thoughts are now more appropriate"
c. "Many people have these delusions."
a. Persecutory
b. Grandiose
c. Jealous
d. Somatic
Situation: Helen, with a diagnosis of disorganized
schizophrenia is creating a disturbance in the day room.
She is yelling and pointing at another patient, accusing
him to stealing her purse. Several patients are in the day
room when this incident starts.
73. The nurse is preparing to care for a client diagnosed
with catatonic schizophrenia. In anticipation of this
client's arrival, what should the nurse do?
a. Notify security
b. Prepare a magnesium sulfate drip
c. Place a specialty mattress overlay on the bed
d. Communicable the client's nothing-by-mouth status to
the dietary department
74. The nurse is caring for a client whom she suspects is
paranoid. How would the nurse confirm this
assessment?
a. indirect questioning
b. Direct questioning
c. Les-ad-in-sentences
d. Open-ended sentences
75. Which of the following is an example of a negative
symptom of schizophrenia?
c. Affect more women than men
d. May be related to certain medical conditionsa
a. Delusions
b. Disorganized speech
c. Flat affect
d. Catatonic behavior
80. A patient with schizophrenia (catatonic type) is
mute and can't perform activities of daily living. The
patient stares out the window for hours. What is your
first priority in this situation?
76. The patient tells you that a "voice" keeps laughing
at him and tells him he must crawl on his hands and
knees like a dog. Which of the following would be the
most appropriate response?
a. Assist the patient with feeding
b. Assist the patient with showering and tasks for
hygiene
c. Reassure the patient about safely, and try to orient
him to his surroundings
d. Encourage, socialization with peers, and provide a
stimulating environment
a. "They are imaginary voices and we're here to make
them go, away."
b. "If it makes you feel better, do what the voices tell
you."
c. "The voices can't hurt you here in the hospital"
d. "Even though I don't hear the voices, I understand that
you do."
77. A 23-year-old patient is receiving antipsychotic
medication to treat his schizophrenia. He's
experiencing some motor abnormalities called
extrapyramidal effects. Which of the following
extrapyramidal effects occurs most frequently in
younger make patients?
a. Akathisia
b. Akinesia
c. Dystonia
d. Pseudoparkinsonism
78. Which of the following should you do next?
a. Firmly redirect the patient to her room to discuss the
incident
b. Call the assistance and place the patient in locked
seclusion
c. Help the patient look for her purse
d. Don't intervene - the patients need a little bit of room
in which to work out differences
Situation: John is admitted with a diagnosis of paranoid
schizophrenia.
81. Which of the following would you suspect in a
patient receiving Chlorpromazine (Thorazine) who
complains of a sore throat and has a fever?
a. An allergic reaction
b. Jaundice
c. Dyskinesia
d. Agranulocytosis
82. While providing information for the family of a
patient with schizophrenia, you should be sure to
inform them about which of the following
characteristics of the disorder?
a. Relapse can be prevented if the patient takes
medication
b. Support is available to help family members meet
their own needs
c. Improvement should occur if the patient's
environment is carefully maintained
d. Stressful situations in the family in the family can
precipitate a relapse in the patient
83. While caring for John, the nurse knows that John
may have trouble with:
a. Staff who are cheerful
b. Simple direct sentences
c. Multiple commands
d. Violent behaviors
79. You're reaching a community group about
schizophrenia disorders. You explain the different types
of schizophrenia and delusional disorders. You also
explain that, unlike schizophrenia, delusional disorders:
84 Which nursing diagnosis is most likely to be
associated with a person who has a medical diagnosis
of schizophrenia, paranoid type?
a. Tend to begin in early childhood
b. Affect more men than women
a. Fear of being along
b. Perceptual disturbance related to delusion of
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253
persecution
c. Social isolation related to impaired ability to trust
d. Impaired social skills related to inadequate developed
superego
hospital
b. Provide nutritious food and a quite place to rest
c. Protect the client and others from harm
d. Create a structured environment
85. Which of the following behaviors can the nurse
anticipate with this client?
Situation: Wendell, 24 year-old student with a primary
sleep disorder, is unable to initiate maintenance of
sleep. Primary sleep disorders may be categorized as
dyssomnias or parasomnias.
a. Negative cognitive distortions
b. Impaired psychomotor development
c. Delusions of grandeur and hyperactivity
d. Alteration of appetite and sleep pattern
Situation: A client is admitted to the hospital. During the
assessment the nurse notes that the client has not slept
for a week. The client is talking rapidly, and throwing his
arms around randomly.
86. When writing an assessment of a client with mood
disorder, the nurse should specify:
a. How flat the client's affect
b. How suicidal the client is
c. How grandiose the client is
d. How the client is behaving
87. It is an apprehensive anticipation of an unknown
danger:
a. Fear
b. Anxiety
c. Antisocial
d. Schizoid
88. It is an, emotional response to a consciously
recognized threat.
a. Fear
b. Anxiety
c. Antisocial
d. Schizoid
89. All but one is an example of situational crisis:
a. Menstruation
b. Role changes
c. Rape
d. Divorce
90. What would be the highest priority in formulating a
nursing care plan for this client?
a. Isolate the client until he or she adjusts to 'the
91. The nurse is caring for a client who complains; of
fat?gue, inability to concentrate, and palpitations. The
client stales that she has been experiencing these
symptoms for the past 6 months. Which factor in the
client’s history has most likely contributed to.these
symptoms?
a. History of recent fever
b. Shift work
c. Hyperthyroidism
d. Fear
92. If Wendell complains of experiencing an
overwhelming urge to sleep and states that he's been
falling asleep while studying and reports that these
episodes occur about 5 times daily Wendell is most
likely experiencing which sleep disorder?
a. Breathing-related sleep disorder
b. Narcolepsy
c. Primary hypersomnia
d. Circadian rhythm disorder
93. The nurse is preparing a teaching plan for a client
diagnosed with primary insomnia. Which of the
following teaching topics should be included in the
plan?
a. Eating unlimited spicy foods, and limiting caffeine and
alcohol
b. Exercising 1 hour before bedtime to promote sleep
c. Importance of steeping whenever the client tires
d. Drinking warm milk before bed to induce sleep
94. Examples of dyssomnia includes:
a. Insomnia, hypersomnia, narcolepsy
b. Sleepwalking, nightmare
c. Snoring while sleeping
d. Non-rapid eye movement
Situation: The following questions refer to therapeutic
communication.
95. When preparing to conduct group therapy, the
nurse keeps in mind that the optimal number of clients
in a group would be:
a. 6 to 8
b. 10 to 12
c. 3 to 5
d. Unlimited
96. What occurs during the working phase of the-nurseclient relationship?
a. The nurse assesses the client's needs and develops a
plan of care
b. The nurse and client together evaluate and modify
the goals of the relationship
c. The nurse and client discuss their feelings about
terminating the relationship
d. The nurse and client explore each other's expectations
of-the relationship
97. A 42 year-old homemaker arrives at the emergency
department with uncomfortable crying and anxiety.
Her husband of 17 years has recently asked her for a
divorce. The patient is sitting in a chair, rocking back
and forth. Which is the best response for the nurse to
make?
a. "You must stop crying so that we can discuss your
feelings about the divorce."
b. "Once you find a job, you will feel much better and
more secure."
c. "I can see how upset you are. Let's sit in the office so
that we can talk about how you're feeling."
d. "Once you have a lawyer looking out for your
interests, you will feel better."
98. A client on the unit tells the nurse that his wife's
nagging really gets on his nerves. He asks the nurse if
she will talk with his wife about nagging during their
family session tomorrow afternoon. Which of the
following would be most therapeutic response to
client?
a. "Tell me more specifically about her complaints"
b. "Can you think why she might nag you so much?"
c. "I'll help you think about how to bring this up
yourself tomorrow."
d. "Why do you want me to initiate this discussion in
tomorrow's session rather than you?"
99. The nurse is working with a client who has just
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stimulated her anger by using a condescending tone of
voice. Which of the following responses by the nurse
would be the most therapeutic?
a. "I feel angry when I hear that tone of voice"
b. "You make me so angry when you talked to me that
way."
c. "Are you trying to make me angry?"
d. "Why do you use that condescending tone of voice
with me?"
100. A 35 year-old client tells the nurse that he never
disagrees with anyone and that he has loved everyone
he's ever known. What would be the nurse's best
response to this client?
a. "How do you manage to do that?"
b. "That's hard to believe. Most people couldn't to that."
c. "What do you do with your feelings of dissatisfaction
or anger?"
d. "How did you come to adopt such a way of life?"
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TEST I - Foundation of Professional Nursing
Practice
1. The nurse In-charge in labor and delivery unit
administered a dose of terbutaline to a client
without checking the client’s pulse. The standard
that would be used to determine if the nurse
was negligent is:
a. The physician’s orders.
b. The action of a clinical nurse specialist
who is recognized expert in the field.
c. The statement in the drug literature
about administration of terbutaline.
d. The actions of a reasonably prudent
nurse with similar education and
experience.
2. Nurse Trish is caring for a female client with a
history of GI bleeding, sickle cell disease, and a
platelet count of 22,000/μl. The female client is
dehydrated and receiving dextrose 5% in halfnormal saline solution at 150 ml/hr. The client
complains of severe bone pain and is scheduled
to receive a dose of morphine sulfate. In
administering the medication, Nurse Trish
should avoid which route?
a. I.V
b. I.M
c. Oral
d. S.C
3. Dr. Garcia writes the following order for the
client who has been recently admitted “Digoxin
.125 mg P.O. once daily.” To prevent a dosage
error, how should the nurse document this order
onto 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 diagnosed
with deep vein thrombosis. Which nursing
diagnosis should receive the highest priority?
a. Ineffective peripheral tissue perfusion
related to venous congestion.
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral
vascular disease.
d. Impaired gas exchange related to
increased blood flow.
5. Nurse Betty is assigned to the following clients.
The client that the nurse would see first after
endorsement?
a. A 34 year-old post-operative
appendectomy client of five hours who
is complaining of pain.
b. A 44 year-old myocardial infarction (MI)
client who is complaining of nausea.
c. A 26 year-old client admitted for
dehydration whose intravenous (IV) has
infiltrated.
d. A 63 year-old post operative’s
abdominal hysterectomy client of three
days whose incisional dressing is
saturated with serosanguinous fluid.
6. Nurse Gail places a client in a four-point restraint
following orders from the physician. The client
care 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 receiving
H2 receptor antagonist therapy. The nurse Incharge knows the purpose of this therapy is to:
a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange
8. The doctor orders hourly urine output
measurement for a postoperative male client.
The nurse Trish records the following amounts of
output for 2 consecutive hours: 8 a.m.: 50 ml; 9
a.m.: 60 ml. Based on these amounts, which
action should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly
urine output
9. Tony, a basketball player twist his right ankle
while playing on the court and seeks care for
ankle pain and swelling. After the nurse applies
ice to the ankle for 30 minutes, which statement
by Tony suggests that ice application has been
effective?
a. “My ankle looks less swollen now”.
b. “My ankle feels warm”.
c. “My ankle appears redder now”.
d. “I need something stronger for pain
relief”
10. The physician prescribes a loop diuretic for a
client. When administering this drug, the nurse
anticipates that the client may develop which
electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia
11. She finds out that some managers have
benevolent-authoritative style of management.
Which of the following behaviors will she exhibit
most likely?
a. Have condescending trust and
confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among
subordinates.
12. Nurse Amy is aware that the following is true
about functional nursing
a. Provides continuous, coordinated and
comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group
collaboration.
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 order
b. Standard written order
c. Standing order
d. Stat order
14. A female client with a fecal impaction frequently
exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
15. Nurse Linda prepares to perform an otoscopic
examination on a female client. For proper
visualization, the nurse should position the
client's ear by:
a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
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d. Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a
male client who is having external radiation
therapy:
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 area
when it is red or sore.
17. In assisting a female client for immediate
surgery, the nurse In-charge is aware that she
should:
a. Encourage the client to void following
preoperative medication.
b. Explore the client’s fears and anxieties
about the surgery.
c. Assist the client in removing dentures
and nail polish.
d. Encourage the client to drink water prior
to surgery.
18. A male client is admitted and diagnosed with
acute pancreatitis after a holiday celebration of
excessive food and alcohol. Which assessment
finding reflects this diagnosis?
a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric
and back pain.
19. Which dietary guidelines are important for nurse
Oliver to implement in caring for the client with
burns?
a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate
diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.
20. Nurse Hazel will administer a unit of whole
blood, which priority information should the
nurse have about the client?
a. Blood pressure and pulse rate.
b. Height and weight.
c. Calcium and potassium levels
d. Hgb and Hct levels.
21. Nurse Michelle witnesses a female client sustain
a fall and suspects that the leg may be broken.
The nurse takes which priority action?
a. Takes a set of vital signs.
257
b. Call the radiology department for X-ray.
c. Reassure the client that everything will
be alright.
d. Immobilize the leg before moving the
client.
22. A male client is being transferred to the nursing
unit for admission after receiving a radium
implant for bladder cancer. The nurse in-charge
would take which priority action in the care of
this client?
a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent
rest periods.
d. Encourage family and friends to visit.
23. A newly admitted female client was diagnosed
with agranulocytosis. The nurse formulates
which priority nursing diagnosis?
a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge
24. A male client is receiving total parenteral
nutrition suddenly demonstrates signs and
symptoms of an air embolism. What is the
priority action by the nurse?
a. Notify the physician.
b. Place the client on the left side in the
Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.
25. Nurse May attends an educational conference
on leadership styles. The nurse is sitting with a
nurse employed at a large trauma center who
states that the leadership style at the trauma
center is task-oriented and directive. The nurse
determines that the leadership style used at the
trauma center is:
a. Autocratic.
b. Laissez-faire.
c. Democratic.
d. Situational
26. The physician orders DS 500 cc with KCl 10
mEq/liter at 30 cc/hr. The nurse in-charge is
going to hang a 500 cc bag. KCl is supplied 20
mEq/10 cc. How many cc’s of KCl will be added
to the IV solution?
a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc
27. A child of 10 years old is to receive 400 cc of IV
fluid in an 8 hour shift. The IV drip factor is 60.
The IV rate that will deliver this amount is:
a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour
28. The nurse is aware that the most important
nursing action when a client returns from
surgery is:
a. Assess the IV for type of fluid and rate of
flow.
b. Assess the client for presence of pain.
c. Assess the Foley catheter for patency
and urine output
d. Assess the dressing for drainage.
29. Which of the following vital sign assessments
that may indicate cardiogenic shock after
myocardial infarction?
a. BP – 80/60, Pulse – 110 irregular
b. BP – 90/50, Pulse – 50 regular
c. BP – 130/80, Pulse – 100 regular
d. BP – 180/100, Pulse – 90 irregular
30. Which is the most appropriate nursing action in
obtaining a blood pressure measurement?
a. Take the proper equipment, place the
client in a comfortable position, and
record the appropriate information in
the client’s chart.
b. Measure the client’s arm, if you are not
sure of the size of cuff to use.
c. Have the client recline or sit comfortably
in a chair with the forearm at the level of
the heart.
d. Document the measurement, which
extremity was used, and the position
that the client was in during the
measurement.
31. Asking the questions to determine if the person
understands the health teaching provided by the
nurse would be included during which step of
the nursing process?
a. Assessment
b. Evaluation
c. Implementation
d. Planning and goals
32. Which of the following item is considered the
single most important factor in assisting the
health professional in arriving at a diagnosis or
determining the person’s needs?
a. Diagnostic test results
b. Biographical date
c. History of present illness
d. Physical examination
33. In preventing the development of an external
rotation deformity of the hip in a client who
must remain in bed for any period of time, the
most appropriate nursing action would be to
use:
a. Trochanter roll extending from the crest
of the ileum to the mid-thigh.
b. Pillows under the lower legs.
c. Footboard
d. Hip-abductor pillow
34. Which stage of pressure ulcer development does
the ulcer extend into the subcutaneous tissue?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
35. When the method of wound healing is one in
which wound edges are not surgically
approximated and integumentary continuity is
restored by granulations, the wound healing is
termed
a. Second intention healing
b. Primary intention healing
c. Third intention healing
d. First intention healing
36. An 80-year-old male client is admitted to the
hospital with a diagnosis of pneumonia. Nurse
Oliver learns that the client lives alone and
hasn’t been eating or drinking. When assessing
him for dehydration, nurse Oliver would expect
to find:
a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia
37. The physician prescribes meperidine (Demerol),
75 mg I.M. every 4 hours as needed, to control a
client’s postoperative pain. The package insert is
258
“Meperidine, 100 mg/ml.” How many milliliters
of meperidine should the client receive?
a. 0.75
b. 0.6
c. 0.5
d. 0.25
38. A male client with diabetes mellitus is receiving
insulin. Which statement correctly describes an
insulin unit?
a. It’s a common measurement in the
metric system.
b. It’s the basis for solids in the avoirdupois
system.
c. It’s the smallest measurement in the
apothecary system.
d. It’s a measure of effect, not a standard
measure of weight or quantity.
39. Nurse Oliver measures a client’s temperature at
102° F. What is the equivalent Centigrade
temperature?
a. 40.1 °C
b. 38.9 °C
c. 48 °C
d. 38 °C
40. The nurse is assessing a 48-year-old client who
has come to the physician’s office for his annual
physical exam. One of the first physical signs of
aging is:
a. Accepting limitations while developing
assets.
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 female
client to treat a pneumothorax. The tube is
connected to water-seal drainage. The nurse incharge 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 slightly
elevated.
d. Keeping the chest drainage system
below the level of the chest.
42. Nurse Trish must verify the client’s identity
before administering medication. She is aware
that the safest way to verify identity is to:
a. Check the client’s identification band.
b. Ask the client to state his name.
259
c. State the client’s name out loud and
wait a client to repeat it.
d. Check the room number and the client’s
name 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 should
run the I.V. infusion at a rate of:
a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute
44. If a central venous catheter becomes
disconnected accidentally, what should the
nurse in-charge do immediately?
a. Clamp the catheter
b. Call another nurse
c. Call the physician
d. Apply a dry sterile dressing to the site.
45. A female client was recently admitted. She has
fever, weight loss, and watery diarrhea is being
admitted to the facility. While assessing the
client, Nurse Hazel inspects the client’s abdomen
and notice that it is slightly concave. Additional
assessment 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 a
client with pneumonia. For this examination,
nurse Betty should use the:
a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand
47. Which type of evaluation occurs continuously
throughout the teaching and learning process?
a. Summative
b. Informative
c. Formative
d. Retrospective
48. A 45 year old client, has no family history of
breast cancer or other risk factors for this
disease. Nurse John should instruct her to have
mammogram how often?
a. Twice per year
b. Once per year
c. Every 2 years
d. Once, to establish baseline
49. A male client has the following arterial blood gas
values: pH 7.30; Pao2 89 mmHg; Paco2 50
mmHg; and HCO3 26mEq/L. Based on these
values, Nurse Patricia should expect which
condition?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
50. Nurse Len refers a female client with terminal
cancer to a local hospice. What is the goal of this
referral?
a. To help the client find appropriate
treatment options.
b. To provide support for the client and
family in coping with terminal illness.
c. To ensure that the client gets counseling
regarding health care costs.
d. To teach the client and family about
cancer and its treatment.
51. When caring for a male client with a 3-cm stage I
pressure ulcer on the coccyx, which of the
following actions can the nurse institute
independently?
a. Massaging the area with an astringent
every 2 hours.
b. Applying an antibiotic cream to the area
three times per day.
c. Using normal saline solution to clean the
ulcer and applying a protective dressing
as necessary.
d. Using a povidone-iodine wash on the
ulceration three times per day.
52. Nurse Oliver must apply an elastic bandage to a
client’s ankle and calf. He should apply the
bandage beginning at the client’s:
a. Knee
b. Ankle
c. Lower thigh
d. Foot
53. A 10 year old child with type 1 diabetes develops
diabetic ketoacidosis and receives a continuous
insulin infusion. Which condition represents the
greatest risk to this child?
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia
54. Nurse Len is administering sublingual nitrglycerin
(Nitrostat) to the newly admitted client.
Immediately afterward, the client may
experience:
a. Throbbing headache or dizziness
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.
55. Nurse Michelle hears the alarm sound on the
telemetry monitor. The nurse quickly looks at
the monitor and notes that a client is in a
ventricular tachycardia. The nurse rushes to the
client’s room. Upon reaching the client’s
bedside, the nurse would take which action
first?
a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the client’s level of consciousness
56. Nurse Hazel is preparing to ambulate a female
client. The best and the safest position for the
nurse 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 care
given to the potential organ donor who has been
diagnosed with brain death. The nurse
determines that the standard of care had been
maintained if which of the following data is
observed?
a. Urine output: 45 ml/hr
b. Capillary refill: 5 seconds
c. Serum pH: 7.32
d. Blood pressure: 90/48 mmHg
58. Nurse Amy has an order to obtain a urinalysis
from a male client with an indwelling urinary
catheter. The nurse avoids which of the
following, which contaminate the specimen?
a. Wiping the port with an alcohol swab
before inserting the syringe.
b. Aspirating a sample from the port on the
drainage bag.
c. Clamping the tubing of the drainage bag.
260
d. Obtaining the specimen from the urinary
drainage bag.
59. Nurse Meredith is in the process of giving a
client a bed bath. In the middle of the
procedure, the unit secretary calls the nurse on
the intercom to tell the nurse that there is an
emergency phone call. The appropriate nursing
action is to:
a. Immediately walk out of the client’s
room and answer the phone call.
b. Cover the client, place the call light
within reach, and answer the phone call.
c. Finish the bed bath before answering
the phone call.
d. Leave the client’s door open so the client
can be monitored and the nurse can
answer the phone call.
60. Nurse Janah is collecting a sputum specimen for
culture and sensitivity testing from a client who
has a productive cough. Nurse Janah plans to
implement which intervention to obtain the
specimen?
a. Ask the client to expectorate a small
amount of sputum into the emesis basin.
b. Ask the client to obtain the specimen
after breakfast.
c. Use a sterile plastic container for
obtaining the specimen.
d. Provide tissues for expectoration and
obtaining the specimen.
61. Nurse Ron is observing a male client using a
walker. The nurse determines that the client is
using the walker correctly if the client:
a. Puts all the four points of the walker flat
on the floor, puts weight on the hand
pieces, and then walks into it.
b. Puts weight on the hand pieces, moves
the walker forward, and then walks into
it.
c. Puts weight on the hand pieces, slides
the walker forward, and then walks into
it.
d. Walks into the walker, puts weight on
the hand pieces, and then puts all four
points of the walker flat on the floor.
62. Nurse Amy has documented an entry regarding
client care in the client’s medical record. When
checking the entry, the nurse realizes that
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incorrect information was documented. How
does the nurse correct this error?
a. Erases the error and writes in the correct
information.
b. Uses correction fluid to cover up the
incorrect information and writes in the
correct information.
c. Draws one line to cross out the incorrect
information and then initials the change.
d. Covers up the incorrect information
completely using a black pen and writes
in the correct information
63. Nurse Ron is assisting with transferring a client
from the operating room table to a stretcher. To
provide safety to the client, the nurse should:
a. Moves the client rapidly from the table
to the stretcher.
b. Uncovers the client completely before
transferring to the stretcher.
c. Secures the client safety belts after
transferring to the stretcher.
d. Instructs the client to move self from the
table to the stretcher.
64. Nurse Myrna is providing instructions to a
nursing assistant assigned to give a bed bath to a
client who is on contact precautions. Nurse
Myrna instructs the nursing assistant to use
which of the following protective items when
giving bed bath?
a. Gown and goggles
b. Gown and gloves
c. Gloves and shoe protectors
d. Gloves and goggles
65. Nurse Oliver is caring for a client with impaired
mobility that occurred as a result of a stroke. The
client has right sided arm and leg weakness. The
nurse would suggest that the client use which of
the following assistive devices that would
provide the best stability for ambulating?
a. Crutches
b. Single straight-legged cane
c. Quad cane
d. Walker
66. A male client with a right pleural effusion noted
on a chest X-ray is being prepared for
thoracentesis. The client experiences severe
dizziness when sitting upright. To provide a safe
environment, the nurse assists the client to
which position for the procedure?
a. Prone with head turned toward the side
supported by a pillow.
b. Sims’ position with the head of the bed
flat.
c. Right side-lying with the head of the bed
elevated 45 degrees.
d. Left side-lying with the head of the bed
elevated 45 degrees.
67. Nurse John develops methods for data
gathering. Which of the following criteria of a
good instrument refers to the ability of the
instrument to yield the same results upon its
repeated administration?
a. Validity
b. Specificity
c. Sensitivity
d. Reliability
68. Harry knows that he has to protect the rights of
human research subjects. Which of the following
actions of Harry ensures anonymity?
a. Keep the identities of the subject secret
b. Obtain informed consent
c. Provide equal treatment to all the
subjects of the study.
d. Release findings only to the participants
of the study
69. Patient’s refusal to divulge information is a
limitation because it is beyond the control of
Tifanny”. What type of research is appropriate
for this study?
a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical
70. Nurse Ronald is aware that the best tool for data
gathering is?
a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation
71. Monica is aware that there are times when only
manipulation of study variables is possible and
the elements of control or randomization are
not attendant. Which type of research is
referred to this?
a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design
72. Cherry notes down ideas that were derived from
the description of an investigation written by the
person who conducted it. Which type of
reference source refers to this?
a. Footnote
b. Bibliography
c. Primary source
d. Endnotes
73. When Nurse Trish is providing care to his
patient, she must remember that her duty is
bound not to do doing any action that will cause
the patient harm. This is the meaning of the
bioethical principle:
a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity
74. When a nurse in-charge causes an injury to a
female patient and the injury caused becomes
the proof of the negligent act, the presence of
the injury is said to exemplify the principle of:
a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine
75. Nurse Myrna is aware that the Board of Nursing
has quasi-judicial power. An example of this
power is:
a. The Board can issue rules and
regulations that will govern the practice
of nursing
b. The Board can investigate violations of
the nursing law and code of ethics
c. The Board can visit a school applying for
a permit in collaboration with CHED
d. The Board prepares the board
examinations
76. When the license of nurse Krina is revoked, it
means that she:
a. Is no longer allowed to practice the
profession for the rest of her life
b. Will never have her/his license re-issued
since it has been revoked
c. May apply for re-issuance of his/her
license based on certain conditions
stipulated in RA 9173
262
d. Will remain unable to practice
professional nursing
77. Ronald plans to conduct a research on the use of
a new method of pain assessment scale. Which
of the following is the second step in the
conceptualizing phase of the research process?
a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research
problem
d. Design the theoretical and conceptual
framework
78. The leader of the study knows that certain
patients who are in a specialized research setting
tend to respond psychologically to the
conditions of the study. This referred to as :
a. Cause and effect
b. Hawthorne effect
c. Halo effect
d. Horns effect
79. Mary finally decides to use judgment sampling
on her research. Which of the following actions
of is correct?
a. Plans to include whoever is there during
his study.
b. Determines the different nationality of
patients frequently admitted and
decides to get representations samples
from each.
c. Assigns numbers for each of the
patients, place these in a fishbowl and
draw 10 from it.
d. Decides to get 20 samples from the
admitted patients
80. The nursing theorist who developed
transcultural nursing theory is:
a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy
81. Marion is aware that the sampling method that
gives equal chance to all units in the population
to get picked is:
a. Random
b. Accidental
c. Quota
d. Judgment
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82. John plans to use a Likert Scale to his study to
determine the:
a. Degree of agreement and disagreement
b. Compliance to expected standards
c. Level of satisfaction
d. Degree of acceptance
83. Which of the following theory addresses the four
modes of adaptation?
a. Madeleine Leininger
b. Sr. Callista Roy
c. Florence Nightingale
d. Jean Watson
84. Ms. Garcia is responsible to the number of
personnel reporting to her. This principle refers
to:
a. Span of control
b. Unity of command
c. Downward communication
d. Leader
85. Ensuring that there is an informed consent on
the part of the patient before a surgery is done,
illustrates the bioethical principle of:
a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence
86. Nurse Reese is teaching a female client with
peripheral 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 pressure
ulcers. When developing the client's diet plan,
the nurse should include:
a. Fresh orange slices
b. Steamed broccoli
c. Ice cream
d. Ground beef patties
88. The nurse prepares to administer a cleansing
enema. What is the most common client
position used for this procedure?
a. Lithotomy
b. Supine
c. Prone
d. Sims’ left lateral
89. Nurse Marian is preparing to administer a blood
transfusion. Which action should the nurse take
first?
a. Arrange for typing and cross matching of
the client’s blood.
b. Compare the client’s identification
wristband with the tag on the unit of
blood.
c. Start an I.V. infusion of normal saline
solution.
d. Measure the client’s vital signs.
90. A 65 years old male client requests his
medication at 9 p.m. instead of 10 p.m. so that
he can go to sleep earlier. Which type of nursing
intervention is required?
a. Independent
b. Dependent
c. Interdependent
d. Intradependent
91. A female client is to be discharged from an acute
care facility after treatment for right leg
thrombophlebitis. The Nurse Betty notes that
the client's leg is pain-free, without redness or
edema. The nurse's actions reflect which step of
the nursing process?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation
92. Nursing care for a female client includes
removing elastic stockings once per day. The
Nurse Betty is aware that the rationale for this
intervention?
a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and
relax
d. To permit veins in the legs to fill with
blood.
93. Which nursing intervention takes highest priority
when caring for a newly admitted client who's
receiving a blood transfusion?
a. Instructing the client to report any
itching, swelling, or dyspnea.
b. Informing the client that the transfusion
usually take 1 ½ to 2 hours.
c. Documenting blood administration in
the client care record.
d. Assessing the client’s vital signs when
the transfusion ends.
94. A male client complains of abdominal discomfort
and nausea while receiving tube feedings. Which
intervention is most appropriate for this
problem?
a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the
concentration of the formula.
c. Place the client in semi-Fowler's position
while feeding.
d. Change the feeding container every 12
hours.
95. Nurse Patricia is reconstituting a powdered
medication in a vial. After adding the solution to
the powder, she nurse should:
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5
minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.
96. Which intervention should the nurse Trish use
when administering oxygen by face mask to a
female client?
a. Secure the elastic band tightly around
the client's head.
b. Assist the client to the semi-Fowler
position if possible.
c. Apply the face mask from the client's
chin up over the nose.
d. Loosen the connectors between the
oxygen equipment and humidifier.
97. The maximum transfusion time for a unit of
packed red blood cells (RBCs) is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours
98. Nurse Monique is monitoring the effectiveness
of a client's drug therapy. When should the
nurse Monique obtain a blood sample to
measure the trough drug level?
a. 1 hour before administering the next
dose.
b. Immediately before administering the
next dose.
c. Immediately after administering the
next dose.
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d. 30 minutes after administering the next
dose.
99. Nurse May is aware that the main advantage of
using a floor stock system is:
a. The nurse can implement medication
orders quickly.
b. The nurse receives input from the
pharmacist.
c. The system minimizes transcription
errors.
d. The system reinforces accurate
calculations.
100. Nurse Oliver is assessing a client's abdomen.
Which finding should the nurse report as
abnormal?
a. Dullness over the liver.
b. Bowel sounds occurring every 10
seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal
arteries.
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Answers and Rationale – Foundation of
Professional Nursing Practice
8.
1. Answer: (D) The actions of a reasonably prudent
nurse with similar education and experience.
Rationale: The standard of care is determined
by the average degree of skill, care, and
diligence by nurses in similar circumstances.
2.
Answer: (B) I.M
Rationale: With a platelet count of 22,000/μl,
the clients tends to bleed easily. Therefore,
the nurse should avoid using the I.M. route
because the area is a highly vascular and can
bleed 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 a
zero before a decimal point so that no one
misreads the figure, which could result in a
dosage error. The nurse should never insert a
zero at the end of a dosage that includes a
decimal point because this could be misread,
possibly leading to a tenfold increase in the
dosage.
4.
Answer: (A) Ineffective peripheral tissue
perfusion related to venous congestion.
Rationale: Ineffective peripheral tissue
perfusion related to venous congestion takes
the highest priority because venous
inflammation and clot formation impede blood
flow in a client with deep vein thrombosis.
5.
Answer: (B) A 44 year-old myocardial
infarction (MI) client who is complaining of
nausea.
Rationale: Nausea is a symptom of impending
myocardial infarction (MI) and should be
assessed immediately so that treatment can
be instituted and further damage to the heart
is avoided.
6.
Answer: (C) Check circulation every 15-30
minutes.
Rationale: Restraints encircle the limbs, which
place the client at risk for circulation being
restricted to the distal areas of the
extremities. Checking the client’s circulation
every 15-30 minutes will allow the nurse to
adjust the restraints before injury from
decreased blood flow occurs.
7.
Answer: (A) Prevent stress ulcer
Rationale: Curling’s ulcer occurs as a
generalized stress response in burn patients.
This results in a decreased production of
mucus and increased secretion of gastric acid.
9.
10.
11.
12.
13.
14.
15.
The best treatment for this prophylactic use of
antacids and H2 receptor blockers.
Answer: (D) Continue to monitor and record
hourly urine output
Rationale: Normal urine output for an adult is
approximately 1 ml/minute (60 ml/hour).
Therefore, this client's output is normal.
Beyond continued evaluation, no nursing
action is warranted.
Answer: (B) “My ankle feels warm”.
Rationale: Ice application decreases pain and
swelling. Continued or increased pain, redness,
and increased warmth are signs of
inflammation that shouldn't occur after ice
application
Answer: (B) Hyperkalemia
Rationale: A loop diuretic removes water and,
along with it, sodium and potassium. This may
result in hypokalemia, hypovolemia, and
hyponatremia.
Answer:(A) Have condescending trust and
confidence in their subordinates
Rationale: Benevolent-authoritative managers
pretentiously show their trust and confidence
to their followers.
Answer: (A) Provides continuous, coordinated
and comprehensive nursing services.
Rationale: Functional nursing is focused on
tasks and activities and not on the care of the
patients.
Answer: (B) Standard written order
Rationale: This is a standard written order.
Prescribers write a single order for
medications given only once. A stat order is
written for medications given immediately for
an urgent client problem. A standing order,
also known as a protocol, establishes
guidelines for treating a particular disease or
set of symptoms in special care areas such as
the coronary care unit. Facilities also may
institute medication protocols that specifically
designate drugs that a nurse may not give.
Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid
stools results from seepage of unformed
bowel contents around the impacted stool in
the rectum. Clients with fecal impaction don't
pass hard, brown, formed stools because the
feces can't move past the impaction. These
clients typically report the urge to defecate
(although they can't pass stool) and a
decreased appetite.
Answer: (C) Pulling the helix up and back
16.
17.
18.
19.
20.
21.
22.
23.
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Rationale: To perform an otoscopic
examination on an adult, the nurse grasps the
helix of the ear and pulls it up and back to
straighten the ear canal. For a child, the nurse
grasps the helix and pulls it down to straighten
the ear canal. Pulling the lobule in any
direction wouldn't straighten the ear canal for
visualization.
Answer: (A) Protect the irritated skin from
sunlight.
Rationale: Irradiated skin is very sensitive and
must be protected with clothing or sunblock.
The priority approach is the avoidance of
strong sunlight.
Answer: (C) Assist the client in removing
dentures and nail polish.
Rationale: Dentures, hairpins, and combs must
be removed. Nail polish must be removed so
that cyanosis can be easily monitored by
observing the nail beds.
Answer: (D) Sudden onset of continuous
epigastric and back pain.
Rationale: The autodigestion of tissue by the
pancreatic enzymes results in pain from
inflammation, edema, and possible
hemorrhage. Continuous, unrelieved epigastric
or back pain reflects the inflammatory process
in the pancreas.
Answer: (B) Provide high-protein, highcarbohydrate diet.
Rationale: A positive nitrogen balance is
important for meeting metabolic needs, tissue
repair, and resistance to infection. Caloric
goals may be as high as 5000 calories per day.
Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to
recognize the signs of an anaphylactic or
hemolytic reaction to the transfusion.
Answer: (D) Immobilize the leg before moving
the client.
Rationale: If the nurse suspects a fracture,
splinting the area before moving the client is
imperative. The nurse should call for
emergency help if the client is not hospitalized
and call for a physician for the hospitalized
client.
Answer: (B) Admit the client into a private
room.
Rationale: The client who has a radiation
implant is placed in a private room and has a
limited number of visitors. This reduces the
exposure of others to the radiation.
Answer: (C) Risk for infection
24.
25.
26.
27.
28.
29.
30.
31.
32.
Rationale: Agranulocytosis is characterized by
a reduced number of leukocytes (leucopenia)
and neutrophils (neutropenia) in the blood.
The client is at high risk for infection because
of the decreased body defenses against
microorganisms. Deficient knowledge related
to the nature of the disorder may be
appropriate diagnosis but is not the priority.
Answer: (B) Place the client on the left side in
the Trendelenburg position.
Rationale: Lying on the left side may prevent
air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic
pressure, which decreases the amount of
blood pulled into the vena cava during
aspiration.
Answer: (A) Autocratic.
Rationale: The autocratic style of leadership is
a task-oriented and directive.
Answer: (D) 2.5 cc
Rationale: 2.5 cc is to be added, because only a
500 cc bag of solution is being medicated
instead of a 1 liter.
Answer: (A) 50 cc/ hour
Rationale: A rate of 50 cc/hr. The child is to
receive 400 cc over a period of 8 hours = 50
cc/hr.
Answer: (B) Assess the client for presence of
pain.
Rationale: Assessing the client for pain is a
very important measure. Postoperative pain is
an indication of complication. The nurse
should also assess the client for pain to
provide for the client’s comfort.
Answer: (A) BP – 80/60, Pulse – 110 irregular
Rationale: The classic signs of cardiogenic
shock are low blood pressure, rapid and weak
irregular pulse, cold, clammy skin, decreased
urinary output, and cerebral hypoxia.
Answer: (A) Take the proper equipment, place
the client in a comfortable position, and
record the appropriate information in the
client’s chart.
Rationale: It is a general or comprehensive
statement about the correct procedure, and it
includes the basic ideas which are found in the
other options
Answer: (B) Evaluation
Rationale: Evaluation includes observing the
person, asking questions, and comparing the
patient’s behavioral responses with the
expected outcomes.
Answer: (C) History of present illness
267
33.
34.
35.
36.
37.
38.
39.
40.
Rationale: The history of present illness is the
single most important factor in assisting the
health professional in arriving at a diagnosis or
determining the person’s needs.
Answer: (A) Trochanter roll extending from the
crest of the ileum to the mid-thigh.
Rationale: A trochanter roll, properly placed,
provides resistance to the external rotation of
the hip.
Answer: (C) Stage III
Rationale: Clinically, a deep crater or without
undermining of adjacent tissue is noted.
Answer: (A) Second intention healing
Rationale: When wounds dehisce, they will
allowed to heal by secondary Intention
Answer: (D) Tachycardia
Rationale: With an extracellular fluid or plasma
volume deficit, compensatory mechanisms
stimulate the heart, causing an increase in
heart rate.
Answer: (A) 0.75
Rationale: To determine the number of
milliliters the client should receive, the nurse
uses the fraction method in the following
equation.
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg
75 = 100X
75/100 = X
0.75 ml (or ¾ ml) = X
Answer: (D) it’s a measure of effect, not a
standard measure of weight or quantity.
Rationale: An insulin unit is a measure of
effect, not a standard measure of weight or
quantity. Different drugs measured in units
may have no relationship to one another in
quality or quantity.
Answer: (B) 38.9 °C
Rationale: To convert Fahrenheit degreed to
Centigrade, use this formula
°C = (°F – 32) ÷ 1.8
°C = (102 – 32) ÷ 1.8
°C = 70 ÷ 1.8
°C = 38.9
Answer: (C) Failing eyesight, especially close
vision.
Rationale: Failing eyesight, especially close
vision, is one of the first signs of aging in
middle life (ages 46 to 64). More frequent
aches and pains begin in the early late years
(ages 65 to 79). Increase in loss of muscle tone
occurs in later years (age 80 and older).
41.
42.
43.
44.
45.
46.
Answer: (A) Checking and taping all
connections
Rationale: Air leaks commonly occur if the
system isn’t secure. Checking all connections
and taping them will prevent air leaks. The
chest drainage system is kept lower to
promote drainage – not to prevent leaks.
Answer: (A) Check the client’s identification
band.
Rationale: Checking the client’s identification
band is the safest way to verify a client’s
identity because the band is assigned on
admission and isn’t be removed at any time. (If
it is removed, it must be replaced). Asking the
client’s name or having the client repeated his
name would be appropriate only for a client
who’s alert, oriented, and able to understand
what is being said, but isn’t the safe standard
of practice. Names on bed aren’t always
reliable
Answer: (B) 32 drops/minute
Rationale: Giving 1,000 ml over 8 hours is the
same as giving 125 ml over 1 hour (60
minutes). Find the number of milliliters per
minute as follows:
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/ 15 gtt
X = 32 gtt/minute, or 32 drops/minute
Answer: (A) Clamp the catheter
Rationale: If a central venous catheter
becomes disconnected, the nurse should
immediately apply a catheter clamp, if
available. If a clamp isn’t available, the nurse
can place a sterile syringe or catheter plug in
the catheter hub. After cleaning the hub with
alcohol or povidone-iodine solution, the nurse
must replace the I.V. extension and restart the
infusion.
Answer: (D) Auscultation, percussion, and
palpation.
Rationale: The correct order of assessment for
examining the abdomen is inspection,
auscultation, percussion, and palpation. The
reason for this approach is that the less
intrusive techniques should be performed
before the more intrusive techniques.
Percussion and palpation can alter natural
findings during auscultation.
Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or
ball, of the hand to assess tactile fremitus,
47.
48.
49.
50.
51.
52.
268
thrills, and vocal vibrations through the chest
wall. The fingertips and finger pads best
distinguish texture and shape. The dorsal
surface best feels warmth.
Answer: (C) Formative
Rationale: Formative (or concurrent)
evaluation occurs continuously throughout the
teaching and learning process. One benefit is
that the nurse can adjust teaching strategies
as necessary to enhance learning. Summative,
or retrospective, evaluation occurs at the
conclusion of the teaching and learning
session. Informative is not a type of
evaluation.
Answer: (B) Once per year
Rationale: Yearly mammograms should begin
at age 40 and continue for as long as the
woman is in good health. If health risks, such
as family history, genetic tendency, or past
breast cancer, exist, more frequent
examinations may be necessary.
Answer: (A) Respiratory acidosis
Rationale: The client has a below-normal
(acidic) blood pH value and an above-normal
partial pressure of arterial carbon dioxide
(Paco2) value, indicating respiratory acidosis.
In respiratory alkalosis, the pH value is above
normal and in the Paco2 value is below
normal. In metabolic acidosis, the pH and
bicarbonate (Hco3) values are below normal.
In metabolic alkalosis, the pH and Hco3 values
are above normal.
Answer: (B) To provide support for the client
and family in coping with terminal illness.
Rationale: Hospices provide supportive care
for terminally ill clients and their families.
Hospice care doesn’t focus on counseling
regarding health care costs. Most client
referred to hospices have been treated for
their disease without success and will receive
only palliative care in the hospice.
Answer: (C) Using normal saline solution to
clean the ulcer and applying a protective
dressing as necessary.
Rationale: Washing the area with normal
saline solution and applying a protective
dressing are within the nurse’s realm of
interventions and will protect the area. Using a
povidone-iodine wash and an antibiotic cream
require a physician’s order. Massaging with an
astringent can further damage the skin.
Answer: (D) Foot
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Rationale: An elastic bandage should be
applied form the distal area to the proximal
area. This method promotes venous return. In
this case, the nurse should begin applying the
bandage at the client’s foot. Beginning at the
ankle, lower thigh, or knee does not promote
venous return.
Answer: (B) Hypokalemia
Rationale: Insulin administration causes
glucose and potassium to move into the cells,
causing hypokalemia.
Answer: (A) Throbbing headache or dizziness
Rationale: Headache and dizziness often occur
when nitroglycerin is taken at the beginning of
therapy. However, the client usually develops
tolerance
Answer: (D) Check the client’s level of
consciousness
Rationale: Determining unresponsiveness is
the first step assessment action to take. When
a client is in ventricular tachycardia, there is a
significant decrease in cardiac output.
However, checking the unresponsiveness
ensures whether the client is affected by the
decreased cardiac output.
Answer: (B) On the affected side of the client.
Rationale: When walking with clients, the
nurse should stand on the affected side and
grasp the security belt in the midspine area of
the small of the back. The nurse should
position the free hand at the shoulder area so
that the client can be pulled toward the nurse
in the event that there is a forward fall. The
client is instructed to look up and outward
rather than at his or her feet.
Answer: (A) Urine output: 45 ml/hr
Rationale: Adequate perfusion must be
maintained to all vital organs in order for the
client to remain visible as an organ donor. A
urine output of 45 ml per hour indicates
adequate renal perfusion. Low blood pressure
and delayed capillary refill time are circulatory
system indicators of inadequate perfusion. A
serum pH of 7.32 is acidotic, which adversely
affects all body tissues.
Answer: (D ) Obtaining the specimen from the
urinary drainage bag.
Rationale: A urine specimen is not taken from
the urinary drainage bag. Urine undergoes
chemical changes while sitting in the bag and
does not necessarily reflect the current client
status. In addition, it may become
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contaminated with bacteria from opening the
system.
Answer: (B) Cover the client, place the call
light within reach, and answer the phone call.
Rationale: Because telephone call is an
emergency, the nurse may need to answer it.
The other appropriate action is to ask another
nurse to accept the call. However, is not one of
the options. To maintain privacy and safety,
the nurse covers the client and places the call
light within the client’s reach. Additionally, the
client’s door should be closed or the room
curtains pulled around the bathing area.
Answer: (C) Use a sterile plastic container for
obtaining the specimen.
Rationale: Sputum specimens for culture and
sensitivity testing need to be obtained using
sterile techniques because the test is done to
determine the presence of organisms. If the
procedure for obtaining the specimen is not
sterile, then the specimen is not sterile, then
the specimen would be contaminated and the
results of the test would be invalid.
Answer: (A) Puts all the four points of the
walker flat on the floor, puts weight on the
hand pieces, and then walks into it.
Rationale: When the client uses a walker, the
nurse stands adjacent to the affected side. The
client is instructed to put all four points of the
walker 2 feet forward flat on the floor before
putting weight on hand pieces. This will ensure
client safety and prevent stress cracks in the
walker. The client is then instructed to move
the walker forward and walk into it.
Answer: (C) Draws one line to cross out the
incorrect information and then initials the
change.
Rationale: To correct an error documented in a
medical record, the nurse draws one line
through the incorrect information and then
initials the error. An error is never erased and
correction fluid is never used in the medical
record.
Answer: (C) Secures the client safety belts
after transferring to the stretcher.
Rationale: During the transfer of the client
after the surgical procedure is complete, the
nurse should avoid exposure of the client
because of the risk for potential heat loss.
Hurried movements and rapid changes in the
position should be avoided because these
predispose the client to hypotension. At the
time of the transfer from the surgery table to
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the stretcher, the client is still affected by the
effects of the anesthesia; therefore, the client
should not move self. Safety belts can prevent
the client from falling off the stretcher.
Answer: (B) Gown and gloves
Rationale: Contact precautions require the use
of gloves and a gown if direct client contact is
anticipated. Goggles are not necessary unless
the nurse anticipates the splashes of blood,
body fluids, secretions, or excretions may
occur. Shoe protectors are not necessary.
Answer: (C) Quad cane
Rationale: Crutches and a walker can be
difficult to maneuver for a client with
weakness on one side. A cane is better suited
for client with weakness of the arm and leg on
one side. However, the quad cane would
provide the most stability because of the
structure of the cane and because a quad cane
has four legs.
Answer: (D) Left side-lying with the head of
the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from
the chest wall, the client is positioned sitting at
the edge of the bed leaning over the bedside
table with the feet supported on a stool. If the
client is unable to sit up, the client is
positioned lying in bed on the unaffected side
with the head of the bed elevated 30 to 45
degrees.
Answer: (D) Reliability
Rationale: Reliability is consistency of the
research instrument. It refers to the
repeatability of the instrument in extracting
the same responses upon its repeated
administration.
Answer: (A) Keep the identities of the subject
secret
Rationale: Keeping the identities of the
research subject secret will ensure anonymity
because this will hinder providing link between
the information given to whoever is its source.
Answer: (A) Descriptive- correlational
Rationale: Descriptive- correlational study is
the most appropriate for this study because it
studies the variables that could be the
antecedents of the increased incidence of
nosocomial infection.
Answer: (C) Use of laboratory data
Rationale: Incidence of nosocomial infection is
best collected through the use of
biophysiologic measures, particularly in vitro
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measurements, hence laboratory data is
essential.
Answer: (B) Quasi-experiment
Rationale: Quasi-experiment is done when
randomization and control of the variables are
not possible.
Answer: (C) Primary source
Rationale: This refers to a primary source
which is a direct account of the investigation
done by the investigator. In contrast to this is a
secondary source, which is written by
someone other than the original researcher.
Answer: (A) Non-maleficence
Rationale: Non-maleficence means do not
cause harm or do any action that will cause
any harm to the patient/client. To do good is
referred as beneficence.
Answer: (C) Res ipsa loquitor
Rationale: Res ipsa loquitor literally means the
thing speaks for itself. This means in
operational terms that the injury caused is the
proof that there was a negligent act.
Answer: (B) The Board can investigate
violations of the nursing law and code of ethics
Rationale: Quasi-judicial power means that the
Board of Nursing has the authority to
investigate violations of the nursing law and
can issue summons, subpoena or subpoena
duces tecum as needed.
Answer: (C) May apply for re-issuance of
his/her license based on certain conditions
stipulated in RA 9173
Rationale: RA 9173 sec. 24 states that for
equity and justice, a revoked license maybe reissued provided that the following conditions
are met: a) the cause for revocation of license
has already been corrected or removed; and,
b) at least four years has elapsed since the
license has been revoked.
Answer: (B) Review related literature
Rationale: After formulating and delimiting the
research problem, the researcher conducts a
review of related literature to determine the
extent of what has been done on the study by
previous researchers.
Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the
study of Elton Mayo and company about the
effect of an intervention done to improve the
working conditions of the workers on their
productivity. It resulted to an increased
productivity but not due to the intervention
but due to the psychological effects of being
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observed. They performed differently because
they were under observation.
Answer: (B) Determines the different
nationality of patients frequently admitted and
decides to get representations samples from
each.
Rationale: Judgment sampling involves
including samples according to the knowledge
of the investigator about the participants in
the study.
Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the
theory on transcultural theory based on her
observations on the behavior of selected
people within a culture.
Answer: (A) Random
Rationale: Random sampling gives equal
chance for all the elements in the population
to be picked as part of the sample.
Answer: (A) Degree of agreement and
disagreement
Rationale: Likert scale is a 5-point summated
scale used to determine the degree of
agreement or disagreement of the
respondents to a statement in a study
Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the
Adaptation Model which involves the
physiologic mode, self-concept mode, role
function mode and dependence mode.
Answer: (A) Span of control
Rationale: Span of control refers to the
number of workers who report directly to a
manager.
Answer: (B) Autonomy
Rationale: Informed consent means that the
patient fully understands about the surgery,
including the risks involved and the alternative
solutions. In giving consent it is done with full
knowledge and is given freely. The action of
allowing the patient to decide whether a
surgery is to be done or not exemplifies the
bioethical principle of autonomy.
Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to
avoid wearing canvas shoes. Canvas shoes
cause the feet to perspire, which may, in turn,
cause skin irritation and breakdown. Both
cotton and cornstarch absorb perspiration.
The client should be instructed to cut toenails
straight across with nail clippers.
Answer: (D) Ground beef patties
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Rationale: Meat is an excellent source of
complete protein, which this client needs to
repair the tissue breakdown caused by
pressure ulcers. Oranges and broccoli supply
vitamin C but not protein. Ice cream supplies
only some incomplete protein, making it less
helpful in tissue repair.
Answer: (D) Sims’ left lateral
Rationale: The Sims' left lateral position is the
most common position used to administer a
cleansing enema because it allows gravity to
aid the flow of fluid along the curve of the
sigmoid colon. If the client can't assume this
position nor has poor sphincter control, the
dorsal recumbent or right lateral position may
be used. The supine and prone positions are
inappropriate and uncomfortable for the
client.
Answer: (A) Arrange for typing and cross
matching of the client’s blood.
Rationale: The nurse first arranges for typing
and cross matching of the client's blood to
ensure compatibility with donor blood. The
other options, although appropriate when
preparing to administer a blood transfusion,
come later.
Answer: (A) Independent
Rationale: Nursing interventions are classified
as independent, interdependent, or
dependent. Altering the drug schedule to
coincide with the client's daily routine
represents an independent intervention,
whereas consulting with the physician and
pharmacist to change a client's medication
because of adverse reactions represents an
interdependent intervention. Administering an
already-prescribed drug on time is a
dependent intervention. An intradependent
nursing intervention doesn't exist.
Answer: (D) Evaluation
Rationale: The nursing actions described
constitute evaluation of the expected
outcomes. The findings show that the
expected outcomes have been achieved.
Assessment consists of the client's history,
physical examination, and laboratory studies.
Analysis consists of considering assessment
information to derive the appropriate nursing
diagnosis. Implementation is the phase of the
nursing process where the nurse puts the plan
of care into action.
Answer: (B) To observe the lower extremities
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Rationale: Elastic stockings are used to
promote venous return. The nurse needs to
remove them once per day to observe the
condition of the skin underneath the stockings.
Applying the stockings increases blood flow to
the heart. When the stockings are in place, the
leg muscles can still stretch and relax, and the
veins can fill with blood.
Answer :(A) Instructing the client to report any
itching, swelling, or dyspnea.
Rationale: Because administration of blood or
blood products may cause serious adverse
effects such as allergic reactions, the nurse
must monitor the client for these effects. Signs
and symptoms of life-threatening allergic
reactions include itching, swelling, and
dyspnea. Although the nurse should inform
the client of the duration of the transfusion
and should document its administration, these
actions are less critical to the client's
immediate health. The nurse should assess
vital signs at least hourly during the
transfusion.
Answer: (B) Decrease the rate of feedings and
the concentration of the formula.
Rationale: Complaints of abdominal
discomfort and nausea are common in clients
receiving tube feedings. Decreasing the rate of
the feeding and the concentration of the
formula should decrease the client's
discomfort. Feedings are normally given at
room temperature to minimize abdominal
cramping. To prevent aspiration during
feeding, the head of the client's bed should be
elevated at least 30 degrees. Also, to prevent
bacterial growth, feeding containers should be
routinely changed every 8 to 12 hours.
Answer: (D) Roll the vial gently between the
palms.
Rationale: Rolling the vial gently between the
palms produces heat, which helps dissolve the
medication. Doing nothing or inverting the vial
wouldn't help dissolve the medication. Shaking
the vial vigorously could cause the medication
to break down, altering its action.
Answer: (B) Assist the client to the semiFowler position if possible.
Rationale: By assisting the client to the semiFowler position, the nurse promotes easier
chest expansion, breathing, and oxygen intake.
The nurse should secure the elastic band so
that the face mask fits comfortably and snugly
rather than tightly, which could lead to
irritation. The nurse should apply the face
mask from the client's nose down to the chin
— not vice versa. The nurse should check the
connectors between the oxygen equipment
and humidifier to ensure that they're airtight;
loosened connectors can cause loss of oxygen.
97. Answer: (B) 4 hours
Rationale: A unit of packed RBCs may be given
over a period of between 1 and 4 hours. It
shouldn't infuse for longer than 4 hours
because the risk of contamination and sepsis
increases after that time. Discard or return to
the blood bank any blood not given within this
time, according to facility policy.
98. Answer: (B) Immediately before administering
the next dose.
Rationale: Measuring the blood drug
concentration helps determine whether the
dosing has achieved the therapeutic goal. For
measurement of the trough, or lowest, blood
level of a drug, the nurse draws a blood
sample immediately before administering the
next dose. Depending on the drug's duration
of action and half-life, peak blood drug levels
typically are drawn after administering the
next dose.
99. Answer: (A) The nurse can implement
medication orders quickly.
Rationale: A floor stock system enables the
nurse to implement medication orders quickly.
It doesn't allow for pharmacist input, nor does
it minimize transcription errors or reinforce
accurate calculations.
100. Answer: (C) Shifting dullness over the
abdomen.
Rationale: Shifting dullness over the abdomen
indicates ascites, an abnormal finding. The
other options are normal abdominal findings.
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273
TEST II - Community Health Nursing and Care of
the Mother and Child
1. May arrives at the health care clinic and tells the
nurse that her last menstrual period was 9
weeks ago. She also tells the nurse that a home
pregnancy test was positive but she began to
have mild cramps and is now having moderate
vaginal bleeding. During the physical
examination of the client, the nurse notes that
May has a dilated cervix. The nurse determines
that May is experiencing which type of abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic
2. Nurse Reese is reviewing the record of a
pregnant client for her first prenatal visit. Which
of the following data, if noted on the client’s
record, would alert the nurse that the client is at
risk for a spontaneous abortion?
a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who
is newly admitted to the hospital with a possible
diagnosis of ectopic pregnancy. Nurse Hazel
develops a plan of care for the client and
determines that which of the following nursing
actions is the priority?
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature
4. Nurse Oliver is teaching a diabetic pregnant
client about nutrition and insulin needs during
pregnancy. The nurse determines that the client
understands dietary and insulin needs if the
client states that the second half of pregnancy
requires:
a. Decreased caloric intake
b. Increased caloric intake
c. Decreased Insulin
d. Increase Insulin
5. Nurse Michelle is assessing a 24 year old client
with a diagnosis of hydatidiform mole. She is
aware that one of the following is unassociated
with this condition?
a. Excessive fetal activity.
b. Larger than normal uterus for
gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic
gonadotropin.
6. A pregnant client is receiving magnesium sulfate
for severe pregnancy induced hypertension
(PIH). The clinical findings that would warrant
use 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 in
labor, the presenting part is at station plus two.
Nurse, correctly interprets it as:
a. Presenting part is 2 cm above the plane
of the ischial spines.
b. Biparietal diameter is at the level of the
ischial spines.
c. Presenting part in 2 cm below the plane
of the ischial spines.
d. Biparietal diameter is 2 cm above the
ischial spines.
8. A pregnant client is receiving oxytocin (Pitocin)
for induction of labor. A condition that warrant
the nurse in-charge to discontinue I.V. infusion
of Pitocin is:
a. Contractions every 1 ½ minutes lasting
70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart
rate.
d. Fetal heart rate baseline 140-160 bpm.
9. Calcium gluconate is being administered to a
client with pregnancy induced hypertension
(PIH). A nursing action that must be initiated as
the plan of care throughout injection of the drug
is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
10. A trial for vaginal delivery after an earlier
caesarean, would likely to be given to a gravida,
who had:
a. First low transverse cesarean was for
active herpes type 2 infections; vaginal
culture at 39 weeks pregnancy was
positive.
b. First and second caesareans were for
cephalopelvic disproportion.
c. First caesarean through a classic incision
as a result of severe fetal distress.
d. First low transverse caesarean was for
breech position. Fetus in this pregnancy
is in a vertex presentation.
11. Nurse Ryan is aware that the best initial
approach when trying to take a crying toddler’s
temperature is:
a. Talk to the mother first and then to the
toddler.
b. Bring extra help so it can be done
quickly.
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 lip
and palate repair. What should the nurse do to
prevent trauma to operative site?
a. Avoid touching the suture line, even
when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow
restraints.
13. Which action should nurse Marian include in the
care 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 administer
medications before feeding.
d. Weigh and bathe the infant before
feeding.
14. Nurse Hazel is teaching a mother who plans to
discontinue breast feeding after 5 months. The
nurse should advise her to include which foods
in 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 is
sitting securely alone on the floor of the clinic.
The mother hides a toy behind her back and the
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infant looks for it. The nurse is aware that
estimated age of the infant would be:
a. 6 months
b. 4 months
c. 8 months
d. 10 months
16. Which of the following is the most prominent
feature of public health nursing?
a. It involves providing home care to sick
people who are not confined in the
hospital.
b. Services are provided free of charge to
people within the catchments area.
c. The public health nurse functions as part
of a team providing a public health
nursing services.
d. Public health nursing focuses on
preventive, not curative, services.
17. When the nurse determines whether resources
were maximized in implementing Ligtas Tigdas,
she is evaluating
a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness
18. Vangie is a new B.S.N. graduate. She wants to
become a Public Health Nurse. Where should
she apply?
a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit
19. Tony is aware the Chairman of the Municipal
Health Board is:
a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician
20. Myra is the public health nurse in a municipality
with a total population of about 20,000. There
are 3 rural health midwives among the RHU
personnel. How many more midwife items will
the RHU need?
a. 1
b. 2
c. 3
d. The RHU does not need any more
midwife item.
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21. According to Freeman and Heinrich, community
health nursing is a developmental service. Which
of the following best illustrates this statement?
a. The community health nurse
continuously develops himself
personally and professionally.
b. Health education and community
organizing are necessary in providing
community health services.
c. Community health nursing is intended
primarily for health promotion and
prevention and treatment of disease.
d. The goal of community health nursing is
to provide nursing services to people in
their own places of residence.
22. Nurse Tina is aware that the disease declared
through Presidential Proclamation No. 4 as a
target for eradication in the Philippines is?
a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus
23. May knows that the step in community
organizing that involves training of potential
leaders in the community is:
a. Integration
b. Community organization
c. Community study
d. Core group formation
24. Beth a public health nurse takes an active role in
community participation. What is the primary
goal of community organizing?
a. To educate the people regarding
community health problems
b. To mobilize the people to resolve
community health problems
c. To maximize the community’s resources
in dealing with health problems.
d. To maximize the community’s resources
in dealing with health problems.
25. Tertiary prevention is needed in which stage of
the natural history of disease?
a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal
26. The nurse is caring for a primigravid client in the
labor and delivery area. Which condition would
place the client at risk for disseminated
intravascular 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 aware
that the fetal heart rate would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute
28. The skin in the diaper area of a 7 month old
infant is excoriated and red. Nurse Hazel should
instruct the mother to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each
diaper change.
d. Decrease the infant’s fluid intake to
decrease saturating diapers.
29. Nurse Carla knows that the common cardiac
anomalies in children with Down Syndrome (trisomy 21) is:
a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect
30. Malou was diagnosed with severe preeclampsia
is now receiving I.V. magnesium sulfate. The
adverse effects associated with magnesium
sulfate is:
a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate
31. A 23 year old client is having her menstrual
period every 2 weeks that last for 1 week. This
type of menstrual pattern is bets defined by:
a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea
32. Jannah is admitted to the labor and delivery
unit. The critical laboratory result for this client
would be:
a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium
33. Nurse Gina is aware that the most common
condition found during the second-trimester of
pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia
34. Nurse Lynette is working in the triage area of an
emergency department. She sees that several
pediatric clients arrive simultaneously. The client
who needs to be treated first is:
a. A crying 5 year old child with a
laceration on his scalp.
b. A 4 year old child with a barking coughs
and flushed appearance.
c. A 3 year old child with Down syndrome
who is pale and asleep in his mother’s
arms.
d. A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s
arms and drooling.
35. Maureen in her third trimester arrives at the
emergency room with painless vaginal bleeding.
Which of the following conditions is suspected?
a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease
36. A young child named Richard is suspected of
having pinworms. The community nurse collects
a stool specimen to confirm the diagnosis. The
nurse should schedule the collection of this
specimen for:
a. Just before bedtime
b. After the child has been bathe
c. Any time during the day
d. Early in the morning
37. In doing a child’s admission assessment, Nurse
Betty should be alert to note which signs or
symptoms of chronic lead poisoning?
a. Irritability and seizures
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b. Dehydration and diarrhea
c. Bradycardia and hypotension
d. Petechiae and hematuria
38. To evaluate a woman’s understanding about the
use of diaphragm for family planning, Nurse
Trish asks her to explain how she will use the
appliance. Which response indicates a need for
further health teaching?
a. “I should check the diaphragm carefully
for holes every time I use it”
b. “I may need a different size of
diaphragm if I gain or lose weight more
than 20 pounds”
c. “The diaphragm must be left in place for
atleast 6 hours after intercourse”
d. “I really need to use the diaphragm and
jelly most during the middle of my
menstrual cycle”.
39. Hypoxia is a common complication of
laryngotracheobronchitis. Nurse Oliver should
frequently assess a child with
laryngotracheobronchitis for:
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever
40. How should Nurse Michelle guide a child who is
blind to walk to the playroom?
a. Without touching the child, talk
continuously as the child walks down the
hall.
b. Walk one step ahead, with the child’s
hand on the nurse’s elbow.
c. Walk slightly behind, gently guiding the
child forward.
d. Walk next to the child, holding the
child’s hand.
41. When assessing a newborn diagnosed with
ductus arteriosus, Nurse Olivia should expect
that the child most likely would have an:
a. Loud, machinery-like murmur.
b. Bluish color to the lips.
c. Decreased BP reading in the upper
extremities
d. Increased BP reading in the upper
extremities.
42. The reason nurse May keeps the neonate in a
neutral thermal environment is that when a
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newborn becomes too cool, the neonate
requires:
a. Less oxygen, and the newborn’s
metabolic rate increases.
b. More oxygen, and the newborn’s
metabolic rate decreases.
c. More oxygen, and the newborn’s
metabolic rate increases.
d. Less oxygen, and the newborn’s
metabolic rate decreases.
43. Before adding potassium to an infant’s I.V. line,
Nurse Ron must be sure to assess whether this
infant has:
a. Stable blood pressure
b. Patant fontanelles
c. Moro’s reflex
d. Voided
44. Nurse Carla should know that the most common
causative factor of dermatitis in infants and
younger children is:
a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch
45. During tube feeding, how far above an infant’s
stomach should the nurse hold the syringe with
formula?
a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches
46. In a mothers’ class, Nurse Lhynnete discussed
childhood diseases such as chicken pox. Which
of the following statements about chicken pox is
correct?
a. The older one gets, the more susceptible
he becomes to the complications of
chicken pox.
b. A single attack of chicken pox will
prevent future episodes, including
conditions such as shingles.
c. To prevent an outbreak in the
community, quarantine may be imposed
by health authorities.
d. Chicken pox vaccine is best given when
there is an impending outbreak in the
community.
47. Barangay Pinoy had an outbreak of German
measles. To prevent congenital rubella, what is
the BEST advice that you can give to women in
the first trimester of pregnancy in the barangay
Pinoy?
a. Advise them on the signs of German
measles.
b. Avoid crowded places, such as markets
and movie houses.
c. Consult at the health center where
rubella vaccine may be given.
d. Consult a physician who may give them
rubella immunoglobulin.
48. Myrna a public health nurse knows that to
determine possible sources of sexually
transmitted infections, the BEST method that
may be undertaken is:
a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects
49. A 33-year old female client came for
consultation at the health center with the chief
complaint of fever for a week. Accompanying
symptoms were muscle pains and body malaise.
A week after the start of fever, the client noted
yellowish discoloration of his sclera. History
showed that he waded in flood waters about 2
weeks before the onset of symptoms. Based on
her history, which disease condition will you
suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis
50. Mickey a 3-year old client was brought to the
health center with the chief complaint of severe
diarrhea and the passage of “rice water” stools.
The client is most probably suffering from which
condition?
a. Giardiasis
b. Cholera
c. Amebiasis
d. Dysentery
51. The most prevalent form of meningitis among
children aged 2 months to 3 years is caused by
which microorganism?
a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis
52. The student nurse is aware that the
pathognomonic sign of measles is Koplik’s spot
and you may see Koplik’s spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck
53. Angel was diagnosed as having Dengue fever.
You will say that there is slow capillary refill
when the color of the nailbed that you pressed
does not return within how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds
54. In Integrated Management of Childhood Illness,
the nurse is aware that the severe conditions
generally require urgent referral to a hospital.
Which of the following severe conditions DOES
NOT always require urgent referral to a hospital?
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease
55. Myrna a public health nurse will conduct
outreach immunization in a barangay Masay
with a population of about 1500. The estimated
number of infants in the barangay would be:
a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants
56. The community nurse is aware that the
biological used in Expanded Program on
Immunization (EPI) should NOT be stored in the
freezer?
a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR
57. It is the most effective way of controlling
schistosomiasis in an endemic area?
a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
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d. Use of protective footwear, such as
rubber boots
58. Several clients is newly admitted and diagnosed
with leprosy. Which of the following clients
should be classified as a case of multibacillary
leprosy?
a. 3 skin lesions, negative slit skin smear
b. 3 skin lesions, positive slit skin smear
c. 5 skin lesions, negative slit skin smear
d. 5 skin lesions, positive slit skin smear
59. Nurses are aware that diagnosis of leprosy is
highly dependent on recognition of symptoms.
Which of the following is an early sign of
leprosy?
a. Macular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge
60. Marie brought her 10 month old infant for
consultation because of fever, started 4 days
prior to consultation. In determining malaria
risk, 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 the
RHU because of cough and colds. Following the
IMCI assessment guide, which of the following is
a danger sign that indicates the need for urgent
referral to a hospital?
a. Inability to drink
b. High grade fever
c. Signs of severe dehydration
d. Cough for more than 30 days
62. Jimmy a 2-year old child revealed “baggy pants”.
As a nurse, using the IMCI guidelines, how will
you manage Jimmy?
a. Refer the child urgently to a hospital for
confinement.
b. Coordinate with the social worker to
enroll 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 health
problems like infections and intestinal
parasitism.
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63. Gina is using Oresol in the management of
diarrhea of her 3-year old child. She asked you
what to do if her child vomits. As a nurse you will
tell her to:
a. Bring the child to the nearest hospital
for further assessment.
b. Bring the child to the health center for
intravenous fluid therapy.
c. Bring the child to the health center for
assessment by the physician.
d. Let the child rest for 10 minutes then
continue giving Oresol more slowly.
64. Nikki a 5-month old infant was brought by his
mother to the health center because of diarrhea
for 4 to 5 times a day. Her skin goes back slowly
after a skin pinch and her eyes are sunken. Using
the IMCI guidelines, you will classify this infant in
which category?
a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.
65. Chris a 4-month old infant was brought by her
mother to the health center because of cough.
His respiratory rate is 42/minute. Using the
Integrated Management of Child Illness (IMCI)
guidelines of assessment, his breathing is
considered as:
a. Fast
b. Slow
c. Normal
d. Insignificant
66. Maylene had just received her 4th dose of
tetanus toxoid. She is aware that her baby will
have protection against tetanus for
a. 1 year
b. 3 years
c. 5 years
d. Lifetime
67. Nurse Ron is aware that unused BCG should be
discarded after how many hours of
reconstitution?
a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day
68. The nurse explains to a breastfeeding mother
that breast milk is sufficient for all of the baby’s
nutrient needs only up to:
a. 5 months
b. 6 months
c. 1 year
d. 2 years
69. Nurse Ron is aware that the gestational age of a
conceptus that is considered viable (able to live
outside the womb) is:
a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks
70. When teaching parents of a neonate the proper
position for the neonate’s sleep, the nurse
Patricia stresses the importance of placing the
neonate on his back to reduce the risk of which
of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
71. Which finding might be seen in baby James a
neonate suspected of having an infection?
a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level
72. Baby Jenny who is small-for-gestation is at
increased risk during the transitional period for
which complication?
a. Anemia probably due to chronic fetal
hyposia
b. Hyperthermia due to decreased
glycogen stores
c. Hyperglycemia due to decreased
glycogen stores
d. Polycythemia probably due to chronic
fetal hypoxia
73. Marjorie has just given birth at 42 weeks’
gestation. When the nurse assessing the
neonate, which physical finding is expected?
a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body
74. After reviewing the Myrna’s maternal history of
magnesium sulfate during labor, which condition
would nurse Richard anticipate as a potential
problem in the neonate?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia
75. Which symptom would indicate the Baby
Alexandra was adapting appropriately to extrauterine life without difficulty?
a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60
breaths/minute
d. Respiratory rate 60 to 80
breaths/minute
76. When teaching umbilical cord care for Jennifer a
new mother, the nurse Jenny would include
which information?
a. Apply peroxide to the cord with each
diaper change
b. Cover the cord with petroleum jelly after
bathing
c. Keep the cord dry and open to air
d. Wash the cord with soap and water each
day during a tub bath.
77. Nurse John is performing an assessment on a
neonate. Which of the following findings is
considered common in the healthy neonate?
a. Simian crease
b. Conjunctival hemorrhage
c. Cystic hygroma
d. Bulging fontanelle
78. Dr. Esteves decides to artificially rupture the
membranes of a mother who is on labor.
Following this procedure, the nurse Hazel checks
the fetal heart tones for which the following
reasons?
a. To determine fetal well-being.
b. To assess for prolapsed cord
c. To assess fetal position
d. To prepare for an imminent delivery.
79. Which of the following would be least likely to
indicate anticipated bonding behaviors by new
parents?
a. The parents’ willingness to touch and
hold the new born.
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b. The parent’s expression of interest
about the size of the new born.
c. The parents’ indication that they want to
see the newborn.
d. The parents’ interactions with each
other.
80. Following a precipitous delivery, examination of
the client's vagina reveals a fourth-degree
laceration. Which of the following would be
contraindicated when caring for this client?
a. Applying cold to limit edema during the
first 12 to 24 hours.
b. Instructing the client to use two or more
peripads to cushion the area.
c. Instructing the client on the use of sitz
baths if ordered.
d. Instructing the client about the
importance of perineal (kegel) exercises.
81. A pregnant woman accompanied by her
husband, seeks admission to the labor and
delivery area. She states that she's in labor and
says she attended the facility clinic for prenatal
care. Which question should the nurse Oliver ask
her 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 ordered
d. Aspirate the neonate’s nose and mouth
with a bulb syringe.
83. When a client states that her "water broke,"
which of the following actions would be
inappropriate for the nurse to do?
a. Observing the pooling of straw-colored
fluid.
b. Checking vaginal discharge with nitrazine
paper.
c. Conducting a bedside ultrasound for an
amniotic fluid index.
d. Observing for flakes of vernix in the
vaginal discharge.
84. A baby girl is born 8 weeks premature. At birth,
she has no spontaneous respirations but is
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successfully resuscitated. Within several hours
she develops respiratory grunting, cyanosis,
tachypnea, nasal flaring, and retractions. She's
diagnosed with respiratory distress syndrome,
intubated, and placed on a ventilator. Which
nursing action should be included in the baby's
plan of care to prevent retinopathy of
prematurity?
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 newborn
calorie intake?
a. 110 to 130 calories per kg.
b. 30 to 40 calories per lb of body weight.
c. At least 2 ml per feeding
d. 90 to 100 calories per kg
86. Nurse John is knowledgeable that usually
individual twins will grow appropriately and at
the same rate as singletons until how many
weeks?
a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks
87. Which of the following classifications applies to
monozygotic twins for whom the cleavage of the
fertilized ovum occurs more than 13 days after
fertilization?
a. conjoined twins
b. diamniotic dichorionic twins
c. diamniotic monochorionic twin
d. monoamniotic monochorionic twins
88. Tyra experienced painless vaginal bleeding has
just been diagnosed as having a placenta previa.
Which of the following procedures is usually
performed to diagnose placenta previa?
a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound
89. Nurse Arnold knows that the following changes
in respiratory functioning during pregnancy is
considered normal:
a. Increased tidal volume
b. Increased expiratory volume
c. Decreased inspiratory capacity
d. Decreased oxygen consumption
90. Emily has gestational diabetes and it is usually
managed by which of the following therapy?
a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin
91. Magnesium sulfate is given to Jemma with
preeclampsia to prevent which of the following
condition?
a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure
92. Cammile with sickle cell anemia has an increased
risk for having a sickle cell crisis during
pregnancy. Aggressive management of a sickle
cell crisis includes which of the following
measures?
a. Antihypertensive agents
b. Diuretic agents
c. I.V. fluids
d. Acetaminophen (Tylenol) for pain
93. Which of the following drugs is the antidote for
magnesium toxicity?
a. Calcium gluconate (Kalcinate)
b. Hydralazine (Apresoline)
c. Naloxone (Narcan)
d. Rho (D) immune globulin (RhoGAM)
94. Marlyn is screened for tuberculosis during her
first prenatal visit. An intradermal injection of
purified protein derivative (PPD) of the
tuberculin bacilli is given. She is considered to
have a positive test for which of the following
results?
a. An indurated wheal under 10 mm in
diameter appears in 6 to 12 hours.
b. An indurated wheal over 10 mm in
diameter appears in 48 to 72 hours.
c. A flat circumcised area under 10 mm in
diameter appears in 6 to 12 hours.
d. A flat circumcised area over 10 mm in
diameter appears in 48 to 72 hours.
95. Dianne, 24 year-old is 27 weeks’ pregnant
arrives at her physician’s office with complaints
of fever, nausea, vomiting, malaise, unilateral
flank pain, and costovertebral angle tenderness.
Which of the following diagnoses is most likely?
a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)
96. Rh isoimmunization in a pregnant client
develops during which of the following
conditions?
a. Rh-positive maternal blood crosses into
fetal blood, stimulating fetal antibodies.
b. Rh-positive fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
c. Rh-negative fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
d. Rh-negative maternal blood crosses into
fetal blood, stimulating fetal antibodies.
97. To promote comfort during labor, the nurse John
advises a client to assume certain positions and
avoid others. Which position may cause
maternal hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
d. Standing position
98. Celeste who used heroin during her pregnancy
delivers a neonate. When assessing the neonate,
the nurse Lhynnette expects to find:
a. Lethargy 2 days after birth.
b. Irritability and poor sucking.
c. A flattened nose, small eyes, and thin
lips.
d. Congenital defects such as limb
anomalies.
99. The uterus returns to the pelvic cavity in which
of the following time frames?
a. 7th to 9th day postpartum.
b. 2 weeks postpartum.
c. End of 6th week postpartum.
d. When the lochia changes to alba.
100.
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Maureen, a primigravida client, age 20, has
just completed a difficult, forceps-assisted
delivery of twins. Her labor was unusually
long and required oxytocin (Pitocin)
augmentation. The nurse who's caring for her
should stay alert for:
a.
b.
c.
d.
Uterine inversion
Uterine atony
Uterine involution
Uterine discomfort
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Answers and Rationale – Community Health
Nursing and Care of the Mother and Child
9.
1. Answer: (A) Inevitable
Rationale: An inevitable abortion is termination
of pregnancy that cannot be prevented.
Moderate to severe bleeding with mild
cramping and cervical dilation would be noted
in this type of abortion.
2. Answer: (B) History of syphilis
Rationale: Maternal infections such as syphilis,
toxoplasmosis, and rubella are causes of
spontaneous abortion.
3. Answer: (C) Monitoring apical pulse
Rationale: Nursing care for the client with a
possible ectopic pregnancy is focused on
preventing or identifying hypovolemic shock
and controlling pain. An elevated pulse rate is
an indicator of shock.
4. Answer: (B) Increased caloric intake
Rationale: Glucose crosses the placenta, but
insulin does not. High fetal demands for
glucose, combined with the insulin resistance
caused by hormonal changes in the last half of
pregnancy can result in elevation of maternal
blood glucose levels. This increases the
mother’s demand for insulin and is referred to
as the diabetogenic effect of pregnancy.
5. Answer: (A) Excessive fetal activity.
Rationale: The most common signs and
symptoms of hydatidiform mole includes
elevated levels of human chorionic
gonadotropin, vaginal bleeding, larger than
normal uterus for gestational age, failure to
detect fetal heart activity even with sensitive
instruments, excessive nausea and vomiting,
and early development of pregnancy-induced
hypertension. Fetal activity would not be noted.
6. Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an
indicator of hypermagnesemia, which requires
administration of calcium gluconate.
7. Answer: (C) Presenting part in 2 cm below the
plane of the ischial spines.
Rationale: Fetus at station plus two indicates
that the presenting part is 2 cm below the
plane of the ischial spines.
8. Answer: (A) Contractions every 1 ½ minutes
lasting 70-80 seconds.
Rationale: Contractions every 1 ½ minutes
lasting 70-80 seconds, is indicative of
hyperstimulation of the uterus, which could
10.
11.
12.
13.
14.
15.
result in injury to the mother and the fetus if
Pitocin is not discontinued.
Answer: (C) EKG tracings
Rationale: A potential side effect of calcium
gluconate administration is cardiac arrest.
Continuous monitoring of cardiac activity (EKG)
throught administration of calcium gluconate is
an essential part of care.
Answer: (D) First low transverse caesarean was
for breech position. Fetus in this pregnancy is in
a vertex presentation.
Rationale: This type of client has no obstetrical
indication for a caesarean section as she did
with her first caesarean delivery.
Answer: (A) Talk to the mother first and then to
the toddler.
Rationale: When dealing with a crying toddler,
the best approach is to talk to the mother and
ignore the toddler first. This approach helps the
toddler get used to the nurse before she
attempts any procedures. It also gives the
toddler an opportunity to see that the mother
trusts the nurse.
Answer: (D) Place the infant’s arms in soft
elbow restraints.
Rationale: Soft restraints from the upper arm to
the wrist prevent the infant from touching her
lip but allow him to hold a favorite item such as
a blanket. Because they could damage the
operative site, such as objects as pacifiers,
suction catheters, and small spoons shouldn’t
be placed in a baby’s mouth after cleft repair. A
baby in a prone position may rub her face on
the sheets and traumatize the operative site.
The suture line should be cleaned gently to
prevent infection, which could interfere with
healing and damage the cosmetic appearance
of the repair.
Answer: (B) Allow the infant to rest before
feeding.
Rationale: Because feeding requires so much
energy, an infant with heart failure should rest
before feeding.
Answer: (C) Iron-rich formula only.
Rationale: The infants at age 5 months should
receive iron-rich formula and that they
shouldn’t receive solid food, even baby food
until age 6 months.
Answer: (D) 10 months
Rationale: A 10 month old infant can sit alone
and understands object permanence, so he
would look for the hidden toy. At age 4 to 6
months, infants can’t sit securely alone. At age
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
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8 months, infants can sit securely alone but
cannot understand the permanence of objects.
Answer: (D) Public health nursing focuses on
preventive, not curative, services.
Rationale: The catchments area in PHN consists
of a residential community, many of whom are
well individuals who have greater need for
preventive rather than curative services.
Answer: (B) Efficiency
Rationale: Efficiency is determining whether the
goals were attained at the least possible cost.
Answer: (D) Rural Health Unit
Rationale: R.A. 7160 devolved basic health
services to local government units (LGU’s ). The
public health nurse is an employee of the LGU.
Answer: (A) Mayor
Rationale: The local executive serves as the
chairman of the Municipal Health Board.
Answer: (A) 1
Rationale: Each rural health midwife is given a
population assignment of about 5,000.
Answer: (B) Health education and community
organizing are necessary in providing
community health services. Rationale: The
community health nurse develops the health
capability of people through health education
and community organizing activities.
Answer: (B) Measles
Rationale: Presidential Proclamation No. 4 is on
the Ligtas Tigdas Program.
Answer: (D) Core group formation
Rationale: In core group formation, the nurse is
able to transfer the technology of community
organizing to the potential or informal
community leaders through a training program.
Answer: (D) To maximize the community’s
resources in dealing with health problems.
Rationale: Community organizing is a
developmental service, with the goal of
developing the people’s self-reliance in dealing
with community health problems. A, B and C
are objectives of contributory objectives to this
goal.
Answer: (D) Terminal
Rationale: Tertiary prevention involves
rehabilitation, prevention of permanent
disability and disability limitations appropriate
for convalescents, the disabled, complicated
cases and the terminally ill (those in the
terminal stage of a disease).
Answer: (A) Intrauterine fetal death.
Rationale: Intrauterine fetal death, abruptio
placentae, septic shock, and amniotic fluid
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
embolism may trigger normal clotting
mechanisms; if clotting factors are depleted,
DIC may occur. Placenta accreta, dysfunctional
labor, and premature rupture of the
membranes aren't associated with DIC.
Answer: (C) 120 to 160 beats/minute
Rationale: A rate of 120 to 160 beats/minute in
the fetal heart appropriate for filling the heart
with blood and pumping it out to the system.
Answer: (A) Change the diaper more often.
Rationale: Decreasing the amount of time the
skin comes contact with wet soiled diapers will
help heal the irritation.
Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen
most in children with Down syndrome,
asplenia, or polysplenia.
Answer: (B) Decreased urine output
Rationale: Decreased urine output may occur in
clients receiving I.V. magnesium and should be
monitored closely to keep urine output at
greater than 30 ml/hour, because magnesium is
excreted through the kidneys and can easily
accumulate to toxic levels.
Answer: (A) Menorrhagia
Rationale: Menorrhagia is an excessive
menstrual period.
Answer: (C) Blood typing
Rationale: Blood type would be a critical value
to have because the risk of blood loss is always
a potential complication during the labor and
delivery process. Approximately 40% of a
woman’s cardiac output is delivered to the
uterus, therefore, blood loss can occur quite
rapidly in the event of uncontrolled bleeding.
Answer: (D) Physiologic anemia
Rationale: Hemoglobin values and hematocrit
decrease during pregnancy as the increase in
plasma volume exceeds the increase in red
blood cell production.
Answer: (D) A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s arms
and drooling.
Rationale: The infant with the airway
emergency should be treated first, because of
the risk of epiglottitis.
Answer: (A) Placenta previa
Rationale: Placenta previa with painless vaginal
bleeding.
Answer: (D) Early in the morning
Rationale: Based on the nurse’s knowledge of
microbiology, the specimen should be collected
early in the morning. The rationale for this
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37.
38.
39.
40.
41.
42.
43.
44.
timing is that, because the female worm lays
eggs at night around the perineal area, the first
bowel movement of the day will yield the best
results. The specific type of stool specimen
used in the diagnosis of pinworms is called the
tape test.
Answer: (A) Irritability and seizures
Rationale: Lead poisoning primarily affects the
CNS, causing increased intracranial pressure.
This condition results in irritability and changes
in level of consciousness, as well as seizure
disorders, hyperactivity, and learning
disabilities.
Answer: (D) “I really need to use the diaphragm
and jelly most during the middle of my
menstrual cycle”.
Rationale: The woman must understand that,
although the “fertile” period is approximately
mid-cycle, hormonal variations do occur and
can result in early or late ovulation. To be
effective, the diaphragm should be inserted
before every intercourse.
Answer: (C) Restlessness
Rationale: In a child, restlessness is the earliest
sign of hypoxia. Late signs of hypoxia in a child
are associated with a change in color, such as
pallor or cyanosis.
Answer: (B) Walk one step ahead, with the
child’s hand on the nurse’s elbow.
Rationale: This procedure is generally
recommended to follow in guiding a person
who is blind.
Answer: (A) Loud, machinery-like murmur.
Rationale: A loud, machinery-like murmur is a
characteristic finding associated with patent
ductus arteriosus.
Answer: (C) More oxygen, and the newborn’s
metabolic rate increases.
Rationale: When cold, the infant requires more
oxygen and there is an increase in metabolic
rate. Non-shievering thermogenesis is a
complex process that increases the metabolic
rate and rate of oxygen consumption,
therefore, the newborn increase heat
production.
Answer: (D) Voided
Rationale: Before administering potassium I.V.
to any client, the nurse must first check that the
client’s kidneys are functioning and that the
client is voiding. If the client is not voiding, the
nurse should withhold the potassium and notify
the physician.
Answer: (c) Laundry detergent
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Rationale: Eczema or dermatitis is an allergic
skin reaction caused by an offending allergen.
The topical allergen that is the most common
causative factor is laundry detergent.
Answer: (A) 6 inches
Rationale: This distance allows for easy flow of
the formula by gravity, but the flow will be slow
enough not to overload the stomach too
rapidly.
Answer: (A) The older one gets, the more
susceptible he becomes to the complications of
chicken pox.
Rationale: Chicken pox is usually more severe in
adults than in children. Complications, such as
pneumonia, are higher in incidence in adults.
Answer: (D) Consult a physician who may give
them rubella immunoglobulin.
Rationale: Rubella vaccine is made up of
attenuated German measles viruses. This is
contraindicated in pregnancy. Immune globulin,
a specific prophylactic against German measles,
may be given to pregnant women.
Answer: (A) Contact tracing
Rationale: Contact tracing is the most practical
and reliable method of finding possible sources
of person-to-person transmitted infections,
such as sexually transmitted diseases.
Answer: (D) Leptospirosis
Rationale: Leptospirosis is transmitted through
contact with the skin or mucous membrane
with water or moist soil contaminated with
urine of infected animals, like rats.
Answer: (B) Cholera
Rationale: Passage of profuse watery stools is
the major symptom of cholera. Both amebic
and bacillary dysentery are characterized by the
presence of blood and/or mucus in the stools.
Giardiasis is characterized by fat malabsorption
and, therefore, steatorrhea.
Answer: (A) Hemophilus influenzae
Rationale: Hemophilus meningitis is unusual
over the age of 5 years. In developing countries,
the peak incidence is in children less than 6
months of age. Morbillivirus is the etiology of
measles. Streptococcus pneumonia and
Neisseria meningitidis may cause meningitis,
but age distribution is not specific in young
children.
Answer: (B) Buccal mucosa
Rationale: Koplik’s spot may be seen on the
mucosa of the mouth or the throat.
Answer: (A) 3 seconds
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Rationale: Adequate blood supply to the area
allows the return of the color of the nailbed
within 3 seconds.
Answer: (B) Severe dehydration
Rationale: The order of priority in the
management of severe dehydration is as
follows: intravenous fluid therapy, referral to a
facility where IV fluids can be initiated within 30
minutes, Oresol or nasogastric tube. When the
foregoing measures are not possible or
effective, then urgent referral to the hospital is
done.
Answer: (A) 45 infants
Rationale: To estimate the number of infants,
multiply total population by 3%.
Answer: (A) DPT
Rationale: DPT is sensitive to freezing. The
appropriate storage temperature of DPT is 2 to
8° C only. OPV and measles vaccine are highly
sensitive to heat and require freezing. MMR is
not an immunization in the Expanded Program
on Immunization.
Answer: (C) Proper use of sanitary toilets
Rationale: The ova of the parasite get out of the
human body together with feces. Cutting the
cycle at this stage is the most effective way of
preventing the spread of the disease to
susceptible hosts.
Answer: (D) 5 skin lesions, positive slit skin
smear
Rationale: A multibacillary leprosy case is one
who has a positive slit skin smear and at least 5
skin lesions.
Answer: (C) Thickened painful nerves
Rationale: 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 late
symptoms.
Answer: (B) Ask where the family resides.
Rationale: Because malaria is endemic, the first
question to determine malaria risk is where the
client’s family resides. If the area of residence is
not a known endemic area, ask if the child had
traveled within the past 6 months, where she
was brought and whether she stayed overnight
in that area.
Answer: (A) Inability to drink
Rationale: A sick child aged 2 months to 5 years
must be referred urgently to a hospital if
he/she has one or more of the following signs:
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not able to feed or drink, vomits everything,
convulsions, abnormally sleepy or difficult to
awaken.
Answer: (A) Refer the child urgently to a
hospital for confinement.
Rationale: “Baggy pants” is a sign of severe
marasmus. The best management is urgent
referral to a hospital.
Answer: (D) Let the child rest for 10 minutes
then continue giving Oresol more slowly.
Rationale: If the child vomits persistently, that
is, he vomits everything that he takes in, he has
to be referred urgently to a hospital. Otherwise,
vomiting is managed by letting the child rest for
10 minutes and then continuing with Oresol
administration. Teach the mother to give Oresol
more slowly.
Answer: (B) Some dehydration
Rationale: Using the assessment guidelines of
IMCI, a child (2 months to 5 years old) with
diarrhea is classified as having SOME
DEHYDRATION if he shows 2 or more of the
following signs: restless or irritable, sunken
eyes, the skin goes back slow after a skin pinch.
Answer: (C) Normal
Rationale: In IMCI, a respiratory rate of
50/minute or more is fast breathing for an
infant aged 2 to 12 months.
Answer: (A) 1 year
Rationale: The baby will have passive natural
immunity by placental transfer of antibodies.
The mother will have active artificial immunity
lasting for about 10 years. 5 doses will give the
mother lifetime protection.
Answer: (B) 4 hours
Rationale: While the unused portion of other
biologicals in EPI may be given until the end of
the day, only BCG is discarded 4 hours after
reconstitution. This is why BCG immunization is
scheduled only in the morning.
Answer: (B) 6 months
Rationale: After 6 months, the baby’s nutrient
needs, especially the baby’s iron requirement,
can no longer be provided by mother’s milk
alone.
Answer: (C) 24 weeks
Rationale: At approximately 23 to 24 weeks’
gestation, the lungs are developed enough to
sometimes maintain extrauterine life. The lungs
are the most immature system during the
gestation period. Medical care for premature
labor begins much earlier (aggressively at 21
weeks’ gestation)
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70. Answer: (B) Sudden infant death syndrome
(SIDS)
Rationale: Supine positioning is recommended
to reduce the risk of SIDS in infancy. The risk of
aspiration is slightly increased with the supine
position. Suffocation would be less likely with
an infant supine than prone and the position
for GER requires the head of the bed to be
elevated.
71. Answer: (C) Decreased temperature
Rationale: Temperature instability, especially
when it results in a low temperature in the
neonate, may be a sign of infection. The
neonate’s color often changes with an infection
process but generally becomes ashen or
mottled. The neonate with an infection will
usually show a decrease in activity level or
lethargy.
72. Answer: (D) Polycythemia probably due to
chronic fetal hypoxia
Rationale: The small-for-gestation neonate is at
risk for developing polycythemia during the
transitional period in an attempt to decrease
hypoxia. The neonates are also at increased risk
for developing hypoglycemia and hypothermia
due to decreased glycogen stores.
73. Answer: (C) Desquamation of the epidermis
Rationale: Postdate fetuses lose the vernix
caseosa, and the epidermis may become
desquamated. These neonates are usually very
alert. Lanugo is missing in the postdate
neonate.
74. Answer: (C) Respiratory depression
Rationale: Magnesium sulfate crosses the
placenta and adverse neonatal effects are
respiratory depression, hypotonia, and
bradycardia. The serum blood sugar isn’t
affected by magnesium sulfate. The neonate
would be floppy, not jittery.
75. Answer: (C) Respiratory rate 40 to 60
breaths/minute
Rationale: A respiratory rate 40 to 60
breaths/minute is normal for a neonate during
the transitional period. Nasal flaring,
respiratory rate more than 60 breaths/minute,
and audible grunting are signs of respiratory
distress.
76. Answer: (C) Keep the cord dry and open to air
Rationale: Keeping the cord dry and open to air
helps reduce infection and hastens drying.
Infants aren’t given tub bath but are sponged
off until the cord falls off. Petroleum jelly
prevents the cord from drying and encourages
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infection. Peroxide could be painful and isn’t
recommended.
Answer: (B) Conjunctival hemorrhage
Rationale: Conjunctival hemorrhages are
commonly seen in neonates secondary to the
cranial pressure applied during the birth
process. Bulging fontanelles are a sign of
intracranial pressure. Simian creases are
present in 40% of the neonates with trisomy 21.
Cystic hygroma is a neck mass that can affect
the airway.
Answer: (B) To assess for prolapsed cord
Rationale: After a client has an amniotomy, the
nurse should assure that the cord isn't
prolapsed and that the baby tolerated the
procedure well. The most effective way to do
this is to check the fetal heart rate. Fetal wellbeing is assessed via a nonstress test. Fetal
position is determined by vaginal examination.
Artificial rupture of membranes doesn't
indicate an imminent delivery.
Answer: (D) The parents’ interactions with each
other.
Rationale: Parental interaction will provide the
nurse with a good assessment of the stability of
the family's home life but it has no indication
for parental bonding. Willingness to touch and
hold the newborn, expressing interest about
the newborn's size, and indicating a desire to
see the newborn are behaviors indicating
parental bonding.
Answer: (B) Instructing the client to use two or
more peripads to cushion the area
Rationale: Using two or more peripads would
do little to reduce the pain or promote perineal
healing. Cold applications, sitz baths, and Kegel
exercises are important measures when the
client has a fourth-degree laceration.
Answer: (C) “What is your expected due date?”
Rationale: When obtaining the history of a
client who may be in labor, the nurse's highest
priority is to determine her current status,
particularly her due date, gravidity, and parity.
Gravidity and parity affect the duration of labor
and the potential for labor complications. Later,
the nurse should ask about chronic illnesses,
allergies, and support persons.
Answer: (D) Aspirate the neonate’s nose and
mouth with a bulb syringe.
Rationale: The nurse's first action should be to
clear the neonate's airway with a bulb syringe.
After the airway is clear and the neonate's color
improves, the nurse should comfort and calm
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the neonate. If the problem recurs or the
neonate's color doesn't improve readily, the
nurse should notify the physician.
Administering oxygen when the airway isn't
clear would be ineffective.
Answer: (C) Conducting a bedside ultrasound
for an amniotic fluid index.
Rationale: It isn't within a nurse's scope of
practice to perform and interpret a bedside
ultrasound under these conditions and without
specialized training. Observing for pooling of
straw-colored fluid, checking vaginal discharge
with nitrazine paper, and observing for flakes of
vernix are appropriate assessments for
determining whether a client has ruptured
membranes.
Answer: (C) Monitor partial pressure of oxygen
(Pao2) levels.
Rationale: Monitoring PaO2 levels and reducing
the oxygen concentration to keep PaO2 within
normal limits reduces the risk of retinopathy of
prematurity in a premature infant receiving
oxygen. Covering the infant's eyes and
humidifying the oxygen don't reduce the risk of
retinopathy of prematurity. Because cooling
increases the risk of acidosis, the infant should
be kept warm so that his respiratory distress
isn't aggravated.
Answer: (A) 110 to 130 calories per kg.
Rationale: Calories per kg is the accepted way
of determined appropriate nutritional intake
for a newborn. The recommended calorie
requirement is 110 to 130 calories per kg of
newborn body weight. This level will maintain a
consistent blood glucose level and provide
enough calories for continued growth and
development.
Answer: (C) 30 to 32 weeks
Rationale: Individual twins usually grow at the
same rate as singletons until 30 to 32 weeks’
gestation, then twins don’t’ gain weight as
rapidly as singletons of the same gestational
age. The placenta can no longer keep pace with
the nutritional requirements of both fetuses
after 32 weeks, so there’s some growth
retardation in twins if they remain in utero at
38 to 40 weeks.
Answer: (A) conjoined twins
Rationale: The type of placenta that develops in
monozygotic twins depends on the time at
which cleavage of the ovum occurs. Cleavage in
conjoined twins occurs more than 13 days after
fertilization. Cleavage that occurs less than 3
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day after fertilization results in diamniotic
dicchorionic twins. Cleavage that occurs
between days 3 and 8 results in diamniotic
monochorionic twins. Cleavage that occurs
between days 8 to 13 result in monoamniotic
monochorionic twins.
Answer: (D) Ultrasound
Rationale: Once the mother and the fetus are
stabilized, ultrasound evaluation of the
placenta should be done to determine the
cause of the bleeding. Amniocentesis is
contraindicated in placenta previa. A digital or
speculum examination shouldn’t be done as
this may lead to severe bleeding or
hemorrhage. External fetal monitoring won’t
detect a placenta previa, although it will detect
fetal distress, which may result from blood loss
or placenta separation.
Answer: (A) Increased tidal volume
Rationale: A pregnant client breathes deeper,
which increases the tidal volume of gas moved
in and out of the respiratory tract with each
breath. The expiratory volume and residual
volume decrease as the pregnancy progresses.
The inspiratory capacity increases during
pregnancy. The increased oxygen consumption
in the pregnant client is 15% to 20% greater
than in the nonpregnant state.
Answer: (A) Diet
Rationale: Clients with gestational diabetes are
usually managed by diet alone to control their
glucose intolerance. Oral hypoglycemic drugs
are contraindicated in pregnancy. Long-acting
insulin usually isn’t needed for blood glucose
control in the client with gestational diabetes.
Answer: (D) Seizure
Rationale: The anticonvulsant mechanism of
magnesium is believes to depress seizure foci in
the brain and peripheral neuromuscular
blockade. Hypomagnesemia isn’t a
complication of preeclampsia. Antihypertensive
drug other than magnesium are preferred for
sustained hypertension. Magnesium doesn’t
help prevent hemorrhage in preeclamptic
clients.
Answer: (C) I.V. fluids
Rationale: A sickle cell crisis during pregnancy is
usually managed by exchange transfusion
oxygen, and L.V. Fluids. The client usually needs
a stronger analgesic than acetaminophen to
control the pain of a crisis. Antihypertensive
drugs usually aren’t necessary. Diuretic
wouldn’t be used unless fluid overload resulted.
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93. Answer: (A) Calcium gluconate (Kalcinate)
Rationale: Calcium gluconate is the antidote for
magnesium toxicity. Ten milliliters of 10%
calcium gluconate is given L.V. push over 3 to 5
minutes. Hydralazine is given for sustained
elevated blood pressure in preeclamptic clients.
Rho (D) immune globulin is given to women
with Rh-negative blood to prevent antibody
formation from RH-positive conceptions.
Naloxone is used to correct narcotic toxicity.
94. Answer: (B) An indurated wheal over 10 mm in
diameter appears in 48 to 72 hours.
Rationale: A positive PPD result would be an
indurated wheal over 10 mm in diameter that
appears in 48 to 72 hours. The area must be a
raised wheal, not a flat circumcised area to be
considered positive.
95. Answer: (C) Pyelonephritis
Rationale The symptoms indicate acute
pyelonephritis, a serious condition in a
pregnant client. UTI symptoms include dysuria,
urgency, frequency, and suprapubic
tenderness. Asymptomatic bacteriuria doesn’t
cause symptoms. Bacterial vaginosis causes
milky white vaginal discharge but no systemic
symptoms.
96. Answer: (B) Rh-positive fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
Rationale: Rh isoimmunization occurs when Rhpositive fetal blood cells cross into the maternal
circulation and stimulate maternal antibody
production. In subsequent pregnancies with Rhpositive fetuses, maternal antibodies may cross
back into the fetal circulation and destroy the
fetal blood cells.
97. Answer: (C) Supine position
Rationale: The supine position causes
compression of the client's aorta and inferior
vena cava by the fetus. This, in turn, inhibits
maternal circulation, leading to maternal
hypotension and, ultimately, fetal hypoxia. The
other positions promote comfort and aid labor
progress. For instance, the lateral, or side-lying,
position improves maternal and fetal
circulation, enhances comfort, increases
maternal relaxation, reduces muscle tension,
and eliminates pressure points. The squatting
position promotes comfort by taking advantage
of gravity. The standing position also takes
advantage of gravity and aligns the fetus with
the pelvic angle.
98. Answer: (B) Irritability and poor sucking.
Rationale: Neonates of heroin-addicted
mothers are physically dependent on the drug
and experience withdrawal when the drug is no
longer supplied. Signs of heroin withdrawal
include irritability, poor sucking, and
restlessness. Lethargy isn't associated with
neonatal heroin addiction. A flattened nose,
small eyes, and thin lips are seen in infants with
fetal alcohol syndrome. Heroin use during
pregnancy hasn't been linked to specific
congenital anomalies.
99. Answer: (A) 7th to 9th day postpartum
Rationale: The normal involutional process
returns the uterus to the pelvic cavity in 7 to 9
days. A significant involutional complication is
the failure of the uterus to return to the pelvic
cavity within the prescribed time period. This is
known as subinvolution.
100. Answer: (B) Uterine atony
Rationale: Multiple fetuses, extended labor
stimulation with oxytocin, and traumatic
delivery commonly are associated with uterine
atony, which may lead to postpartum
hemorrhage. Uterine inversion may precede or
follow delivery and commonly results from
apparent excessive traction on the umbilical
cord and attempts to deliver the placenta
manually. Uterine involution and some uterine
discomfort are normal after delivery.
TEST III - Care of Clients with Physiologic and
Psychosocial Alterations
1. Nurse Michelle should know that the drainage is
normal 4 days after a sigmoid colostomy when
the stool is:
a. Green liquid
b. Solid formed
c. Loose, bloody
d. Semiformed
2. Where would nurse Kristine place the call light
for a male client with a right-sided brain attack
and left homonymous hemianopsia?
a. On the client’s right side
b. On the client’s left side
c. Directly in front of the client
d. Where the client like
3. A male client is admitted to the emergency
department following an accident. What are the
first nursing actions of the nurse?
a. Check respiration, circulation,
neurological response.
b. Align the spine, check pupils, and check
for hemorrhage.
c. Check respirations, stabilize spine, and
check circulation.
d. Assess level of consciousness and
circulation.
4. In evaluating the effect of nitroglycerin, Nurse
Arthur should know that it reduces preload and
relieves angina by:
a. Increasing contractility and slowing
heart rate.
b. Increasing AV conduction and heart rate.
c. Decreasing contractility and oxygen
consumption.
d. Decreasing venous return through
vasodilation.
5. Nurse Patricia finds a female client who is postmyocardial infarction (MI) slumped on the side
rails of the bed and unresponsive to shaking or
shouting. Which is the nurse next action?
a. Call for help and note the time.
b. Clear the airway
c. Give two sharp thumps to the
precordium, and check the pulse.
d. Administer two quick blows.
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6. Nurse Monett is caring for a client recovering
from gastro-intestinal bleeding. The nurse
should:
a. Plan care so the client can receive 8
hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and
medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before
admission, 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 and
notify the physician.
b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is
lower than normal.
8. A client undergone ileostomy, when should the
drainage appliance be applied to the stoma?
a. 24 hours later, when edema has
subsided.
b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care
procedures.
9. A client undergone spinal anesthetic, it will be
important that the nurse immediately position
the client in:
a. On the side, to prevent obstruction of
airway by tongue.
b. Flat on back.
c. On the back, with knees flexed 15
degrees.
d. Flat on the stomach, with the head
turned to the side.
10. While monitoring a male client several hours
after a motor vehicle accident, which
assessment data suggest increasing intracranial
pressure?
a. Blood pressure is decreased from
160/90 to 110/70.
b. Pulse is increased from 87 to 95, with an
occasional skipped beat.
c. The client is oriented when aroused
from sleep, and goes back to sleep
immediately.
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d. The client refuses dinner because of
anorexia.
11. Mrs. Cruz, 80 years old is diagnosed with
pneumonia. Which of the following symptoms
may appear first?
a. Altered mental status and dehydration
b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough
12. A male client has active tuberculosis (TB). Which
of the following symptoms will be exhibit?
a. Chest and lower back pain
b. Chills, fever, night sweats, and
hemoptysis
c. Fever of more than 104°F (40°C) and
nausea
d. Headache and photophobia
13. Mark, a 7-year-old client is brought to the
emergency department. He’s tachypneic and
afebrile and has a respiratory rate of 36
breaths/minute and has a nonproductive cough.
He recently had a cold. Form this history; the
client may have which of the following
conditions?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease
(COPD)
d. Emphysema
14. Marichu was given morphine sulfate for pain.
She is sleeping and her respiratory rate is 4
breaths/minute. If action isn’t taken quickly, she
might have which of the following reactions?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own
15. A 77-year-old male client is admitted for elective
knee surgery. Physical examination reveals
shallow respirations but no sign of respiratory
distress. Which of the following is a normal
physiologic change related to aging?
a. Increased elastic recoil of the lungs
b. Increased number of functional
capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity
16. Nurse John is caring for a male client receiving
lidocaine I.V. Which factor is the most relevant
to administration of this medication?
a. Decrease in arterial oxygen saturation
(SaO2) when measured with a pulse
oximeter.
b. Increase in systemic blood pressure.
c. Presence of premature ventricular
contractions (PVCs) on a cardiac
monitor.
d. Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client taking an
anticoagulant. The nurse should teach the client
to:
a. Report incidents of diarrhea.
b. Avoid foods high in vitamin K
c. Use a straight razor when shaving.
d. Take aspirin to pain relief.
18. Nurse Lhynnette is preparing a site for the
insertion of an I.V. catheter. The nurse should
treat excess hair at the site by:
a. Leaving the hair intact
b. Shaving the area
c. Clipping the hair in the area
d. Removing the hair with a depilatory.
19. Nurse Michelle is caring for an elderly female
with osteoporosis. When teaching the client, the
nurse should include information about which
major complication:
a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowager’s hump
20. Nurse Len is teaching a group of women to
perform BSE. The nurse should explain that the
purpose of performing the examination is to
discover:
a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses
21. When caring for a female client who is being
treated for hyperthyroidism, it is important to:
a. Provide extra blankets and clothing to
keep the client warm.
b. Monitor the client for signs of
restlessness, sweating, and excessive
weight loss during thyroid replacement
therapy.
c. Balance the client’s periods of activity
and rest.
d. Encourage the client to be active to
prevent constipation.
22. Nurse Kris is teaching a client with history of
atherosclerosis. To decrease the risk of
atherosclerosis, the nurse should encourage the
client 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. Nurse
Greta must logroll a client following a:
a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.
24. A 55-year old client underwent cataract removal
with intraocular lens implant. Nurse Oliver is
giving the client discharge instructions. These
instructions should include which of the
following?
a. Avoid lifting objects weighing more than
5 lb (2.25 kg).
b. Lie on your abdomen when in bed
c. Keep rooms brightly lit.
d. Avoiding straining during bowel
movement or bending at the waist.
25. George should be taught about testicular
examinations during:
a. when sexual activity starts
b. After age 69
c. After age 40
d. Before age 20.
26. A male client undergone a colon resection. While
turning him, wound dehiscence with
evisceration occurs. Nurse Trish first response is
to:
a. Call the physician
b. Place a saline-soaked sterile dressing on
the wound.
c. Take a blood pressure and pulse.
d. Pull the dehiscence closed.
27. Nurse Audrey is caring for a client who has
suffered a severe cerebrovascular accident.
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During routine assessment, the nurse notices
Cheyne- Strokes respirations. Cheyne-strokes
respirations are:
a. A progressively deeper breaths followed
by shallower breaths with apneic
periods.
b. Rapid, deep breathing with abrupt
pauses between each breath.
c. Rapid, deep breathing and irregular
breathing without pauses.
d. Shallow breathing with an increased
respiratory rate.
28. Nurse Bea is assessing a male client with heart
failure. The breath sounds commonly
auscultated in clients with heart failure are:
a. Tracheal
b. Fine crackles
c. Coarse crackles
d. Friction rubs
29. The nurse is caring for Kenneth experiencing an
acute asthma attack. The client stops wheezing
and breath sounds aren’t audible. The reason for
this change is that:
a. The attack is over.
b. The airways are so swollen that no air
cannot get through.
c. The swelling has decreased.
d. Crackles have replaced wheezes.
30. Mike with epilepsy is having a seizure. During
the active seizure phase, the nurse should:
a. Place the client on his back remove
dangerous objects, and insert a bite
block.
b. Place the client on his side, remove
dangerous objects, and insert a bite
block.
c. Place the client o his back, remove
dangerous objects, and hold down his
arms.
d. Place the client on his side, remove
dangerous objects, and protect his head.
31. After insertion of a cheat tube for a
pneumothorax, a client becomes hypotensive
with neck vein distention, tracheal shift, absent
breath sounds, and diaphoresis. Nurse Amanda
suspects a tension pneumothorax has occurred.
What cause of tension pneumothorax should the
nurse check for?
a. Infection of the lung.
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b. Kinked or obstructed chest tube
c. Excessive water in the water-seal
chamber
d. Excessive chest tube drainage
32. Nurse Maureen is talking to a male client; the
client begins choking on his lunch. He’s coughing
forcefully. The nurse should:
a. Stand him up and perform the
abdominal thrust maneuver from
behind.
b. Lay him down, straddle him, and
perform the abdominal thrust
maneuver.
c. Leave him to get assistance
d. Stay with him but not intervene at this
time.
33. Nurse Ron is taking a health history of an 84 year
old client. Which information will be most useful
to 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 lips
at 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 hydrogen
peroxide.
35. A 77-year-old male client is admitted with a
diagnosis of dehydration and change in mental
status. He’s being hydrated with L.V. fluids.
When the nurse takes his vital signs, she notes
he has a fever of 103°F (39.4°C) a cough
producing yellow sputum and pleuritic chest
pain. The nurse suspects this client may have
which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Myocardial infarction (MI)
c. Pneumonia
d. Tuberculosis
36. Nurse Oliver is working in an outpatient clinic.
He has been alerted that there is an outbreak of
tuberculosis (TB). Which of the following clients
entering the clinic today most likely to have TB?
a. A 16-year-old female high school
student
b. A 33-year-old day-care worker
c. A 43-yesr-old homeless man with a
history of alcoholism
d. A 54-year-old businessman
37. Virgie with a positive Mantoux test result will be
sent for a chest X-ray. The nurse is aware that
which of the following reasons this is done?
a. To confirm the diagnosis
b. To determine if a repeat skin test is
needed
c. To determine the extent of lesions
d. To determine if this is a primary or
secondary infection
38. Kennedy with acute asthma showing inspiratory
and expiratory wheezes and a decreased forced
expiratory volume should be treated with which
of the following classes of medication right
away?
a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year
history of smoking one to two packs of cigarettes
per day has a chronic cough producing thick
sputum, peripheral edema and cyanotic nail
beds. Based on this information, he most likely
has which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
Situation: Francis, age 46 is admitted to the hospital with
diagnosis of Chronic Lymphocytic Leukemia.
40. The treatment for patients with leukemia is bone
marrow transplantation. Which statement about
bone marrow transplantation is not correct?
a. The patient is under local anesthesia
during the procedure
b. The aspirated bone marrow is mixed
with heparin.
c. The aspiration site is the posterior or
anterior iliac crest.
d. The recipient receives
cyclophosphamide (Cytoxan) for 4
consecutive days before the procedure.
41. After several days of admission, Francis becomes
disoriented and complains of frequent
headaches. The nurse in-charge first action
would be:
a. Call the physician
b. Document the patient’s status in his
charts.
c. Prepare oxygen treatment
d. Raise the side rails
42. During routine care, Francis asks the nurse,
“How can I be anemic if this disease causes
increased my white blood cell production?” The
nurse in-charge best response would be that the
increased number of white blood cells (WBC) is:
a. Crowd red blood cells
b. Are not responsible for the anemia.
c. Uses nutrients from other cells
d. Have an abnormally short life span of
cells.
43. Diagnostic assessment of Francis would probably
not reveal:
a. Predominance of lymhoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial
occlusion of the left leg undergoes an
emergency embolectomy. Six hours later, the
nurse isn’t able to obtain pulses in his left foot
using Doppler ultrasound. The nurse
immediately notifies the physician, and asks her
to prepare the client for surgery. As the nurse
enters the client’s room to prepare him, he
states that he won’t have any more surgery.
Which of the following is the best initial
response by the nurse?
a. Explain the risks of not having the
surgery
b. Notifying the physician immediately
c. Notifying the nursing supervisor
d. Recording the client’s refusal in the
nurses’ notes
45. During the endorsement, which of the following
clients should the on-duty nurse assess first?
a. The 58-year-old client who was admitted
2 days ago with heart failure, blood
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pressure of 126/76 mm Hg, and a
respiratory rate of 22 breaths/ minute.
b. The 89-year-old client with end-stage
right-sided heart failure, blood pressure
of 78/50 mm Hg, and a “do not
resuscitate” order
c. The 62-year-old client who was admitted
1 day ago with thrombophlebitis and is
receiving L.V. heparin
d. The 75-year-old client who was admitted
1 hour ago with new-onset atrial
fibrillation and is receiving L.V. dilitiazem
(Cardizem)
46. Honey, a 23-year old client complains of
substernal chest pain and states that her heart
feels like “it’s racing out of the chest”. She
reports no history of cardiac disorders. The
nurse attaches her to a cardiac monitor and
notes sinus tachycardia with a rate of
136beats/minutes. Breath sounds are clear and
the respiratory rate is 26 breaths/minutes.
Which of the following drugs should the nurse
question the client about using?
a. Barbiturates
b. Opioids
c. Cocaine
d. Benzodiazepines
47. A 51-year-old female client tells the nurse incharge that she has found a painless lump in her
right breast during her monthly selfexamination. Which assessment finding would
strongly suggest that this client's lump is
cancerous?
a. Eversion of the right nipple and mobile
mass
b. Nonmobile mass with irregular edges
c. Mobile mass that is soft and easily
delineated
d. Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks the
nurse, "What is the usual treatment for this type
of cancer?" Which treatment should the nurse
name?
a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy
49. Cristina undergoes a biopsy of a suspicious
lesion. The biopsy report classifies the lesion
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according to the TNM staging system as follows:
TIS, N0, M0. What does this classification mean?
a. No evidence of primary tumor, no
abnormal regional lymph nodes, and no
evidence of distant metastasis
b. Carcinoma in situ, no abnormal regional
lymph nodes, and no evidence of distant
metastasis
c. Can't assess tumor or regional lymph
nodes and no evidence of metastasis
d. Carcinoma in situ, no demonstrable
metastasis of the regional lymph nodes,
and ascending degrees of distant
metastasis
50. Lydia undergoes a laryngectomy to treat
laryngeal cancer. When teaching the client how
to care for the neck stoma, the nurse should
include which instruction?
a. "Keep the stoma uncovered."
b. "Keep the stoma dry."
c. "Have a family member perform stoma
care initially until you get used to the
procedure."
d. "Keep the stoma moist."
51. A 37-year-old client with uterine cancer asks the
nurse, "Which is the most common type of
cancer in women?" The nurse replies that it's
breast cancer. Which type of cancer causes the
most deaths in women?
a. Breast cancer
b. Lung cancer
c. Brain cancer
d. Colon and rectal cancer
52. Antonio with lung cancer develops Horner's
syndrome when the tumor invades the ribs and
affects the sympathetic nerve ganglia. When
assessing for signs and symptoms of this
syndrome, the nurse should note:
a. miosis, partial eyelid ptosis, and
anhidrosis on the affected side of the
face.
b. chest pain, dyspnea, cough, weight loss,
and fever.
c. arm and shoulder pain and atrophy of
arm and hand muscles, both on the
affected side.
d. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should
reply that it stands for:
a. prostate-specific antigen, which is used
to screen for prostate cancer.
b. protein serum antigen, which is used to
determine protein levels.
c. pneumococcal strep antigen, which is a
bacteria that causes pneumonia.
d. Papanicolaou-specific antigen, which is
used to screen for cervical cancer.
54. What is the most important postoperative
instruction that nurse Kate must give a client
who has just returned from the operating room
after receiving a subarachnoid block?
a. "Avoid drinking liquids until the gag
reflex returns."
b. "Avoid eating milk products for 24
hours."
c. "Notify a nurse if you experience blood
in your urine."
d. "Remain supine for the time specified by
the physician."
55. A male client suspected of having colorectal
cancer will require which diagnostic study to
confirm the diagnosis?
a. Stool Hematest
b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy
d. Abdominal computed tomography (CT)
scan
56. During a breast examination, which finding most
strongly suggests that the Luz has breast cancer?
a. Slight asymmetry of the breasts.
b. A fixed nodular mass with dimpling of
the overlying skin
c. Bloody discharge from the nipple
d. Multiple firm, round, freely movable
masses that change with the menstrual
cycle
57. A female client with cancer is being evaluated
for possible metastasis. Which of the following is
one of the most common metastasis sites for
cancer cells?
a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic
resonance imaging (MRI) to confirm or rule out a
spinal cord lesion. During the MRI scan, which of
the 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 wedding
band.
59. Nurse Cecile is teaching a female client about
preventing osteoporosis. Which of the following
teaching points is correct?
a. Obtaining an X-ray of the bones every 3
years is recommended to detect bone
loss.
b. To avoid fractures, the client should
avoid strenuous exercise.
c. The recommended daily allowance of
calcium may be found in a wide variety
of foods.
d. Obtaining the recommended daily
allowance of calcium requires taking a
calcium supplement.
60. Before Jacob undergoes arthroscopy, the nurse
reviews the assessment findings for
contraindications for this procedure. Which
finding is a contraindication?
a. Joint pain
b. Joint deformity
c. Joint flexion of less than 50%
d. Joint stiffness
61. Mr. Rodriguez is admitted with severe pain in
the knees. Which form of arthritis is
characterized by urate deposits and joint pain,
usually in the feet and legs, and occurs primarily
in men over age 30?
a. Septic arthritis
b. Traumatic arthritis
c. Intermittent arthritis
d. Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered
for a 64-year-old client with stroke in evolution.
The infusion contains 25,000 units of heparin in
500 ml of saline solution. How many milliliters
per hour should be given?
a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour
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63. A 76-year-old male client had a thromboembolic
right stroke; his left arm is swollen. Which of the
following conditions may cause swelling after a
stroke?
a. Elbow contracture secondary to
spasticity
b. Loss of muscle contraction decreasing
venous return
c. Deep vein thrombosis (DVT) due to
immobility of the ipsilateral side
d. Hypoalbuminemia due to protein
escaping from an inflamed glomerulus
64. Heberden’s nodes are a common sign of
osteoarthritis. Which of the following statement
is correct about this deformity?
a. It appears only in men
b. It appears on the distal interphalangeal
joint
c. It appears on the proximal
interphalangeal joint
d. It appears on the dorsolateral aspect of
the interphalangeal joint.
65. Which of the following statements explains the
main difference between rheumatoid arthritis
and osteoarthritis?
a. Osteoarthritis is gender-specific,
rheumatoid arthritis isn’t
b. Osteoarthritis is a localized disease
rheumatoid arthritis is systemic
c. Osteoarthritis is a systemic disease,
rheumatoid arthritis is localized
d. Osteoarthritis has dislocations and
subluxations, rheumatoid arthritis
doesn’t
66. Mrs. Cruz uses a cane for assistance in walking.
Which of the following statements is true about
a cane or other assistive devices?
a. A walker is a better choice than a cane.
b. The cane should be used on the affected
side
c. The cane should be used on the
unaffected side
d. A client with osteoarthritis should be
encouraged to ambulate without the
cane
67. A male client with type 1 diabetes is scheduled
to receive 30 U of 70/30 insulin. There is no
70/30 insulin available. As a substitution, the
nurse may give the client:
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a. 9 U regular insulin and 21 U neutral
protamine 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 which
medication to a client with gout?
a. aspirin
b. furosemide (Lasix)
c. colchicines
d. calcium gluconate (Kalcinate)
69. Mr. Domingo with a history of hypertension is
diagnosed with primary hyperaldosteronism.
This diagnosis indicates that the client's
hypertension is caused by excessive hormone
secretion from which of the following glands?
a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid
70. For a diabetic male client with a foot ulcer, the
doctor orders bed rest, a wet-to-dry dressing
change every shift, and blood glucose
monitoring before meals and bedtime. Why are
wet-to-dry dressings used for this client?
a. They contain exudate and provide a
moist wound environment.
b. They protect the wound from
mechanical trauma and promote
healing.
c. They debride the wound and promote
healing by secondary intention.
d. They prevent the entrance of
microorganisms and minimize wound
discomfort.
71. Nurse Zeny is caring for a client in acute
addisonian crisis. Which laboratory data would
the nurse expect to find?
a. Hyperkalemia
b. Reduced blood urea nitrogen (BUN)
c. Hypernatremia
d. Hyperglycemia
72. A client is admitted for treatment of the
syndrome of inappropriate antidiuretic hormone
(SIADH). Which nursing intervention is
appropriate?
a. Infusing I.V. fluids rapidly as ordered
b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing I.V.
fluids as ordered
73. A female client tells nurse Nikki that she has
been working hard for the last 3 months to
control her type 2 diabetes mellitus with diet
and exercise. To determine the effectiveness of
the client's 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 protamine
Hagedorn (NPH) insulin to a diabetic client at 7
a.m. At what time would the nurse expect the
client to be most at risk for a hypoglycemic
reaction?
a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm
75. The adrenal cortex is responsible for producing
which substances?
a. Glucocorticoids and androgens
b. Catecholamines and epinephrine
c. Mineralocorticoids and catecholamines
d. Norepinephrine and epinephrine
76. On the third day after a partial thyroidectomy,
Proserfina exhibits muscle twitching and
hyperirritability of the nervous system. When
questioned, the client reports numbness and
tingling of the mouth and fingertips. Suspecting
a life-threatening electrolyte disturbance, the
nurse notifies the surgeon immediately. Which
electrolyte disturbance most commonly follows
thyroid surgery?
a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
d. Hypermagnesemia
77. Which laboratory test value is elevated in clients
who smoke and can't be used as a general
indicator of cancer?
a. Acid phosphatase level
b. Serum calcitonin level
c. Alkaline phosphatase level
d. Carcinoembryonic antigen level
78. Francis with anemia has been admitted to the
medical-surgical unit. Which assessment findings
are characteristic of iron-deficiency anemia?
a. Nights sweats, weight loss, and diarrhea
b. Dyspnea, tachycardia, and pallor
c. Nausea, vomiting, and anorexia
d. Itching, rash, and jaundice
79. In teaching a female client who is HIV-positive
about pregnancy, the nurse would know more
teaching is necessary when the client says:
a. The baby can get the virus from my
placenta."
b. "I'm planning on starting on birth control
pills."
c. "Not everyone who has the virus gives
birth to a baby who has the virus."
d. "I'll need to have a C-section if I become
pregnant and have a baby."
80. When preparing Judy with acquired
immunodeficiency syndrome (AIDS) for
discharge to the home, the nurse should be sure
to include which instruction?
a. "Put on disposable gloves before
bathing."
b. "Sterilize all plates and utensils in boiling
water."
c. "Avoid sharing such articles as
toothbrushes and razors."
d. "Avoid eating foods from serving dishes
shared by other family members."
81. Nurse Marie is caring for a 32-year-old client
admitted with pernicious anemia. Which set of
findings should the nurse expect when assessing
the client?
a. Pallor, bradycardia, and reduced pulse
pressure
b. Pallor, tachycardia, and a sore tongue
c. Sore tongue, dyspnea, and weight gain
d. Angina, double vision, and anorexia
82. After receiving a dose of penicillin, a client
develops dyspnea and hypotension. Nurse
Celestina suspects the client is experiencing
anaphylactic shock. What should the nurse do
first?
a. Page an anesthesiologist immediately
and prepare to intubate the client.
b. Administer epinephrine, as prescribed,
and prepare to intubate the client if
necessary.
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c. Administer the antidote for penicillin, as
prescribed, and continue to monitor the
client's vital signs.
d. Insert an indwelling urinary catheter and
begin to infuse I.V. fluids as ordered.
83. Mr. Marquez with rheumatoid arthritis is about
to begin aspirin therapy to reduce inflammation.
When teaching the client about aspirin, the
nurse discusses adverse reactions to prolonged
aspirin 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 human
immunodeficiency virus (HIV). After recovering
from the initial shock of the diagnosis, the client
expresses a desire to learn as much as possible
about HIV and acquired immunodeficiency
syndrome (AIDS). When teaching the client
about the immune system, the nurse states that
adaptive immunity is provided by which type of
white blood cell?
a. Neutrophil
b. Basophil
c. Monocyte
d. Lymphocyte
85. In an individual with Sjögren's syndrome, nursing
care 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 most
important for the nurse to advise the physician
to order:
a. enzyme-linked immunosuppressant
assay (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 for
fatigue, night sweats, and a 20-lb weight loss in 6
weeks. To confirm that the client has been
infected with the human immunodeficiency virus
(HIV), the nurse expects the physician to order:
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a. 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 performed
before a Joe goes into surgery. What does this
test seek to identify?
a. Potential hepatic dysfunction indicated
by decreased blood urea nitrogen (BUN)
and creatinine levels
b. Low levels of urine constituents normally
excreted in the urine
c. Abnormally low hematocrit (HCT) and
hemoglobin (Hb) levels
d. Electrolyte imbalance that could affect
the blood's ability to coagulate properly
89. While monitoring a client for the development
of disseminated intravascular coagulation (DIC),
the nurse should take note of what assessment
parameters?
a. Platelet count, prothrombin time, and
partial thromboplastin time
b. Platelet count, blood glucose levels, and
white blood cell (WBC) count
c. Thrombin time, calcium levels, and
potassium levels
d. Fibrinogen level, WBC, and platelet
count
90. When taking a dietary history from a newly
admitted female client, Nurse Len should
remember that which of the following foods is a
common allergen?
a. Bread
b. Carrots
c. Orange
d. Strawberries
91. Nurse John is caring for clients in the outpatient
clinic. Which of the following phone calls should
the nurse return first?
a. A client with hepatitis A who states, “My
arms and legs are itching.”
b. A client with cast on the right leg who
states, “I have a funny feeling in my right
leg.”
c. A client with osteomyelitis of the spine
who states, “I am so nauseous that I
can’t eat.”
d. A client with rheumatoid arthritis who
states, “I am having trouble sleeping.”
92. Nurse Sarah is caring for clients on the surgical
floor and has just received report from the
previous shift. Which of the following clients
should the nurse see first?
a. A 35-year-old admitted three hours ago
with a gunshot wound; 1.5 cm area of
dark drainage noted on the dressing.
b. A 43-year-old who had a mastectomy
two days ago; 23 ml of serosanguinous
fluid noted in the Jackson-Pratt drain.
c. A 59-year-old with a collapsed lung due
to an accident; no drainage noted in the
previous eight hours.
d. A 62-year-old who had an abdominalperineal resection three days ago; client
complaints of chills.
93. Nurse Eve is caring for a client who had a
thyroidectomy 12 hours ago for treatment of
Grave’s disease. The nurse would be most
concerned if which of the following was
observed?
a. Blood pressure 138/82, respirations 16,
oral temperature 99 degrees Fahrenheit.
b. The client supports his head and neck
when turning his head to the right.
c. The client spontaneously flexes his wrist
when the blood pressure is obtained.
d. The client is drowsy and complains of
sore throat.
94. Julius is admitted with complaints of severe pain
in the lower right quadrant of the abdomen. To
assist with pain relief, the nurse should take
which of the following actions?
a. Encourage the client to change positions
frequently in bed.
b. Administer Demerol 50 mg IM q 4 hours
and PRN.
c. Apply warmth to the abdomen with a
heating pad.
d. Use comfort measures and pillows to
position the client.
95. Nurse Tina prepares a client for peritoneal
dialysis. Which of the following actions should
the nurse take first?
a. Assess for a bruit and a thrill.
b. Warm the dialysate solution.
c. Position the client on the left side.
d. Insert a Foley catheter
96. Nurse Jannah teaches an elderly client with
right-sided weakness how to use cane. Which of
the following behaviors, if demonstrated by the
client to the nurse, indicates that the teaching
was effective?
a. The client holds the cane with his right
hand, moves the can forward followed
by the right leg, and then moves the left
leg.
b. The client holds the cane with his right
hand, moves the cane forward followed
by his left leg, and then moves the right
leg.
c. The client holds the cane with his left
hand, moves the cane forward followed
by the right leg, and then moves the left
leg.
d. The client holds the cane with his left
hand, moves the cane forward followed
by his left leg, and then moves the right
leg.
97. An elderly client is admitted to the nursing home
setting. The client is occasionally confused and
her gait is often unsteady. Which of the
following actions, if taken by the nurse, is most
appropriate?
a. Ask the woman’s family to provide
personal items such as photos or
mementos.
b. Select a room with a bed by the door so
the woman can look down the hall.
c. Suggest the woman eat her meals in the
room with her roommate.
d. Encourage the woman to ambulate in
the halls twice a day.
98. Nurse Evangeline teaches an elderly client how
to use a standard aluminum walker. Which of
the following behaviors, if demonstrated by the
client, indicates that the nurse’s teaching was
effective?
a. The client slowly pushes the walker
forward 12 inches, then takes small
steps forward while leaning on the
walker.
b. The client lifts the walker, moves it
forward 10 inches, and then takes
several small steps forward.
c. The client supports his weight on the
walker while advancing it forward, then
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takes small steps while balancing on the
walker.
d. The client slides the walker 18 inches
forward, then takes small steps while
holding onto the walker for balance.
99. Nurse Deric is supervising a group of elderly
clients in a residential home setting. The nurse
knows that the elderly are at greater risk of
developing sensory deprivation for what reason?
a. Increased sensitivity to the side effects
of medications.
b. Decreased visual, auditory, and
gustatory abilities.
c. Isolation from their families and familiar
surroundings.
d. Decrease musculoskeletal function and
mobility.
100.
A male client with emphysema becomes
restless and confused. What step should
nurse Jasmine take next?
a. Encourage the client to perform pursed
lip breathing.
b. Check the client’s temperature.
c. Assess the client’s potassium level.
d. Increase the client’s oxygen flow rate.
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Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations
1.
2.
3.
4.
5.
6.
7.
8.
Answer: (C) Loose, bloody
Rationale: Normal bowel function and softformed stool usually do not occur until around
the seventh day following surgery. The stool
consistency is related to how much water is
being absorbed.
Answer: (A) On the client’s right side
Rationale: The client has left visual field
blindness. The client will see only from the
right side.
Answer: (C) Check respirations, stabilize spine,
and check circulation
Rationale: Checking the airway would be
priority, and a neck injury should be
suspected.
Answer: (D) Decreasing venous return through
vasodilation.
Rationale: The significant effect of
nitroglycerin is vasodilation and decreased
venous return, so the heart does not have to
work hard.
Answer: (A) Call for help and note the time.
Rationale: Having established, by stimulating
the client, that the client is unconscious rather
than sleep, the nurse should immediately call
for help. This may be done by dialing the
operator from the client’s phone and giving
the hospital code for cardiac arrest and the
client’s room number to the operator, of if the
phone is not available, by pulling the
emergency call button. Noting the time is
important baseline information for cardiac
arrest procedure
Answer: (C) Make sure that the client takes
food and medications at prescribed intervals.
Rationale: Food and drug therapy will prevent
the accumulation of hydrochloric acid, or will
neutralize and buffer the acid that does
accumulate.
Answer: (B) Continue treatment as ordered.
Rationale: The effects of heparin are
monitored by the PTT is normally 30 to 45
seconds; the therapeutic level is 1.5 to 2 times
the normal level.
Answer: (B) In the operating room.
Rationale: 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
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these enzymes is begun at once. Skin exposed
to these enzymes even for a short time
becomes reddened, painful, and excoriated.
Answer: (B) Flat on back.
Rationale: To avoid the complication of a
painful spinal headache that can last for
several days, the client is kept in flat in a
supine position for approximately 4 to 12
hours postoperatively. Headaches are
believed to be causes by the seepage of
cerebral spinal fluid from the puncture site. By
keeping the client flat, cerebral spinal fluid
pressures are equalized, which avoids trauma
to the neurons.
Answer: (C) The client is oriented when
aroused from sleep, and goes back to sleep
immediately.
Rationale: This finding suggest that the level
of consciousness is decreasing.
Answer: (A) Altered mental status and
dehydration
Rationale: Fever, chills, hemortysis, dyspnea,
cough, and pleuritic chest pain are the
common symptoms of pneumonia, but elderly
clients may first appear with only an altered
lentil status and dehydration due to a blunted
immune response.
Answer: (B) Chills, fever, night sweats, and
hemoptysis
Rationale: Typical signs and symptoms are
chills, fever, night sweats, and hemoptysis.
Chest pain may be present from coughing, but
isn’t usual. Clients with TB typically have lowgrade fevers, not higher than 102°F (38.9°C).
Nausea, headache, and photophobia aren’t
usual TB symptoms.
Answer:(A) Acute asthma
Rationale: Based on the client’s history and
symptoms, acute asthma is the most likely
diagnosis. He’s unlikely to have bronchial
pneumonia without a productive cough and
fever and he’s too young to have developed
(COPD) and emphysema.
Answer: (B) Respiratory arrest
Rationale: Narcotics can cause respiratory
arrest if given in large quantities. It’s unlikely
the client will have asthma attack or a seizure
or wake up on his own.
Answer: (D) Decreased vital capacity
Rationale: Reduction in vital capacity is a
normal physiologic change includes decreased
elastic recoil of the lungs, fewer functional
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capillaries in the alveoli, and an increased in
residual volume.
Answer: (C) Presence of premature ventricular
contractions (PVCs) on a cardiac monitor.
Rationale: Lidocaine drips are commonly used
to treat clients whose arrhythmias haven’t
been controlled with oral medication and who
are having PVCs that are visible on the cardiac
monitor. SaO2, blood pressure, and ICP are
important factors but aren’t as significant as
PVCs in the situation.
Answer: (B) Avoid foods high in vitamin K
Rationale: The client should avoid consuming
large amounts of vitamin K because vitamin K
can interfere with anticoagulation. The client
may need to report diarrhea, but isn’t effect
of taking an anticoagulant. An electric razornot a straight razor-should be used to prevent
cuts that cause bleeding. Aspirin may increase
the risk of bleeding; acetaminophen should be
used to pain relief.
Answer: (C) Clipping the hair in the area
Rationale: Hair can be a source of infection
and should be removed by clipping. Shaving
the area can cause skin abrasions and
depilatories can irritate the skin.
Answer: (A) Bone fracture
Rationale: Bone fracture is a major
complication of osteoporosis that results
when loss of calcium and phosphate increased
the fragility of bones. Estrogen deficiencies
result from menopause-not osteoporosis.
Calcium and vitamin D supplements may be
used to support normal bone metabolism, But
a negative calcium balance isn’t a
complication of osteoporosis. Dowager’s
hump results from bone fractures. It develops
when repeated vertebral fractures increase
spinal curvature.
Answer: (C) Changes from previous
examinations.
Rationale: Women are instructed to examine
themselves to discover changes that have
occurred in the breast. Only a physician can
diagnose lumps that are cancerous, areas of
thickness or fullness that signal the presence
of a malignancy, or masses that are fibrocystic
as opposed to malignant.
Answer: (C) Balance the client’s periods of
activity and rest.
Rationale: A client with hyperthyroidism
needs to be encouraged to balance periods of
activity and rest. Many clients with
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hyperthyroidism are hyperactive and complain
of feeling very warm.
Answer: (B) Increase his activity level.
Rationale: The client should be encouraged to
increase his activity level. aintaining an ideal
weight; following a low-cholesterol, low
sodium diet; and avoiding stress are all
important factors in decreasing the risk of
atherosclerosis.
Answer: (A) Laminectomy
Rationale: The client who has had spinal
surgery, such as laminectomy, must be log
rolled to keep the spinal column straight when
turning. Thoracotomy and cystectomy may
turn themselves or may be assisted into a
comfortable position. Under normal
circumstances, hemorrhoidectomy is an
outpatient procedure, and the client may
resume normal activities immediately after
surgery.
Answer: (D) Avoiding straining during bowel
movement or bending at the waist.
Rationale: The client should avoid straining,
lifting heavy objects, and coughing harshly
because these activities increase intraocular
pressure. Typically, the client is instructed to
avoid lifting objects weighing more than 15 lb
(7kg) – not 5lb. instruct the client when lying
in bed to lie on either the side or back. The
client should avoid bright light by wearing
sunglasses.
Answer: (D) Before age 20.
Rationale: Testicular cancer commonly occurs
in men between ages 20 and 30. A male client
should be taught how to perform testicular
self- examination before age 20, preferably
when he enters his teens.
Answer: (B) Place a saline-soaked sterile
dressing on the wound.
Rationale: The nurse should first place salinesoaked sterile dressings on the open wound to
prevent tissue drying and possible infection.
Then the nurse should call the physician and
take the client’s vital signs. The dehiscence
needs to be surgically closed, so the nurse
should never try to close it.
Answer: (A) A progressively deeper breaths
followed by shallower breaths with apneic
periods.
Rationale: Cheyne-Strokes respirations are
breaths that become progressively deeper
fallowed by shallower respirations with
apneas periods. Biot’s respirations are rapid,
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deep breathing with abrupt pauses between
each breath, and equal depth between each
breath. Kussmaul’s respirationa are rapid,
deep breathing without pauses. Tachypnea is
shallow breathing with increased respiratory
rate.
Answer: (B) Fine crackles
Rationale: Fine crackles are caused by fluid in
the alveoli and commonly occur in clients with
heart failure. Tracheal breath sounds are
auscultated over the trachea. Coarse crackles
are caused by secretion accumulation in the
airways. Friction rubs occur with pleural
inflammation.
Answer: (B) The airways are so swollen that no
air cannot get through
Rationale: During an acute attack, wheezing
may stop and breath sounds become
inaudible because the airways are so swollen
that air can’t get through. If the attack is over
and swelling has decreased, there would be
no more wheezing and less emergent concern.
Crackles do not replace wheezes during an
acute asthma attack.
Answer: (D) Place the client on his side,
remove dangerous objects, and protect his
head.
Rationale: During the active seizure phase,
initiate precautions by placing the client on his
side, removing dangerous objects, and
protecting his head from injury. A bite block
should never be inserted during the active
seizure phase. Insertion can break the teeth
and lead to aspiration.
Answer: (B) Kinked or obstructed chest tube
Rationales: Kinking and blockage of the chest
tube is a common cause of a tension
pneumothorax. Infection and excessive
drainage won’t cause a tension
pneumothorax. Excessive water won’t affect
the chest tube drainage.
Answer: (D) Stay with him but not intervene at
this time.
Rationale: If the client is coughing, he should
be able to dislodge the object or cause a
complete obstruction. If complete obstruction
occurs, the nurse should perform the
abdominal thrust maneuver with the client
standing. If the client is unconscious, she
should lay him down. A nurse should never
leave a choking client alone.
Answer: (B) Current health promotion
activities
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Rationale: Recognizing an individual’s positive
health measures is very useful. General health
in the previous 10 years is important,
however, the current activities of an 84 year
old client are most significant in planning care.
Family history of disease for a client in later
years is of minor significance. Marital status
information may be important for discharge
planning but is not as significant for
addressing the immediate medical problem.
Answer: (C) Place the client in a side lying
position, with the head of the bed lowered.
Rationale: The client should be positioned in a
side-lying position with the head of the bed
lowered to prevent aspiration. A small amount
of toothpaste should be used and the mouth
swabbed or suctioned to remove pooled
secretions. Lemon glycerin can be drying if
used for extended periods. Brushing the teeth
with the client lying supine may lead to
aspiration. Hydrogen peroxide is caustic to
tissues and should not be used.
Answer: (C) Pneumonia
Rationale: Fever productive cough and
pleuritic chest pain are common signs and
symptoms of pneumonia. The client with
ARDS has dyspnea and hypoxia with
worsening hypoxia over time, if not treated
aggressively. Pleuritic chest pain varies with
respiration, unlike the constant chest pain
during an MI; so this client most likely isn’t
having an MI. the client with TB typically has a
cough producing blood-tinged sputum. A
sputum culture should be obtained to confirm
the nurse’s suspicions.
Answer: (C) A 43-yesr-old homeless man with
a history of alcoholism
Rationale: Clients who are economically
disadvantaged, malnourished, and have
reduced immunity, such as a client with a
history of alcoholism, are at extremely high
risk for developing TB. A high school student,
day- care worker, and businessman probably
have a much low risk of contracting TB.
Answer: (C ) To determine the extent of
lesions
Rationale: If the lesions are large enough, the
chest X-ray will show their presence in the
lungs. Sputum culture confirms the diagnosis.
There can be false-positive and false-negative
skin test results. A chest X-ray can’t determine
if this is a primary or secondary infection.
Answer: (B) Bronchodilators
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Rationale: Bronchodilators are the first line of
treatment for asthma because bronchoconstriction is the cause of reduced airflow.
Beta- adrenergic blockers aren’t used to treat
asthma and can cause broncho- constriction.
Inhaled oral steroids may be given to reduce
the inflammation but aren’t used for
emergency relief.
Answer: (C) Chronic obstructive bronchitis
Rationale: Because of this extensive smoking
history and symptoms the client most likely
has chronic obstructive bronchitis. Client with
ARDS have acute symptoms of hypoxia and
typically need large amounts of oxygen.
Clients with asthma and emphysema tend not
to have chronic cough or peripheral edema.
Answer: (A) The patient is under local
anesthesia during the procedure Rationale:
Before the procedure, the patient is
administered with drugs that would help to
prevent infection and rejection of the
transplanted cells such as antibiotics,
cytotoxic, and corticosteroids. During the
transplant, the patient is placed under general
anesthesia.
Answer: (D) Raise the side rails
Rationale: A patient who is disoriented is at
risk of falling out of bed. The initial action of
the nurse should be raising the side rails to
ensure patients safety.
Answer: (A) Crowd red blood cells
Rationale: The excessive production of white
blood cells crowd out red blood cells
production which causes anemia to occur.
Answer: (B) Leukocytosis
Rationale: Chronic Lymphocytic leukemia (CLL)
is characterized by increased production of
leukocytes and lymphocytes resulting in
leukocytosis, and proliferation of these cells
within the bone marrow, spleen and liver.
Answer: (A) Explain the risks of not having the
surgery
Rationale: The best initial response is to
explain the risks of not having the surgery. If
the client understands the risks but still
refuses the nurse should notify the physician
and the nurse supervisor and then record the
client’s refusal in the nurses’ notes.
Answer: (D) The 75-year-old client who was
admitted 1 hour ago with new-onset atrial
fibrillation and is receiving L.V. dilitiazem
(Cardizem)
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Rationale: The client with atrial fibrillation has
the greatest potential to become unstable and
is on L.V. medication that requires close
monitoring. After assessing this client, the
nurse should assess the client with
thrombophlebitis who is receiving a heparin
infusion, and then the 58- year-old client
admitted 2 days ago with heart failure (his
signs and symptoms are resolving and don’t
require immediate attention). The lowest
priority is the 89-year-old with end-stage
right-sided heart failure, who requires timeconsuming supportive measures.
Answer: (C) Cocaine
Rationale: Because of the client’s age and
negative medical history, the nurse should
question her about cocaine use. Cocaine
increases myocardial oxygen consumption and
can cause coronary artery spasm, leading to
tachycardia, ventricular fibrillation, myocardial
ischemia, and myocardial infarction.
Barbiturate overdose may trigger respiratory
depression and slow pulse. Opioids can cause
marked respiratory depression, while
benzodiazepines can cause drowsiness and
confusion.
Answer: (B) Nonmobile mass with irregular
edges
Rationale: Breast cancer tumors are fixed,
hard, and poorly delineated with irregular
edges. A mobile mass that is soft and easily
delineated is most often a fluid-filled benign
cyst. Axillary lymph nodes may or may not be
palpable on initial detection of a cancerous
mass. Nipple retraction — not eversion —
may be a sign of cancer.
Answer: (C) Radiation
Rationale: The usual treatment for vaginal
cancer is external or intravaginal radiation
therapy. Less often, surgery is performed.
Chemotherapy typically is prescribed only if
vaginal cancer is diagnosed in an early stage,
which is rare. Immunotherapy isn't used to
treat vaginal cancer.
Answer: (B) Carcinoma in situ, no abnormal
regional lymph nodes, and no evidence of
distant metastasis
Rationale: TIS, N0, M0 denotes carcinoma in
situ, no abnormal regional lymph nodes, and
no evidence of distant metastasis. No
evidence of primary tumor, no abnormal
regional lymph nodes, and no evidence of
distant metastasis is classified as T0, N0, M0. If
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the tumor and regional lymph nodes can't be
assessed and no evidence of metastasis exists,
the lesion is classified as TX, NX, M0. A
progressive increase in tumor size, no
demonstrable metastasis of the regional
lymph nodes, and ascending degrees of
distant metastasis is classified as T1, T2, T3, or
T4; N0; and M1, M2, or M3.
Answer: (D) "Keep the stoma moist."
Rationale: The nurse should instruct the client
to keep the stoma moist, such as by applying a
thin layer of petroleum jelly around the edges,
because a dry stoma may become irritated.
The nurse should recommend placing a stoma
bib over the stoma to filter and warm air
before it enters the stoma. The client should
begin performing stoma care without
assistance as soon as possible to gain
independence in self-care activities.
Answer: (B) Lung cancer
Rationale: Lung cancer is the most deadly type
of cancer in both women and men. Breast
cancer ranks second in women, followed (in
descending order) by colon and rectal cancer,
pancreatic cancer, ovarian cancer, uterine
cancer, lymphoma, leukemia, liver cancer,
brain cancer, stomach cancer, and multiple
myeloma.
Answer: (A) miosis, partial eyelid ptosis, and
anhidrosis on the affected side of the face.
Rationale: Horner's syndrome, which occurs
when a lung tumor invades the ribs and
affects the sympathetic nerve ganglia, is
characterized by miosis, partial eyelid ptosis,
and anhidrosis on the affected side of the
face. Chest pain, dyspnea, cough, weight loss,
and fever are associated with pleural tumors.
Arm and shoulder pain and atrophy of the arm
and hand muscles on the affected side suggest
Pancoast's tumor, a lung tumor involving the
first thoracic and eighth cervical nerves within
the brachial plexus. Hoarseness in a client
with lung cancer suggests that the tumor has
extended to the recurrent laryngeal nerve;
dysphagia suggests that the lung tumor is
compressing the esophagus.
53. Answer: (A) prostate-specific antigen,
which is used to screen for prostate cancer.
Rationale: PSA stands for prostate-specific
antigen, which is used to screen for prostate
cancer. The other answers are incorrect.
Answer: (D) "Remain supine for the time
specified by the physician." Rationale: The
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nurse should instruct the client to remain
supine for the time specified by the physician.
Local anesthetics used in a subarachnoid block
don't alter the gag reflex. No interactions
between local anesthetics and food occur.
Local anesthetics don't cause hematuria.
Answer: (C) Sigmoidoscopy
Rationale: Used to visualize the lower GI tract,
sigmoidoscopy and proctoscopy aid in the
detection of two-thirds of all colorectal
cancers. Stool Hematest detects blood, which
is a sign of colorectal cancer; however, the
test doesn't confirm the diagnosis. CEA may
be elevated in colorectal cancer but isn't
considered a confirming test. An abdominal CT
scan is used to stage the presence of
colorectal cancer.
Answer: (B) A fixed nodular mass with
dimpling of the overlying skin
Rationale: A fixed nodular mass with dimpling
of the overlying skin is common during late
stages of breast cancer. Many women have
slightly asymmetrical breasts. Bloody nipple
discharge is a sign of intraductal papilloma, a
benign condition. Multiple firm, round, freely
movable masses that change with the
menstrual cycle indicate fibrocystic breasts, a
benign condition.
Answer: (A) Liver
Rationale: The liver is one of the five most
common cancer metastasis sites. The others
are the lymph nodes, lung, bone, and brain.
The colon, reproductive tract, and WBCs are
occasional metastasis sites.
Answer: (D) The client wears a watch and
wedding band.
Rationale: During an MRI, the client should
wear no metal objects, such as jewelry,
because the strong magnetic field can pull on
them, causing injury to the client and (if they
fly off) to others. The client must lie still
during the MRI but can talk to those
performing the test by way of the microphone
inside the scanner tunnel. The client should
hear thumping sounds, which are caused by
the sound waves thumping on the magnetic
field.
Answer: (C) The recommended daily
allowance of calcium may be found in a wide
variety of foods.
Rationale: Premenopausal women require
1,000 mg of calcium per day. Postmenopausal
women require 1,500 mg per day. It's often,
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though not always, possible to get the
recommended daily requirement in the foods
we eat. Supplements are available but not
always necessary. Osteoporosis doesn't show
up on ordinary X-rays until 30% of the bone
loss has occurred. Bone densitometry can
detect bone loss of 3% or less. This test is
sometimes recommended routinely for
women over 35 who are at risk. Strenuous
exercise won't cause fractures.
Answer: (C) Joint flexion of less than 50%
Rationale: Arthroscopy is contraindicated in
clients with joint flexion of less than 50%
because of technical problems in inserting the
instrument into the joint to see it clearly.
Other contraindications for this procedure
include skin and wound infections. Joint pain
may be an indication, not a contraindication,
for arthroscopy. Joint deformity and joint
stiffness aren't contraindications for this
procedure.
Answer: (D) Gouty arthritis
Rationale: Gouty arthritis, a metabolic disease,
is characterized by urate deposits and pain in
the joints, especially those in the feet and
legs. Urate deposits don't occur in septic or
traumatic arthritis. Septic arthritis results from
bacterial invasion of a joint and leads to
inflammation of the synovial lining. Traumatic
arthritis results from blunt trauma to a joint or
ligament. Intermittent arthritis is a rare,
benign condition marked by regular, recurrent
joint effusions, especially in the knees.
Answer: (B) 30 ml/hou
Rationale: An infusion prepared with 25,000
units of heparin in 500 ml of saline solution
yields 50 units of heparin per milliliter of
solution. The equation is set up as 50 units
times X (the unknown quantity) equals 1,500
units/hour, X equals 30 ml/hour.
Answer: (B) Loss of muscle contraction
decreasing venous return
Rationale: In clients with hemiplegia or
hemiparesis loss of muscle contraction
decreases venous return and may cause
swelling of the affected extremity.
Contractures, or bony calcifications may occur
with a stroke, but don’t appear with swelling.
DVT may develop in clients with a stroke but is
more likely to occur in the lower extremities.
A stroke isn’t linked to protein loss.
Answer: (B) It appears on the distal
interphalangeal joint
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Rationale: Heberden’s nodes appear on the
distal interphalageal joint on both men and
women. Bouchard’s node appears on the
dorsolateral aspect of the proximal
interphalangeal joint.
Answer: (B) Osteoarthritis is a localized
disease rheumatoid arthritis is systemic
Rationale: Osteoarthritis is a localized disease,
rheumatoid arthritis is systemic. Osteoarthritis
isn’t gender-specific, but rheumatoid arthritis
is. Clients have dislocations and subluxations
in both disorders.
Answer: (C) The cane should be used on the
unaffected side
Rationale: A cane should be used on the
unaffected side. A client with osteoarthritis
should be encouraged to ambulate with a
cane, walker, or other assistive device as
needed; their use takes weight and stress off
joints.
Answer: (A) a. 9 U regular insulin and 21 U
neutral protamine Hagedorn (NPH).
Rationale: A 70/30 insulin preparation is 70%
NPH and 30% regular insulin. Therefore, a
correct substitution requires mixing 21 U of
NPH and 9 U of regular insulin. The other
choices are incorrect dosages for the
prescribed insulin.
Answer: (C) colchicines
Rationale: A disease characterized by joint
inflammation (especially in the great toe),
gout is caused by urate crystal deposits in the
joints. The physician prescribes colchicine to
reduce these deposits and thus ease joint
inflammation. Although aspirin is used to
reduce joint inflammation and pain in clients
with osteoarthritis and rheumatoid arthritis, it
isn't indicated for gout because it has no
effect on urate crystal formation. Furosemide,
a diuretic, doesn't relieve gout. Calcium
gluconate is used to reverse a negative
calcium balance and relieve muscle cramps,
not to treat gout.
Answer: (A) Adrenal cortex
Rationale: Excessive secretion of aldosterone
in the adrenal cortex is responsible for the
client's hypertension. This hormone acts on
the renal tubule, where it promotes
reabsorption of sodium and excretion of
potassium and hydrogen ions. The pancreas
mainly secretes hormones involved in fuel
metabolism. The adrenal medulla secretes the
catecholamines — epinephrine and
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norepinephrine. The parathyroids secrete
parathyroid hormone.
Answer: (C) They debride the wound and
promote healing by secondary intention
Rationale: For this client, wet-to-dry dressings
are most appropriate because they clean the
foot ulcer by debriding exudate and necrotic
tissue, thus promoting healing by secondary
intention. Moist, transparent dressings
contain exudate and provide a moist wound
environment. Hydrocolloid dressings prevent
the entrance of microorganisms and minimize
wound discomfort. Dry sterile dressings
protect the wound from mechanical trauma
and promote healing.
Answer: (A) Hyperkalemia
Rationale: In adrenal insufficiency, the client
has hyperkalemia due to reduced aldosterone
secretion. BUN increases as the glomerular
filtration rate is reduced. Hyponatremia is
caused by reduced aldosterone secretion.
Reduced cortisol secretion leads to impaired
glyconeogenesis and a reduction of glycogen
in the liver and muscle, causing hypoglycemia.
Answer: (C) Restricting fluids
Rationale: To reduce water retention in a
client with the SIADH, the nurse should
restrict fluids. Administering fluids by any
route would further increase the client's
already heightened fluid load.
Answer: (D) glycosylated hemoglobin level.
Rationale: Because some of the glucose in the
bloodstream attaches to some of the
hemoglobin and stays attached during the
120-day life span of red blood cells,
glycosylated hemoglobin levels provide
information about blood glucose levels during
the previous 3 months. Fasting blood glucose
and urine glucose levels only give information
about glucose levels at the point in time when
they were obtained. Serum fructosamine
levels provide information about blood
glucose control over the past 2 to 3 weeks.
Answer: (C) 4:00 pm
Rationale: NPH is an intermediate-acting
insulin that peaks 8 to 12 hours after
administration. Because the nurse
administered NPH insulin at 7 a.m., the client
is at greatest risk for hypoglycemia from 3
p.m. to 7 p.m.
Answer: (A) Glucocorticoids and androgens
Rationale: The adrenal glands have two
divisions, the cortex and medulla. The cortex
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produces three types of hormones:
glucocorticoids, mineralocorticoids, and
androgens. The medulla produces
catecholamines— epinephrine and
norepinephrine.
Answer: (A) Hypocalcemia
Rationale: Hypocalcemia may follow thyroid
surgery if the parathyroid glands were
removed accidentally. Signs and symptoms of
hypocalcemia may be delayed for up to 7 days
after surgery. Thyroid surgery doesn't directly
cause serum sodium, potassium, or
magnesium abnormalities. Hyponatremia may
occur if the client inadvertently received too
much fluid; however, this can happen to any
surgical client receiving I.V. fluid therapy, not
just one recovering from thyroid surgery.
Hyperkalemia and hypermagnesemia usually
are associated with reduced renal excretion of
potassium and magnesium, not thyroid
surgery.
Answer: (D) Carcinoembryonic antigen level
Rationale: In clients who smoke, the level of
carcinoembryonic antigen is elevated.
Therefore, it can't be used as a general
indicator of cancer. However, it is helpful in
monitoring cancer treatment because the
level usually falls to normal within 1 month if
treatment is successful. An elevated acid
phosphatase level may indicate prostate
cancer. An elevated alkaline phosphatase level
may reflect bone metastasis. An elevated
serum calcitonin level usually signals thyroid
cancer.
Answer: (B) Dyspnea, tachycardia, and pallor
Rationale: Signs of iron-deficiency anemia
include dyspnea, tachycardia, and pallor as
well as fatigue, listlessness, irritability, and
headache. Night sweats, weight loss, and
diarrhea may signal acquired
immunodeficiency syndrome (AIDS). Nausea,
vomiting, and anorexia may be signs of
hepatitis B. Itching, rash, and jaundice may
result from an allergic or hemolytic reaction.
Answer: (D) "I'll need to have a C-section if I
become pregnant and have a baby."
Rationale: The human immunodeficiency virus
(HIV) is transmitted from mother to child via
the transplacental route, but a Cesarean
section delivery isn't necessary when the
mother is HIV-positive. The use of birth
control will prevent the conception of a child
who might have HIV. It's true that a mother
80.
81.
82.
83.
84.
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who's HIV positive can give birth to a baby
who's HIV negative.
Answer: (C) "Avoid sharing such articles as
toothbrushes and razors."
Rationale: The human immunodeficiency virus
(HIV), which causes AIDS, is most
concentrated in the blood. For this reason, the
client shouldn't share personal articles that
may be blood-contaminated, such as
toothbrushes and razors, with other family
members. HIV isn't transmitted by bathing or
by eating from plates, utensils, or serving
dishes used by a person with AIDS.
Answer: (B) Pallor, tachycardia, and a sore
tongue
Rationale: Pallor, tachycardia, and a sore
tongue are all characteristic findings in
pernicious anemia. Other clinical
manifestations include anorexia; weight loss; a
smooth, beefy red tongue; a wide pulse
pressure; palpitations; angina; weakness;
fatigue; and paresthesia of the hands and feet.
Bradycardia, reduced pulse pressure, weight
gain, and double vision aren't characteristic
findings in pernicious anemia.
Answer: (B) Administer epinephrine, as
prescribed, and prepare to intubate the client
if necessary.
Rationale: To reverse anaphylactic shock, the
nurse first should administer epinephrine, a
potent bronchodilator as prescribed. The
physician is likely to order additional
medications, such as antihistamines and
corticosteroids; if these medications don't
relieve the respiratory compromise associated
with anaphylaxis, the nurse should prepare to
intubate the client. No antidote for penicillin
exists; however, the nurse should continue to
monitor the client's vital signs. A client who
remains hypotensive may need fluid
resuscitation and fluid intake and output
monitoring; however, administering
epinephrine is the first priority.
Answer: (D) bilateral hearing loss.
Rationale: Prolonged use of aspirin and other
salicylates sometimes causes bilateral hearing
loss of 30 to 40 decibels. Usually, this adverse
effect resolves within 2 weeks after the
therapy is discontinued. Aspirin doesn't lead
to weight gain or fine motor tremors. Large or
toxic salicylate doses may cause respiratory
alkalosis, not respiratory acidosis.
Answer: (D) Lymphocyte
85.
86.
87.
Rationale: The lymphocyte provides adaptive
immunity — recognition of a foreign antigen
and formation of memory cells against the
antigen. Adaptive immunity is mediated by B
and T lymphocytes and can be acquired
actively or passively. The neutrophil is crucial
to phagocytosis. The basophil plays an
important role in the release of inflammatory
mediators. The monocyte functions in
phagocytosis and monokine production.
Answer: (A) moisture replacement.
Rationale: Sjogren's syndrome is an
autoimmune disorder leading to progressive
loss of lubrication of the skin, GI tract, ears,
nose, and vagina. Moisture replacement is the
mainstay of therapy. Though malnutrition and
electrolyte imbalance may occur as a result of
Sjogren's syndrome's effect on the GI tract, it
isn't the predominant problem. Arrhythmias
aren't a problem associated with Sjogren's
syndrome.
Answer: (C) stool for Clostridium difficile test.
Rationale: Immunosuppressed clients — for
example, clients receiving chemotherapy, —
are at risk for infection with C. difficile, which
causes "horse barn" smelling diarrhea.
Successful treatment begins with an accurate
diagnosis, which includes a stool test. The
ELISA test is diagnostic for human
immunodeficiency virus (HIV) and isn't
indicated in this case. An electrolyte panel and
hemogram may be useful in the overall
evaluation of a client but aren't diagnostic for
specific causes of diarrhea. A flat plate of the
abdomen may provide useful information
about bowel function but isn't indicated in the
case of "horse barn" smelling diarrhea.
Answer: (D) Western blot test with ELISA.
Rationale: HIV infection is detected by
analyzing blood for antibodies to HIV, which
form approximately 2 to 12 weeks after
exposure to HIV and denote infection. The
Western blot test — electrophoresis of
antibody proteins — is more than 98%
accurate in detecting HIV antibodies when
used in conjunction with the ELISA. It isn't
specific when used alone. E-rosette
immunofluorescence is used to detect viruses
in general; it doesn't confirm HIV infection.
Quantification of T-lymphocytes is a useful
monitoring test but isn't diagnostic for HIV.
The ELISA test detects HIV antibody particles
but may yield inaccurate results; a positive
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88.
89.
90.
91.
92.
93.
94.
95.
ELISA result must be confirmed by the
Western blot test.
Answer: (C) Abnormally low hematocrit (HCT)
and hemoglobin (Hb) levels
Rationale: Low preoperative HCT and Hb
levels indicate the client may require a blood
transfusion before surgery. If the HCT and Hb
levels decrease during surgery because of
blood loss, the potential need for a
transfusion increases. Possible renal failure is
indicated by elevated BUN or creatinine levels.
Urine constituents aren't found in the blood.
Coagulation is determined by the presence of
appropriate clotting factors, not electrolytes.
Answer: (A) Platelet count, prothrombin time,
and partial thromboplastin time
Rationale: The diagnosis of DIC is based on the
results of laboratory studies of prothrombin
time, platelet count, thrombin time, partial
thromboplastin time, and fibrinogen level as
well as client history and other assessment
factors. Blood glucose levels, WBC count,
calcium levels, and potassium levels aren't
used to confirm a diagnosis of DIC.
Answer: (D) Strawberries
Rationale: Common food allergens include
berries, peanuts, Brazil nuts, cashews,
shellfish, and eggs. Bread, carrots, and
oranges rarely cause allergic reactions.
Answer: (B) A client with cast on the right leg
who states, “I have a funny feeling in my right
leg.”
Rationale: It may indicate neurovascular
compromise, requires immediate assessment.
Answer: (D) A 62-year-old who had an
abdominal-perineal resection three days ago;
client complaints of chills.
Rationale: The client is at risk for peritonitis;
should be assessed for further symptoms and
infection.
Answer: (C) The client spontaneously flexes
his wrist when the blood pressure is obtained.
Rationale: Carpal spasms indicate
hypocalcemia.
Answer: (D) Use comfort measures and
pillows to position the client.
Rationale: Using comfort measures and
pillows to position the client is a nonpharmacological methods of pain relief.
Answer: (B) Warm the dialysate solution.
Rationale: Cold dialysate increases discomfort.
The solution should be warmed to body
temperature in warmer or heating pad; don’t
use microwave oven.
96. Answer: (C) The client holds the cane with his
left hand, moves the cane forward followed
by the right leg, and then moves the left leg.
Rationale: The cane acts as a support and aids
in weight bearing for the weaker right leg.
97. Answer: (A) Ask the woman’s family to
provide personal items such as photos or
mementos.
Rationale: Photos and mementos provide
visual stimulation to reduce sensory
deprivation.
98. Answer: (B) The client lifts the walker, moves
it forward 10 inches, and then takes several
small steps forward.
Rationale: A walker needs to be picked up,
placed down on all legs.
99. Answer: (C) Isolation from their families and
familiar surroundings.
Rationale: Gradual loss of sight, hearing, and
taste interferes with normal functioning.
100. Answer: (A) Encourage the client to perform
pursed lip breathing.
Rationale: Purse lip breathing prevents the
collapse of lung unit and helps client control
rate and depth of breathing.
TEST IV - Care of Clients with Physiologic and
Psychosocial Alterations
1. Randy has undergone kidney transplant, what
assessment would prompt Nurse Katrina to
suspect organ rejection?
a. Sudden weight loss
b. Polyuria
c. Hypertension
d. Shock
2. The immediate objective of nursing care for an
overweight, mildly hypertensive male client with
ureteral colic and hematuria is to decrease:
a. Pain
b. Weight
c. Hematuria
d. Hypertension
3. Matilda, with hyperthyroidism is to receive
Lugol’s iodine solution before a subtotal
thyroidectomy is performed. The nurse is aware
that this medication is given to:
a. Decrease the total basal metabolic rate.
b. Maintain the function of the parathyroid
glands.
c. Block the formation of thyroxine by the
thyroid gland.
d. Decrease the size and vascularity of the
thyroid gland.
4. Ricardo, was diagnosed with type I diabetes. The
nurse is aware that acute hypoglycemia also can
develop in the client who is diagnosed with:
a. Liver disease
b. Hypertension
c. Type 2 diabetes
d. Hyperthyroidism
5. Tracy is receiving combination chemotherapy for
treatment of metastatic carcinoma. Nurse Ruby
should monitor the client for the systemic side
effect of:
a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia
6. Norma, with recent colostomy expresses
concern about the inability to control the
passage of gas. Nurse Oliver should suggest that
the client plan to:
a. Eliminate foods high in cellulose.
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b. Decrease fluid intake at meal times.
c. Avoid foods that in the past caused
flatus.
d. Adhere to a bland diet prior to social
events.
7. Nurse Ron begins to teach a male client how to
perform colostomy irrigations. The nurse would
evaluate that the instructions were understood
when the client states, “I should:
a. Lie on my left side while instilling the
irrigating solution.”
b. Keep the irrigating container less than
18 inches above the stoma.”
c. Instill a minimum of 1200 ml of irrigating
solution to stimulate evacuation of the
bowel.”
d. Insert the irrigating catheter deeper into
the stoma if cramping occurs during the
procedure.”
8. Patrick is in the oliguric phase of acute tubular
necrosis and is experiencing fluid and electrolyte
imbalances. The client is somewhat confused
and complains of nausea and muscle weakness.
As part of the prescribed therapy to correct this
electrolyte imbalance, the nurse would expect
to:
a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal
saline via I.V.
9. Mario has burn injury. After Forty48 hours, the
physician orders for Mario 2 liters of IV fluid to
be administered q12 h. The drop factor of the
tubing is 10 gtt/ml. The nurse should set the
flow to provide:
a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min
10. Terence suffered from burn injury. Using the rule
of nines, which has the largest percent of burns?
a. Face and neck
b. Right upper arm and penis
c. Right thigh and penis
d. Upper trunk
11. Herbert, a 45 year old construction engineer is
brought to the hospital unconscious after falling
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from a 2-story building. When assessing the
client, the nurse would be most concerned if the
assessment revealed:
a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature
12. Nurse Sherry is teaching male client regarding
his permanent artificial pacemaker. Which
information given by the nurse shows her
knowledge deficit about the artificial cardiac
pacemaker?
a. take the pulse rate once a day, in the
morning upon awakening
b. May be allowed to use electrical
appliances
c. Have regular follow up care
d. May engage in contact sports
13. The nurse is ware that the most relevant
knowledge about oxygen administration to a
male client with COPD is
a. Oxygen at 1-2L/min is given to maintain
the hypoxic stimulus for breathing.
b. Hypoxia stimulates the central
chemoreceptors in the medulla that
makes the client breath.
c. Oxygen is administered best using a nonrebreathing mask
d. Blood gases are monitored using a pulse
oximeter.
14. Tonny has undergoes a left thoracotomy and a
partial pneumonectomy. Chest tubes are
inserted, and one-bottle water-seal drainage is
instituted in the operating room. In the
postanesthesia care unit Tonny is placed in
Fowler's position on either his right side or on
his 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 return
15. Kristine is scheduled for a bronchoscopy. When
teaching Kristine what to expect afterward, the
nurse's highest priority of information would be:
a. Food and fluids will be withheld for at
least 2 hours.
b. Warm saline gargles will be done q 2h.
c. Coughing and deep-breathing exercises
will be done q2h.
d. Only ice chips and cold liquids will be
allowed initially.
16. Nurse Tristan is caring for a male client in acute
renal failure. The nurse should expect hypertonic
glucose, insulin infusions, and sodium
bicarbonate to be used to treat:
a. hypernatremia.
b. hypokalemia.
c. hyperkalemia.
d. hypercalcemia.
17. Ms. X has just been diagnosed with condylomata
acuminata (genital warts). What information is
appropriate to tell this client?
a. This condition puts her at a higher risk
for cervical cancer; therefore, she should
have a Papanicolaou (Pap) smear
annually.
b. The most common treatment is
metronidazole (Flagyl), which should
eradicate the problem within 7 to 10
days.
c. The potential for transmission to her
sexual partner will be eliminated if
condoms are used every time they have
sexual intercourse.
d. The human papillomavirus (HPV), which
causes condylomata acuminata, can't be
transmitted during oral sex.
18. Maritess was recently diagnosed with a
genitourinary problem and is being examined in
the emergency department. When palpating her
kidneys, the nurse should keep which anatomical
fact in mind?
a. The left kidney usually is slightly higher
than the right one.
b. The kidneys are situated just above the
adrenal glands.
c. The average kidney is approximately 5
cm (2") long and 2 to 3 cm (¾" to 1-1/8")
wide.
d. The kidneys lie between the 10th and
12th thoracic vertebrae.
19. Jestoni with chronic renal failure (CRF) is
admitted to the urology unit. The nurse is aware
that the diagnostic test are consistent with CRF if
the result is:
a. Increased pH with decreased hydrogen
ions.
b. Increased serum levels of potassium,
magnesium, and calcium.
c. Blood urea nitrogen (BUN) 100 mg/dl
and serum creatinine 6.5 mg/ dl.
d. Uric acid analysis 3.5 mg/dl and
phenolsulfonphthalein (PSP) excretion
75%.
20. Katrina has an abnormal result on a
Papanicolaou test. After admitting that she read
her chart while the nurse was out of the room,
Katrina asks what dysplasia means. Which
definition should the nurse provide?
a. Presence of completely undifferentiated
tumor cells that don't resemble cells of
the tissues of their origin.
b. Increase in the number of normal cells in
a normal arrangement in a tissue or an
organ.
c. Replacement of one type of fully
differentiated cell by another in tissues
where the second type normally isn't
found.
d. Alteration in the size, shape, and
organization of differentiated cells.
21. During a routine checkup, Nurse Mariane
assesses a male client with acquired
immunodeficiency syndrome (AIDS) for signs and
symptoms of cancer. What is the most common
AIDS-related cancer?
a. Squamous cell carcinoma
b. Multiple myeloma
c. Leukemia
d. Kaposi's sarcoma
22. Ricardo is scheduled for a prostatectomy, and
the anesthesiologist plans to use a spinal
(subarachnoid) block during surgery. In the
operating room, the nurse positions the client
according to the anesthesiologist's instructions.
Why does the client require special positioning
for this type of anesthesia?
a. To prevent confusion
b. To prevent seizures
c. To prevent cerebrospinal fluid (CSF)
leakage
d. To prevent cardiac arrhythmias
23. A male client had a nephrectomy 2 days ago and
is now complaining of abdominal pressure and
nausea. The first nursing action should be to:
a. Auscultate bowel sounds.
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b. Palpate the abdomen.
c. Change the client's position.
d. Insert a rectal tube.
24. Wilfredo with a recent history of rectal bleeding
is being prepared for a colonoscopy. How should
the nurse Patricia position the client for this test
initially?
a. Lying on the right side with legs straight
b. Lying on the left side with knees bent
c. Prone with the torso elevated
d. Bent over with hands touching the floor
25. A male client with inflammatory bowel disease
undergoes an ileostomy. On the first day after
surgery, Nurse Oliver notes that the client's
stoma appears dusky. How should the nurse
interpret this finding?
a. Blood supply to the stoma has been
interrupted.
b. This is a normal finding 1 day after
surgery.
c. The ostomy bag should be adjusted.
d. An intestinal obstruction has occurred.
26. Anthony suffers burns on the legs, which nursing
intervention helps prevent contractures?
a. Applying knee splints
b. Elevating the foot of the bed
c. Hyperextending the client's palms
d. Performing shoulder range-of-motion
exercises
27. Nurse Ron is assessing a client admitted with
second- and third-degree burns on the face,
arms, and chest. Which finding indicates a
potential 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 a
cerebrovascular accident (CVA) is too weak to
move on his own. To help the client avoid
pressure ulcers, Nurse Celia should:
a. Turn him frequently.
b. Perform passive range-of-motion (ROM)
exercises.
c. Reduce the client's fluid intake.
d. Encourage the client to use a footboard.
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29. Nurse Maria plans to administer dexamethasone
cream to a female client who has dermatitis over
the anterior chest. How should the nurse apply
this topical agent?
a. With a circular motion, to enhance
absorption.
b. With an upward motion, to increase
blood supply to the affected area
c. In long, even, outward, and downward
strokes in the direction of hair growth
d. In long, even, outward, and upward
strokes in the direction opposite hair
growth
30. Nurse Kate is aware that one of the following
classes of medication protects the ischemic
myocardium by blocking catecholamines and
sympathetic nerve stimulation is:
a. Beta -adrenergic blockers
b. Calcium channel blocker
c. Narcotics
d. Nitrates
31. A male client has jugular distention. On what
position should the nurse place the head of the
bed to obtain the most accurate reading of
jugular vein distention?
a. High Fowler’s
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position
32. The nurse is aware that one of the following
classes of medications maximizes cardiac
performance in clients with heart failure by
increasing ventricular contractility?
a. Beta-adrenergic blockers
b. Calcium channel blocker
c. Diuretics
d. Inotropic agents
33. A male client has a reduced serum high-density
lipoprotein (HDL) level and an elevated lowdensity lipoprotein (LDL) level. Which of the
following dietary modifications is not
appropriate for this client?
a. Fiber intake of 25 to 30 g daily
b. Less than 30% of calories from fat
c. Cholesterol intake of less than 300 mg
daily
d. Less than 10% of calories from saturated
fat
34. A 37-year-old male client was admitted to the
coronary care unit (CCU) 2 days ago with an
acute myocardial infarction. Which of the
following actions would breach the client
confidentiality?
a. The CCU nurse gives a verbal report to
the nurse on the telemetry unit before
transferring the client to that unit
b. The CCU nurse notifies the on-call
physician about a change in the client’s
condition
c. The emergency department nurse calls
up the latest electrocardiogram results
to check the client’s progress.
d. At the client’s request, the CCU nurse
updates the client’s wife on his condition
35. A male client arriving in the emergency
department is receiving cardiopulmonary
resuscitation from paramedics who are giving
ventilations through an endotracheal (ET) tube
that they placed in the client’s home. During a
pause in compressions, the cardiac monitor
shows narrow QRS complexes and a heart rate
of beats/minute with a palpable pulse. Which of
the following actions should the nurse take first?
a. Start an L.V. line and administer
amiodarone (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 pressure
measures 126/80 mm Hg. Nurse Katrina
determines that mean arterial pressure (MAP) is
which of the following?
a. 46 mm Hg
b. 80 mm Hg
c. 95 mm Hg
d. 90 mm Hg
37. A female client arrives at the emergency
department with chest and stomach pain and a
report of black tarry stool for several months.
Which of the following order should the nurse
Oliver anticipate?
a. Cardiac monitor, oxygen, creatine kinase
and lactate dehydrogenase levels
b. Prothrombin time, partial
thromboplastin time, fibrinogen and
fibrin split product values.
c. Electrocardiogram, complete blood
count, testing for occult blood,
comprehensive serum metabolic panel.
d. Electroencephalogram, alkaline
phosphatase and aspartate
aminotransferase levels, basic serum
metabolic panel
38. Macario had coronary artery bypass graft (CABG)
surgery 3 days ago. Which of the following
conditions is suspected by the nurse when a
decrease in platelet count from 230,000 ul to
5,000 ul is noted?
a. Pancytopenia
b. Idiopathic thrombocytopemic purpura
(ITP)
c. Disseminated intravascular coagulation
(DIC)
d. Heparin-associated thrombosis and
thrombocytopenia (HATT)
39. Which of the following drugs would be ordered
by the physician to improve the platelet count in
a male client with idiopathic thrombocytopenic
purpura (ITP)?
a. Acetylsalicylic acid (ASA)
b. Corticosteroids
c. Methotrezate
d. Vitamin K
40. A female client is scheduled to receive a heart
valve replacement with a porcine valve. Which
of the following types of transplant is this?
a. Allogeneic
b. Autologous
c. Syngeneic
d. Xenogeneic
41. Marco falls off his bicycle and injuries his ankle.
Which of the following actions shows the initial
response to the injury in the extrinsic pathway?
a. Release of Calcium
b. Release of tissue thromboplastin
c. Conversion of factors XII to factor XIIa
d. Conversion of factor VIII to factor VIIIa
42. Instructions for a client with systemic lupus
erythematosus (SLE) would include information
about which of the following blood dyscrasias?
a. Dressler’s syndrome
b. Polycythemia
c. Essential thrombocytopenia
d. Von Willebrand’s disease
314
43. The nurse is aware that the following symptom
is most commonly an early indication of stage 1
Hodgkin’s disease?
a. Pericarditis
b. Night sweat
c. Splenomegaly
d. Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of
the following functions must frequently
assessed?
a. Blood pressure
b. Bowel sounds
c. Heart sounds
d. Breath sounds
45. The nurse knows that neurologic complications
of multiple myeloma (MM) usually involve which
of the following body system?
a. Brain
b. Muscle spasm
c. Renal dysfunction
d. Myocardial irritability
46. Nurse Patricia is aware that the average length
of time from human immunodeficiency virus
(HIV) infection to the development of acquired
immunodeficiency syndrome (AIDS)?
a. Less than 5 years
b. 5 to 7 years
c. 10 years
d. More than 10 years
47. An 18-year-old male client admitted with heat
stroke begins to show signs of disseminated
intravascular coagulation (DIC). Which of the
following laboratory findings is most consistent
with DIC?
a. Low platelet count
b. Elevated fibrinogen levels
c. Low levels of fibrin degradation products
d. Reduced prothrombin time
48. Mario comes to the clinic complaining of fever,
drenching night sweats, and unexplained weight
loss over the past 3 months. Physical
examination reveals a single enlarged
supraclavicular lymph node. Which of the
following is the most probable diagnosis?
a. Influenza
b. Sickle cell anemia
c. Leukemia
d. Hodgkin’s disease
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49. A male client with a gunshot wound requires an
emergency blood transfusion. His blood type is
AB negative. Which blood type would be the
safest for him to receive?
a. AB Rh-positive
b. A Rh-positive
c. A Rh-negative
d. O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid
leukemia (ALL) and beginning chemotherapy.
50. Stacy is discharged from the hospital following
her chemotherapy treatments. Which statement
of Stacy’s mother indicated that she understands
when she will contact the physician?
a. “I should contact the physician if Stacy
has difficulty in sleeping”.
b. “I will call my doctor if Stacy has
persistent vomiting and diarrhea”.
c. “My physician should be called if Stacy is
irritable and unhappy”.
d. “Should Stacy have continued hair loss, I
need to call the doctor”.
51. Stacy’s mother states to the nurse that it is hard
to see Stacy with no hair. The best response for
the 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 up
your feelings when you are with her or
else she may be upset”.
d. “This is only temporary; Stacy will regrow new hair in 3-6 months, but may
be different in texture”.
52. Stacy has beginning stomatitis. To promote oral
hygiene and comfort, the nurse in-charge
should:
a. Provide frequent mouthwash with
normal saline.
b. Apply viscous Lidocaine to oral ulcers as
needed.
c. Use lemon glycerine swabs every 2
hours.
d. Rinse mouth with Hydrogen Peroxide.
53. During the administration of chemotherapy
agents, Nurse Oliver observed that the IV site is
red and swollen, when the IV is touched Stacy
shouts in pain. The first nursing action to take is:
a. Notify the physician
b. Flush the IV line with saline solution
c. Immediately discontinue the infusion
d. Apply an ice pack to the site, followed by
warm compress.
54. The term “blue bloater” refers to a male client
which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
55. The term “pink puffer” refers to the female
client with which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
56. Jose is in danger of respiratory arrest following
the administration of a narcotic analgesic. An
arterial blood gas value is obtained. Nurse Oliver
would expect the paco2 to be which of the
following values?
a. 15 mm Hg
b. 30 mm Hg
c. 40 mm Hg
d. 80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as
follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm
Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
represents which of the following conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
58. Norma has started a new drug for hypertension.
Thirty minutes after she takes the drug, she
develops chest tightness and becomes short of
breath and tachypneic. She has a decreased level
of consciousness. These signs indicate which of
the following conditions?
a. Asthma attack
b. Pulmonary embolism
c. Respiratory failure
d. Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital
with ascites and jaundice. To rule out cirrhosis of the
liver:
59. Which laboratory test indicates liver cirrhosis?
a. Decreased red blood cell count
b. Decreased serum acid phosphate level
c. Elevated white blood cell count
d. Elevated serum aminotransferase
60. 60.The biopsy of Mr. Gonzales confirms the
diagnosis of cirrhosis. Mr. Gonzales is at
increased risk for excessive bleeding primarily
because of:
a. Impaired clotting mechanism
b. Varix formation
c. Inadequate nutrition
d. Trauma of invasive procedure
61. Mr. Gonzales develops hepatic encephalopathy.
Which clinical manifestation is most common
with this condition?
a. Increased urine output
b. Altered level of consciousness
c. Decreased tendon reflex
d. Hypotension
62. When Mr. Gonzales regained consciousness, the
physician orders 50 ml of Lactose p.o. every 2
hours. Mr. Gozales develops diarrhea. The nurse
best action would be:
a. “I’ll see if your physician is in the
hospital”.
b. “Maybe you’re reacting to the drug; I
will withhold the next dose”.
c. “I’ll lower the dosage as ordered so the
drug causes only 2 to 4 stools a day”.
d. “Frequently, bowel movements are
needed to reduce sodium level”.
63. Which of the following groups of symptoms
indicates a ruptured abdominal aortic
aneurysm?
a. Lower back pain, increased blood
pressure, decreased red blood cell (RBC)
count, increased white blood (WBC)
count.
b. Severe lower back pain, decreased blood
pressure, decreased RBC count,
increased WBC count.
c. Severe lower back pain, decreased blood
pressure, decreased RBC count,
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decreased RBC count, decreased WBC
count.
d. Intermitted lower back pain, decreased
blood pressure, decreased RBC count,
increased WBC count.
64. After undergoing a cardiac catheterization, Tracy
has a large puddle of blood under his buttocks.
Which of the following steps should the nurse
take first?
a. Call for help.
b. Obtain vital signs
c. Ask the client to “lift up”
d. Apply gloves and assess the groin site
65. Which of the following treatment is a suitable
surgical intervention for a client with unstable
angina?
a. Cardiac catheterization
b. Echocardiogram
c. Nitroglycerin
d. Percutaneous transluminal coronary
angioplasty (PTCA)
66. The nurse is aware that the following terms used
to describe reduced cardiac output and
perfusion impairment due to ineffective
pumping of the heart is:
a. Anaphylactic shock
b. Cardiogenic shock
c. Distributive shock
d. Myocardial infarction (MI)
67. A client with hypertension asks the nurse which
factors can cause blood pressure to drop to
normal levels?
a. Kidneys’ excretion to sodium only.
b. Kidneys’ retention of sodium and water
c. Kidneys’ excretion of sodium and water
d. Kidneys’ retention of sodium and
excretion of water
68. Nurse Rose is aware that the statement that
best explains why furosemide (Lasix) is
administered to treat hypertension is:
a. It dilates peripheral blood vessels.
b. It decreases sympathetic
cardioacceleration.
c. It inhibits the angiotensin-coverting
enzymes
d. It inhibits reabsorption of sodium and
water in the loop of Henle.
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69. Nurse Nikki knows that laboratory results
supports the diagnosis of systemic lupus
erythematosus (SLE) is:
a. Elavated serum complement level
b. Thrombocytosis, elevated sedimentation
rate
c. Pancytopenia, elevated antinuclear
antibody (ANA) titer
d. Leukocysis, elevated blood urea nitrogen
(BUN) and creatinine levels
70. Arnold, a 19-year-old client with a mild
concussion is discharged from the emergency
department. Before discharge, he complains of a
headache. When offered acetaminophen, his
mother tells the nurse the headache is severe
and she would like her son to have something
stronger. Which of the following responses by
the nurse is appropriate?
a. “Your son had a mild concussion,
acetaminophen is strong enough.”
b. “Aspirin is avoided because of the
danger of Reye’s syndrome in children or
young adults.”
c. “Narcotics are avoided after a head
injury because they may hide a
worsening condition.”
d. Stronger medications may lead to
vomiting, which increases the
intracarnial pressure (ICP).”
71. When evaluating an arterial blood gas from a
male client with a subdural hematoma, the
nurse notes the Paco2 is 30 mm Hg. Which of
the following responses best describes the
result?
a. Appropriate; lowering carbon dioxide
(CO2) reduces intracranial pressure (ICP)
b. Emergent; the client is poorly
oxygenated
c. Normal
d. Significant; the client has alveolar
hypoventilation
72. When prioritizing care, which of the following
clients should the nurse Olivia assess first?
a. A 17-year-old client’s 24-hours
postappendectomy
b. A 33-year-old client with a recent
diagnosis of Guillain-Barre syndrome
c. A 50-year-old client 3 days
postmyocardial infarction
d. A 50-year-old client with diverticulitis
73. JP has been diagnosed with gout and wants to
know why colchicine is used in the treatment of
gout. Which of the following actions of
colchicines explains why it’s effective for gout?
a. Replaces estrogen
b. Decreases infection
c. Decreases inflammation
d. Decreases bone demineralization
74. Norma asks for information about osteoarthritis.
Which of the following statements about
osteoarthritis is correct?
a. Osteoarthritis is rarely debilitating
b. Osteoarthritis is a rare form of arthritis
c. Osteoarthritis is the most common form
of arthritis
d. Osteoarthritis afflicts people over 60
75. Ruby is receiving thyroid replacement therapy
develops the flu and forgets to take her thyroid
replacement medicine. The nurse understands
that skipping this medication will put the client
at risk for developing which of the following lifethreatening complications?
a. Exophthalmos
b. Thyroid storm
c. Myxedema coma
d. Tibial myxedema
76. Nurse Sugar is assessing a client with Cushing's
syndrome. Which observation should the nurse
report to the physician immediately?
a. Pitting edema of the legs
b. An irregular apical pulse
c. Dry mucous membranes
d. Frequent urination
77. Cyrill with severe head trauma sustained in a car
accident is admitted to the intensive care unit.
Thirty-six hours later, the client's urine output
suddenly rises above 200 ml/hour, leading the
nurse to suspect diabetes insipidus. Which
laboratory findings support the nurse's suspicion
of diabetes insipidus?
a. Above-normal urine and serum
osmolality levels
b. Below-normal urine and serum
osmolality levels
c. Above-normal urine osmolality level,
below-normal serum osmolality level
d. Below-normal urine osmolality level,
above-normal serum osmolality level
78. Jomari is diagnosed with hyperosmolar
hyperglycemic nonketotic syndrome (HHNS) is
stabilized and prepared for discharge. When
preparing the client for discharge and home
management, which of the following statements
indicates that the client understands her
condition and how to control it?
a. "I can avoid getting sick by not becoming
dehydrated and by paying attention to
my need to urinate, drink, or eat more
than usual."
b. "If I experience trembling, weakness,
and headache, I should drink a glass of
soda that contains sugar."
c. "I will have to monitor my blood glucose
level closely and notify the physician if
it's constantly elevated."
d. "If I begin to feel especially hungry and
thirsty, I'll eat a snack high in
carbohydrates."
79. A 66-year-old client has been complaining of
sleeping more, increased urination, anorexia,
weakness, irritability, depression, and bone pain
that interferes with her going outdoors. Based
on these assessment findings, the nurse would
suspect which of the following disorders?
a. Diabetes mellitus
b. Diabetes insipidus
c. Hypoparathyroidism
d. Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering
from addisonian crisis about the need to take
fludrocortisone acetate and hydrocortisone at
home. Which statement by the client indicates
an understanding of the instructions?
a. "I'll take my hydrocortisone in the late
afternoon, before dinner."
b. "I'll take all of my hydrocortisone in the
morning, right after I wake up."
c. "I'll take two-thirds of the dose when I
wake up and one-third in the late
afternoon."
d. "I'll take the entire dose at bedtime."
81. Which of the following laboratory test results
would suggest to the nurse Len that a client has
a corticotropin-secreting pituitary adenoma?
a. High corticotropin and low cortisol levels
b. Low corticotropin and high cortisol levels
c. High corticotropin and high cortisol
levels
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d. Low corticotropin and low cortisol levels
82. A male client is scheduled for a transsphenoidal
hypophysectomy to remove a pituitary tumor.
Preoperatively, the nurse should assess for
potential complications by doing which of the
following?
a. Testing for ketones in the urine
b. Testing urine specific gravity
c. Checking temperature every 4 hours
d. Performing capillary glucose testing
every 4 hours
83. Capillary glucose monitoring is being performed
every 4 hours for a client diagnosed with
diabetic ketoacidosis. Insulin is administered
using a scale of regular insulin according to
glucose results. At 2 p.m., the client has a
capillary glucose level of 250 mg/dl for which he
receives 8 U of regular insulin. Nurse Mariner
should expect the dose's:
a. onset to be at 2 p.m. and its peak to be
at 3 p.m.
b. onset to be at 2:15 p.m. and its peak to
be at 3 p.m.
c. onset to be at 2:30 p.m. and its peak to
be at 4 p.m.
d. onset to be at 4 p.m. and its peak to be
at 6 p.m.
84. The physician orders laboratory tests to confirm
hyperthyroidism in a female client with classic
signs and symptoms of this disorder. Which test
result would confirm the diagnosis?
a. No increase in the thyroid-stimulating
hormone (TSH) level after 30 minutes
during the TSH stimulation test
b. A decreased TSH level
c. An increase in the TSH level after 30
minutes during the TSH stimulation test
d. Below-normal levels of serum
triiodothyronine (T3) and serum
thyroxine (T4) as detected by
radioimmunoassay
85. Rico with diabetes mellitus must learn how to
self-administer insulin. The physician has
prescribed 10 U of U-100 regular insulin and 35
U of U-100 isophane insulin suspension (NPH) to
be taken before breakfast. When teaching the
client how to select and rotate insulin injection
sites, the nurse should provide which
instruction?
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a. "Inject insulin into healthy tissue with
large blood vessels and nerves."
b. "Rotate injection sites within the same
anatomic region, not among different
regions."
c. "Administer insulin into areas of scar
tissue or hypotrophy whenever
possible."
d. "Administer insulin into sites above
muscles that you plan to exercise heavily
later that day."
86. Nurse Sarah expects to note an elevated serum
glucose level in a client with hyperosmolar
hyperglycemic nonketotic syndrome (HHNS).
Which other laboratory finding should the nurse
anticipate?
a. Elevated serum acetone level
b. Serum ketone bodies
c. Serum alkalosis
d. Below-normal serum potassium level
87. For a client with Graves' disease, which nursing
intervention promotes comfort?
a. Restricting intake of oral fluids
b. Placing extra blankets on the client's bed
c. Limiting intake of high-carbohydrate
foods
d. Maintaining room temperature in the
low-normal range
88. Patrick is treated in the emergency department
for a Colles' fracture sustained during a fall.
What is a Colles' fracture?
a. Fracture of the distal radius
b. Fracture of the olecranon
c. Fracture of the humerus
d. Fracture of the carpal scaphoid
89. Cleo is diagnosed with osteoporosis. Which
electrolytes are involved in the development of
this disorder?
a. Calcium and sodium
b. Calcium and phosphorous
c. Phosphorous and potassium
d. Potassium and sodium
90. Johnny a firefighter was involved in
extinguishing a house fire and is being treated to
smoke inhalation. He develops severe hypoxia
48 hours after the incident, requiring intubation
and mechanical ventilation. He most likely has
developed which of the following conditions?
a. Adult respiratory distress syndrome
(ARDS)
b. Atelectasis
c. Bronchitis
d. Pneumonia
91. A 67-year-old client develops acute shortness of
breath and progressive hypoxia requiring right
femur. The hypoxia was probably caused by
which of the following conditions?
a. Asthma attack
b. Atelectasis
c. Bronchitis
d. Fat embolism
92. A client with shortness of breath has decreased
to absent breath sounds on the right side, from
the apex to the base. Which of the following
conditions would best explain this?
a. Acute asthma
b. Chronic bronchitis
c. Pneumonia
d. Spontaneous pneumothorax
93. A 62-year-old male client was in a motor vehicle
accident as an unrestrained driver. He’s now in
the emergency department complaining of
difficulty of breathing and chest pain. On
auscultation of his lung field, no breath sounds
are present in the upper lobe. This client may
have which of the following conditions?
a. Bronchitis
b. Pneumonia
c. Pneumothorax
d. Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills
the area of the thoracic cavity?
a. The space remains filled with air only
b. The surgeon fills the space with a gel
c. Serous fluids fills the space and
consolidates the region
d. The tissue from the other lung grows
over to the other side
95. Hemoptysis may be present in the client with a
pulmonary embolism because of which of the
following reasons?
a. Alveolar damage in the infracted area
b. Involvement of major blood vessels in
the occluded area
c. Loss of lung parenchyma
d. Loss of lung tissue
96. Aldo with a massive pulmonary embolism will
have an arterial blood gas analysis performed to
determine the extent of hypoxia. The acid-base
disorder that may be present is?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22year-old client is admitted with a pneumothorax.
The surgeon inserts a chest tube and attaches it
to a chest drainage system. Bubbling soon
appears in the water seal chamber. Which of the
following is the most likely cause of the
bubbling?
a. Air leak
b. Adequate suction
c. Inadequate suction
d. Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a
postoperative client. The client receives 3,000 ml
of Ringer’s lactate solution IV to run over 24
hours. The IV infusion set has a drop factor of 10
drops per milliliter. The nurse should regulate
the client’s IV to deliver how many drops per
minute?
a. 18
b. 21
c. 35
d. 40
99. Mickey, a 6-year-old child with a congenital
heart disorder is admitted with congestive heart
failure. Digoxin (lanoxin) 0.12 mg is ordered for
the child. The bottle of Lanoxin contains .05 mg
of Lanoxin in 1 ml of solution. What amount
should the nurse administer to the child?
a. 1.2 ml
b. 2.4 ml
c. 3.5 ml
d. 4.2 ml
100. Nurse Alexandra teaches a client about elastic
stockings. Which of the following statements,
if made by the client, indicates to the nurse
that the teaching was successful?
a. “I will wear the stockings until the
physician tells me to remove them.”
b. “I should wear the stockings even when I
am sleep.”
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c. “Every four hours I should remove the
stockings for a half hour.”
d. “I should put on the stockings before
getting out of bed in the morning.”
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Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations
1.
Answer: (C) Hypertension
Rationale: Hypertension, along with fever,
and tenderness over the grafted kidney,
reflects acute rejection.
2.
Answer: (A) Pain
Rationale: Sharp, severe pain (renal colic)
radiating toward the genitalia and thigh is
caused by uretheral distention and
smooth muscle spasm; relief form pain is
the priority.
3.
Answer: (D) Decrease the size and
vascularity of the thyroid gland.
Rationale: Lugol’s solution provides
iodine, which aids in decreasing the
vascularity of the thyroid gland, which
limits the risk of hemorrhage when
surgery is performed.
4.
Answer: (A) Liver Disease
Rationale: The client with liver disease has
a decreased ability to metabolize
carbohydrates because of a decreased
ability to form glycogen (glycogenesis) and
to form glucose from glycogen.
5.
Answer: (C) Leukopenia
Rationale: Leukopenia, a reduction in
WBCs, is a systemic effect of
chemotherapy as a result of
myelosuppression.
6.
Answer: (C) Avoid foods that in the past
caused flatus.
Rationale: Foods that bothered a person
preoperatively will continue to do so after
a colostomy.
7.
Answer: (B) Keep the irrigating container
less than 18 inches above the stoma.”
Rationale: This height permits the solution
to flow slowly with little force so that
excessive peristalsis is not immediately
precipitated.
8.
Answer: (A) Administer Kayexalate
Rationale: Kayexalate,a potassium
exchange resin, permits sodium to be
exchanged for potassium in the intestine,
reducing the serum potassium level.
9.
Answer:(B) 28 gtt/min
Rationale: This is the correct flow rate;
multiply the amount to be infused (2000
ml) by the drop factor (10) and divide the
result by the amount of time in minutes
(12 hours x 60 minutes)
10.
11.
12.
13.
14.
15.
16.
Answer: (D) Upper trunk
Rationale: The percentage designated for
each burned part of the body using the
rule of nines: Head and neck 9%; Right
upper extremity 9%; Left upper extremity
9%; Anterior trunk 18%; Posterior trunk
18%; Right lower extremity 18%; Left
lower extremity 18%; Perineum 1%.
Answer: (C) Bleeding from ears
Rationale: The nurse needs to perform a
thorough assessment that could indicate
alterations in cerebral function, increased
intracranial pressures, fractures and
bleeding. Bleeding from the ears occurs
only wit