PNLE I for 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 half-normal 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 In-charge 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
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 incharge 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.
B.
C.
D.
Assessment
Evaluation
Implementation
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 midthigh.
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 in-charge can prevent chest tube
air leaks by:
A. Checking and taping all connections.
B. Checking patency of the chest tube.
C. Keeping the head of the bed 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.
B.
C.
D.
Summative
Informative
Formative
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.
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?
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
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
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.
B.
C.
D.
Do nothing.
Invert the vial and let it stand for 3 to 5 minutes.
Shake the vial vigorously.
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.
B.
C.
D.
Dullness over the liver.
Bowel sounds occurring every 10 seconds.
Shifting dullness over the abdomen.
Vascular sounds heard over the renal arteries.
PNLE II for 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 require:
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 caesareans, 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 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
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 (tri-somy 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 secondtrimester 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.
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. Advice 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
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 everyday.
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
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
extra-uterine 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
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. Maureen, a primigravida client, age 20, has just completed a difficult, forcepsassisted 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. Uterine inversion
B. Uterine atony
C. Uterine involution
D. Uterine discomfort
PNLE III for Care of Clients with
Physiologic and Psychosocial
Alterations (Part 1)
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 post-myocardial 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
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. 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 a out patient 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 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 in-charge that she has found a painless
lump in her right breast during her monthly self-examination. 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:
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
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 wetto- 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
lifethreatening 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.
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 20lb 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.”
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 abdominal-perineal 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 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.
PNLE IV for Care of Clients with
Physiologic and Psychosocial
Alterations (Part 2)
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 form 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 non-rebreathing 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 the 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.
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 protect 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 low-density 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 form 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
43. The nurse is aware that the following symptoms 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 re-grow 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. Respirator y 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.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 your 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 re 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 ask 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 clients 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
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?
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 22-year-old client is admitted with a
pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage
system. Bubbling soon appears in the water seal chamber. Which of the following is
the most likely cause of the bubbling?
A. Air leak
B. Adequate suction
C. Inadequate suction
D. Kinked chest 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.
B.
C.
D.
“I will wear the stockings until the physician tells me to remove them.”
“I should wear the stockings even when I am sleep.”
“Every four hours I should remove the stockings for a half hour.”
“I should put on the stockings before getting out of bed in the morning.”
PNLE V for Care of Clients with
Physiologic and Psychosocial
Alterations (Part 3)
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 awhile 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
sleepwake 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 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 symptom-free 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?
A. Antidepressants
B. Anticholinergics
C. Antipsychotics
D. 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. 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. Which
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.
B.
C.
D.
“It is the voice of your conscience, which only you can control.”
“No, I do not hear your voices, but I believe you can hear them”.
“The voices are coming from within you and only you can hear them.”
“Oh, the voices are a symptom of your illness; don’t pay any attention to
them.”
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 characteristics of a client with a major
depression, it would be unusual for the nurse to find that this client demonstrated:
A. Rigidity
B. Stubbornness
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 nay 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 teaching 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. 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.
B.
C.
D.
phenelzine (Nardil)
chlordiazepoxide (Librium)
lithium carbonate (Lithane)
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 lifethreatening 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.
52.Mr. Cruz visits the physician’s office to seek treatment for depression, feelings of
hopelessness, poor appetite, insomnia, fatigue, low selfesteem, 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. Calcium
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.
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
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
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.
B.
C.
D.
Heroin
Cocaine
LSD
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:
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.
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
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.
B.
C.
D.
Splitting
Transference
Countertransference
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
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 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.
B.
C.
D.
Stopping the drug may cause depression
Stopping the drug increases cognitive abilities
Stopping the drug decreases sleeping difficulties
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.
B.
C.
D.
It involves a mood range from moderate depression to hypomania
It involves a single manic depression
It’s a form of depression that occurs in the fall and winter
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.
B.
C.
D.
The client tries to hit the nurse when vital signs must be taken
The client says, “I keep hearing a voice telling me to run away”
The client becomes anxious whenever the nurse leaves the bedside
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
selfesteem. Which of the following statements by the Tommy shows teaching
was successful?
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 year-round basis
C. Be aware you’ll feel increased energy taking this drug
D. This drug will indirectly control essential hypertension
PNLE I Nursing Practice
Scope of this Nursing Test I is parallel to the NP1 NLE Coverage:
 Foundation of Nursing
 Nursing Research
 Professional Adjustment
 Leadership and Management
1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel
(UAP). Which of the following task could the registered nurse safely assigned to a
UAP?
A. Monitor the I&O of a comatose toddler client with salicylate poisoning
B. Perform a complete bed bath on a 2-year-old with multiple injuries from a
serious fall
C. Check the IV of a preschooler with Kawasaki disease
D. Give an outmeal bath to an infant with eczema
2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics
unit. There were three patients assigned to the RN. Which of the following patients
should not be assigned to the floated nurse?
A. A 9-year-old child diagnosed with rheumatic fever
B. A young infant after pyloromyotomy
C. A 4-year-old with VSD following cardiac catheterization
D. A 5-month-old with Kawasaki disease
3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to
assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following
patients could the nurse manager safely assign to the float nurse?
A. A child who had multiple injuries from a serious vehicle accident
B. A child diagnosed with Kawasaki disease and with cardiac complications
C. A child who has had a nephrectomy for Wilm’s tumor
D. A child receiving an IV chelating therapy for lead poisoning
4. The registered nurse is planning to delegate task to a certified nursing assistant.
Which of the following clients should not be assigned to a CAN?
A. A client diagnosed with diabetes and who has an infected toe
B. A client who had a CVA in the past two months
C. A client with Chronic renal failure
D. A client with chronic venous insufficiency
5. The nurse in the medication unit passes the medications for all the clients on the
nursing unit. The head nurse is making rounds with the physician and coordinates
clients’ activities with other departments. The nurse assistant changes the bed lines
and answers call lights. A second nurse is assigned for changing wound dressings; a
licensed practitioner nurse takes vital signs and bathes theclients. This illustrates of
what method of nursing care?
A. Case management method
B. Primary nursing method
C. Team method
D. Functional method
6. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is
responsible for every aspect of care such as formulating the care of plan, intervention
and evaluating the care during her shift. At the end of her shift, the RN will pass this
same task to the next RN in charge. This nursing care illustrates of what kind of
method?
A. primary nursing method
B. case method
C. team method
D. functional method
7. A newly hired nurse on an adult medicine unit with 3 months experience was asked
to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an
interesting assignment that feels overwhelming. The nurse should:
A. resign on the spot from the nursing position and apply for a position that
does not require floating
B. Inform the nursing supervisor and the charge nurse on the pediatric floor
about the nurse’s lack of skill and feelings of hesitations and request
assistance
C. Ask several other nurses how they feel about pediatrics and find someone
else who is willing to accept the assignment
D. Refuse the assignment and leave the unit requesting a vacation a day
8. An experienced nurse who voluntarily trained a less experienced nurse with the
intention of enhancing the skills and knowledge and promoting professional
advancement to the nurse is called a:
A. mentor
B. team leader
C. case manager
D. change agent
9. The pediatrics unit is understaffed and the nurse manager informs the nurses in the
obstetrics unit that she is going to assign one nurse to float in the pediatric units.
Which statement by the designated float nurse may put her job at risk?
A.
B.
C.
D.
“I do not get along with one of the nurses on the pediatrics unit”
“I have a vacation day coming and would like to take that now”
“I do not feel competent to go and work on that area”
“ I am afraid I will get the most serious clients in the unit”
10. The newly hired staff nurse has been working on a medical unit for 3 weeks. The
nurse manager has posted the team leader assignments for the following week. The
new staff knows that a major responsibility of the team leader is to:
A. Provide care to the most acutely ill client on the team
B. Know the condition and needs of all the patients on the team
C. Document the assessments completed by the team members
D. Supervise direct care by nursing assistants
11. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery.
The nurse prepared the consent form and it should be signed by:
A. The Physician
B. The Registered Nurse caring for the client
C. The 15-year-old mother of the baby boy
D. The mother of the girl
12. A nurse caring to a client with Alzheimer’s disease overheard a family member
say to the client, “if you pee one more time, I won’t give you any more food and
drinks”. What initial action is best for the nurse to take?
A. Take no action because it is the family member saying that to the client
B. Talk to the family member and explain that what she/he has said is not
appropriate for the client
C. Give the family member the number for an Elder Abuse Hot line
D. Document what the family member has said
13. Which is true about informed consent?
A. A nurse may accept responsibility signing a consent form if the client is
unable
B. Obtaining consent is not the responsibility of the physician
C. A physician will not subject himself to liability if he withholds any facts
that are necessary to form the basis of an intelligent consent
D. If the nurse witnesses a consent for surgery, the nurse is, in effect,
indicating that the signature is that of the purported person and that the
person’s condition is as indicated at the time of signing
14. A mother in labor told the nurse that she was expecting that her baby has no
chance to survive and expects that the baby will be born dead. The mother accepts the
fate of the baby and informs the nurse that when the baby is born and requires
resuscitation, the mother refuses any treatment to her baby and expresses hostility
toward the nurse while the pediatric team is taking care of the baby. The nurse is
legally obligated to:
A. Notify the pediatric team that the mother has refused resuscitation and any
treatment for the baby and take the baby to the mother
B. Get a court order making the baby a ward of the court
C. Record the statement of the mother, notify the pediatric team, and observe
carefully for signs of impaired bonding and neglect as a reasonable
suspicion of child abuse
D. Do nothing except record the mother’s statement in the medical record
15. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The
nurse is tasks to bring the informed consent document into the client’s room for a
signature. The client asks the nurse for details of the procedure and demands an
explanation why the process of informed consent is necessary. The nurse responds
that informed consent means:
A. The patient releases the physician from all responsibility for the procedure.
B. The immediate family may make decision against the patient’s will.
C. The physician must give the client or surrogates enough information to
make health care judgments consistent with their values and goals.
D. The patient agrees to a procedure ordered by the physician even if the
client does not understand what the outcome will be.
16. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for
an amputation. The client tells the nurse that he will not sign the consent form and he
does not want any surgery or treatment because of religious beliefs about
reincarnation. What is the role of the RN?
A. call a family meeting
B. discuss the religious beliefs with the physician
C. encourage the client to have the surgery
D. inform the client of other options
17. While in the hospital lobby, the RN overhears the three staff discussing the health
condition of her client. What would be the appropriate nursing action for the RN to
take?
A. Tell them it is not appropriate to discuss the condition of the client
B. Ignore them, because it is their right to discuss anything they want to
C. Join in the conversation, giving them supportive input about the case of the
client
D. Report this incident to the nursing supervisor
18. A staff nurse has had a serious issue with her colleague. In this situation, it is best
to:
A. Discuss this with the supervisor
B. Not discuss the issue with anyone. It will probably resolve itself
C. Try to discuss with the colleague about the issue and resolve it when both
are calmer
D. Tell other members of the network what the team member did
19. The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse
may not disclose confidential information when:
A. The nurse discusses the condition of the client in a clinical conference with
other nurses
B. The client asks the nurse to discuss the her condition with the family
C. The father of a woman who just delivered a baby is on the phone to find
out the sex of the baby
D. A researcher from an institutionally approved research study reviews the
medical record of a patient
20. A 17-year-old married client is scheduled for surgery. The nurse taking care of the
client realizes that consent has not been signed after preoperative medications were
given. What should the nurse do?
A. Call the surgeon
B. Ask the spouse to sign the consent
C. Obtain a consent from the client as soon as possible
D. Get a verbal consent from the parents of the client
21. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to
the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be
most correct in mixing it with:
A. Normal Saline
B. Heparinized normal saline
C. 5% dextrose in water
D. Lactated Ringer’s solution
22. The nurse is caring to a client who is hypotensive. Following a large hematemesis,
how should the nurse position the client?
A. Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
B. Low Fowler’s with knees gatched at 30 degrees
C. Supine with the head turned to the left
D. Bed sloped at a 45 degree angle with the head lowest and the legs highest
23. The client is brought to the emergency department after a serious accident. What
would be the initial nursing action of the nurse to the client?
A. assess the level of consciousness and circulation
B. check respirations, circulation, neurological response
C. align the spine, check pupils, check for hemorrhage
D. check respiration, stabilize spine, check circulation
24. A nurse is assigned to care to a client with Parkinson’s disease. What interventions
are important if the nurse wants to improve nutrition and promote effective
swallowing of the client?
A. Eat solid food
B. Give liquids with meals
C. Feed the client
D. Sit in an upright position to eat
25. During tracheal suctioning, the nurse should implement safety measures. Which of
the following should the nurse implements?
A. limit suction pressure to 150-180 mmHg
B. suction for 15-20 seconds
C. wear eye goggles
D. remove the inner cannula
26. The nurse is conducting a discharge instructions to a client diagnosed with
diabetes. What sign of hypoglycemia should be taught to a client?
A. warm, flushed skin
B. hunger and thirst
C. increase urinary output
D. palpitation and weakness
27. A client admitted to the hospital and diagnosed with Addison’s disease. What
would be the appropriate nursing action to the client?
A. administering insulin-replacement therapy
B. providing a low-sodium diet
C. restricting fluids to 1500 ml/day
D. reducing physical and emotional stress
28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which
nursing action is essential to prevent hypoxemia?
A. aucultating the lungs to determine the baseline data to assess the
effectiveness of suctioning
B. removing oral and nasal secretions
C. encouraging the patient to deep breathe and cough to facilitate removal of
upper-airway secretions
D. administering 100% oxygen to reduce the effects of airway obstruction
during suctioning.
29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red
marks on the swollen face resembling a handprint. The nurse does further assessment
to the client. How would the nurse document the finding?
A. Facial edema with ecchymosis and handprint mark: crackles and wheezes
B. Facial edema, with red marks; crackles in the lung
C. Facial edema with ecchymosis that looks like a handprint
D. Red bruise mark and ecchymosis on face
30. On the evening shift, the triage nurse evaluates several clients who were brought
to the emergency department. Which in the following clients should receive highest
priority?
A. an elderly woman complaining of a loss of appetite and fatigue for the past
week
B. A football player limping and complaining of pain and swelling in the right
ankle
C. A 50-year-old man, diaphoretic and complaining of severe chest pain
radiating to his jaw
D. A mother with a 5-year-old boy who says her son has been complaining of
nausea and vomited once since noon
31. A 80-year-old female client is brought to the emergency department by her
caregiver, on the nurse’s assessment; the following are the manifestations of the
client: anorexia, cachexia and multiple bruises. What would be the best nursing
intervention?
A. check the laboratory data for serum albumin, hematocrit, and hemoglobin
B. talk to the client about the caregiver and support system
C. complete a police report on elder abuse
D. complete a gastrointestinal and neurological assessment
32. The night shift nurse is making rounds. When the nurse enters a client’s room, the
client is on the floor next to the bed. What would be the initial action of the nurse?
A. chart that the patient fell
B. call the physician
C. chart that the client was found on the floor next to the bed
D. fill out an incident report
33. The nurse on the night shift is about to administer medication to a preschooler
client and notes that the child has no ID bracelet. The best way for the nurse to
identify the client is to ask:
A. The adult visiting, “The child’s name is ____________________?”
B. The child, “Is your name____________?”
C. Another staff nurse to identify this child
D. The other children in the room what the child’s name is
34. The nurse caring to a client has completed the assessment. Which of the following
will be considered to be the most accurate charting of a lump felt in the right breast?
A. “abnormally felt area in the right breast, drainage noted”
B. “hard nodular mass in right breast nipple”
C. “firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
D. “mass in the right breast 4cmx1cm
35. The physician instructed the nurse that intravenous pyelogram will be done to the
client. The client asks the nurse what is the purpose of the procedure. The appropriate
nursing response is to:
A. outline the kidney vasculature
B. determine the size, shape, and placement of the kidneys
C. test renal tubular function and the patency of the urinary tract
D. measure renal blood flow
36. A client visits the clinic for screening of scoliosis. The nurse should ask the client
to:
A. bend all the way over and touch the toes
B. stand up as straight and tall as possible
C. bend over at a 90-degree angle from the waist
D. bend over at a 45-degree angle from the waist
37. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s
family members come to visit, they would be adhering to respiratory isolation
precautions when they:
A. wash their hands when leaving
B. put on gowns, gloves and masks
C. avoid contact with the client’s roommate
D. keep the client’s room door open
38. An infant is brought to the emergency department and diagnosed with pyloric
stenosis. The parents of the client ask the nurse, “Why does my baby continue to
vomit?” Which of the following would be the best nursing response of the nurse?
A. “Your baby eats too rapidly and overfills the stomach, which causes
vomiting
B. “Your baby can’t empty the formula that is in the stomach into the bowel”
C. “The vomiting is due to the nausea that accompanies pyloric stenosis”
D. “Your baby needs to be burped more thoroughly after feeding”
39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care
facilities. An intradermal tuberculosis test is schedule to be done. The client asks the
nurse what is the purpose of the test. Which of the following would be the best
rationale for this?
A. reactivation of an old tuberculosis infection
B. increased incidence of new cases of tuberculosis in persons over 65 years
old
C. greater exposure to diverse health care workers
D. respiratory problems are characteristic in this population
40. The nurse is making a health teaching to the parents of the client. In teaching
parents how to measure the area of induration in response to a PPD test, the nurse
would be most accurate in advising the parents to measure:
A. both the areas that look red and feel raised
B. The entire area that feels itchy to the child
C. Only the area that looks reddened
D. Only the area that feels raised
41. A community health nurse is schedule to do home visit. She visits to an elderly
person living alone. Which of the following observation would be a concern?
A. Picture windows
B. Unwashed dishes in the sink
C. Clear and shiny floors
D. Brightly lit rooms
42. After a birth, the physician cut the cord of the baby, and before the baby is given
to the mother, what would be the initial nursing action of the nurse?
A. examine the infant for any observable abnormalities
B. confirm identification of the infant and apply bracelet to mother and infant
C. instill prophylactic medication in the infant’s eyes
D. wrap the infant in a prewarmed blanket and cover the head
43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the
scalp, face, neck and arms. The client is scratching the affected areas. What would be
the best nursing intervention to prevent the client from scratching the affected areas?
A. elbow restraints to the arms
B. Mittens to the hands
C. Clove-hitch restraints to the hands
D. A posey jacket to the torso
44. The parents of the hospitalized client ask the nurse how their baby might have
gotten pyloric stenosis. The appropriate nursing response would be:
A. There is no way to determine this preoperatively
B. Their baby was born with this condition
C. Their baby developed this condition during the first few weeks of life
D. Their baby acquired it due to a formula allergy
45. A male client comes to the clinic for check-up. In doing a physical assessment, the
nurse should report to the physician the most common symptom of gonorrhea, which
is:
A. pruritus
B. pus in the urine
C. WBC in the urine
D. Dysuria
46. Which of the following would be the most important goal in the nursing care of an
infant client with eczema?
A. preventing infection
B. maintaining the comfort level
C. providing for adequate nutrition
D. decreasing the itching
47. The nurse is making a discharge instruction to a client receiving chemotherapy.
The client is at risk for bone marrow depression. The nurse gives instructions to the
client about how to prevent infection at home. Which of the following health teaching
would be included?
A. “Get a weekly WBC count”
B. “Do not share a bathroom with children or pregnant woman”
C. “Avoid contact with others while receiving chemotherapy”
D. “Do frequent hand washing and maintain good hygiene”
48. The nurse is assigned to care the client with infectious disease. The best
antimicrobial agent for the nurse to use in handwashing is:
A. Isopropyl alcohol
B. Hexachlorophene (Phisohex)
C. Soap and water
D. Chlorhexidine gluconate (CHG) (Hibiclens)
49. The mother of the client tells the nurse, “ I’m not going to have my baby get any
immunization”. What would be the best nursing response to the mother?
“You and I need to review your rationale for this decision”
“Your baby will not be able to attend day care without immunizations”
“Your decision can be viewed as a form of child abuse and neglect”
“You are needlessly placing other people at risk for communicable
diseases”
50. The nurse is teaching the client about breast self-examination. Which observation
should the client be taught to recognize when doing the examination for detection of
breast cancer?
A.
B.
C.
D.
A.
B.
C.
D.
tender, movable lump
pain on breast self-examination
round, well-defined lump
dimpling of the breast tissue
PNLE II Nursing Practice
The scope of this Nursing Test II is parallel to the NP2 NLE Coverage:
 Maternal and Child Health
 Community Health Nursing
 Communicable Diseases
 Integrated Management of Childhood Illness
1. The student nurse is assigned to take the vital signs of the clients in the pediatric
ward. The student nurse reports to the staff nurse that the parent of a toddler who is 2
days postoperative after a cleft palate repair has given the toddler a pacifier. What
would be the best immediate action of the nurse?
A. Notify the pediatrician of this finding
B. Reassure the student that this is an acceptable action on the parent’s part
C. Discuss this action with the parents
D. Ask the student nurse to remove the pacifier from the toddler’s mouth
2. The nurse is providing a health teaching to the mother of an 8-year-old child with
cystic fibrosis. Which of the following statement if made by the mother would
indicate to the nurse the need for further teaching about the medication regimen of the
child?
A.
B.
C.
D.
“My child might need an extra capsule if the meal is high in fat”
“I’ll give the enzyme capsule before every snack”
“I’ll give the enzyme capsule before every meal”
“My child hates to take pills, so I’ll mix the capsule into a cup of hot
chocolate
3. The mother brought her child to the clinic for follow-up check up. The mother tells
the nurse that 14 days after starting an oral iron supplement, her child’s stools are
black. Which of the following is the best nursing response to the mother?
A. “I will notify the physician, who will probably decrease the dosage
slightly”
B. “This is a normal side effect and means the medication is working”
C. “You sound quite concerned. Would you like to talk about this further?”
D. “I will need a specimen to check the stool for possible bleeding”
4. An 8-year-old boy with asthma is brought to the clinic for check up. The mother
asks the nurse if the treatment given to her son is effective. What would be the
appropriate response of the nurse?
A. I will review first the child’s height on a growth chart to know if the
treatment is working
B. I will review first the child’s weight on a growth chart to know if the
treatment is working
C. I will review first the number of prescriptions refills the child has required
over the last 6 months to give you an accurate answer
D. I will review first the number of times the child has seen the pediatrician
during the last 6 months to give you an accurate answer
5. The nurse is caring to a child client who is receiving tetracycline. The nurse is
aware that in taking this medication, it is very important to:
A. Administer the drug between meals
B. Monitor the child’s hearing
C. Give the drug through a straw
D. Keep the child out of the sunlight
6. A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure
is brought to the emergency department. During assessment, the nurse checks the
apical pulse rate of the infant. The apical pulse rate is 130 beats per minute. Which of
the following is the appropriate nursing action?
A. Retake the apical pulse in 15 minutes
B. Retake the apical pulse in 30 minutes
C. Notify the pediatrician immediately
D. Administer the medication as scheduled
7. The physician prescribed gentamicin (Garamycin) to a child who is also receiving
chemotherapy. Before administering the drug, the nurse should check the results of
the child’s:
A. CBC and platelet count
B. Auditory tests
C. Renal Function tests
D. Abdominal and chest x-rays
8. Which of the following is the suited size of the needle would the nurse select to
administer the IM injection to a preschool child?
A. 18 G, 1-1/2 inch
B. 25 G, 5/8 inch
C. 21 G, 1 inch
D. 18 G, 1inch
9. A 9-year-old boy is admitted to the hospital. The boy is being treated with
salicylates for the migratory polyarthritis accompanying the diagnosis of rheumatic
fever. Which of the following activities performed by the child would give a best sign
that the medication is effective?
A. Listening to story of his mother
B. Listening to the music in the radio
C. Playing mini piano
D. Watching movie in the dvd mini player
10. The physician decided to schedule the 4-year-old client for repair of left
undescended testicle. The Injection of a hormone, HCG finds it less successful for
treatment. To administer a pentobarbital sodium (Nembutal) suppository
preoperatively to this client, in which position should the nurse place him?
A. Supine with foot of bed elevated
B. Prone with legs abducted
C. Sitting with foot of bed elevated
D. Side-lying with upper leg flexed
11. The nurse is caring to a 24-month-old child diagnosed with congenital heart
defect. The physician prescribed digoxin (Lanoxin) to the client. Before the
administration of the drug, the nurse checks the apical pulse rate to be 110 beats per
minute and regular. What would be the next nursing action?
A.
B.
C.
D.
Check the other vital signs and level of consciousness
Withhold the digoxin and notify the physician
Give the digoxin as prescribed
Check the apical and radial simultaneously, and if they are the same, give
the digoxin.
12. An 8-year-old client with cystic fibrosis is admitted to the hospital and will
undergo a chest physiotherapy treatment. The therapy should be properly coordinated
by the nurse with the respiratory therapy department so that treatments occur during:
A. After meals
B. Between meals
C. After medication
D. Around the child’s play schedule
13. The nurse is providing health teaching about the breastfeeding and family
planning to the client who gave birth to a healthy baby girl. Which of the following
statement would alert the nurse that the client needs further teaching?
A. “I understand that the hormones for breastfeeding may affect when my
periods come”
B. “Breastfeeding causes my womb to tighten and bleed less after birth”
C. “I may not have periods while I am breastfeeding, so I don’t need family
planning”
D. “I can get pregnant as early as one month after my baby was born”
14. A toddler is brought to the hospital because of severe diarrhea and vomiting. The
nurse assigned to the client enters the client’s room and finds out that the client is
using a soiled blanket brought in from home. The nurse attempts to remove the
blanket and replace it with a new and clean blanket. The toddler refuses to give the
soiled blanket. The nurse realizes that the best explanation for the toddler’s behavior
is:
A. The toddler did not bond well with the maternal figure
B. The blanket is an important transitional object
C. The toddler is anxious about the hospital experience
D. The toddler is resistive to nursing interventions
15. The nurse has knowledge about the developmental task of the child. In caring a 3year-old-client, the nurse knows that the suited developmental task of this child is to:
A. Learn to play with other children
B. Able to trust others
C. Express all needs through speaking
D. Explore and manipulate the environment
16. A mother who gave birth to her second daughter is so concerned about her 2-year
old daughter. She tells the nurse, “I am afraid that my 2-year-old daughter may not
accept her newly born sister”. It is appropriate to the nurse to response that:
A. The older daughter be given more responsibility and assure her “that she is
a big girl now, and doesn’t need Mommy as much”
B. The older daughter not have interaction with the baby at the hospital,
because she may harm her new sibling
C. The older daughter stay with her grandmother for a few days until the
parents and new baby are settled at home
D. The mother spend time alone with her older daughter when the baby is
sleeping
17. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go
to the playroom. Which of the following is an appropriate toy would the nurse select
for the child:
A. Puzzle
B. Musical automobile
C. Arranging stickers in the album
D. Pounding board and hammer
18. Which of the following clients is at high risk for developmental problem?
A. A toddler with acute Glomerulonephritis on antihypertensive and
antibiotics
B. A 5-year-old with asthma on cromolyn sodium
C. A preschooler with tonsillitis
D. A 2 1/2 –year old boy with cystic fibrosis
19. Which of the following would be the best divesionary activity for the nurse to
select for a 2 weeks hospitalized 3-year-old girl?
A. Crayons and coloring books
B. doll
C. xylophone toy
D. puzzles
20. A nurse is providing safety instructions to the parents of the 11-month-old child.
Which of the following will the nurse includes in the instructions?
A. Plugging all electrical outlets in the house
B. Installing a gate at the top and bottom of any stairs in the home
C. Purchasing an infant car seat as soon as possible
D. Begin to teach the child not to place small objects in the mouth
21. An 8-year-old girl is in second grade and the parents decided to enroll her to a new
school. While the child is focusing on adjusting to new environment and peers, her
grades suffer. The child’s father severely punishes the child and forces her daughter to
study after school. The father does not allow also her daughter to play with other
children. These data indicate to the nurse that this child is deprived of forming which
normal phase of development?
A. Heterosexual relationships
B. A love relationship with the father
C. A dependency relationship with the father
D. Close relationship with peers
22. A 5-year-old boy client is scheduled for hernia surgery. The nurse is preparing to
do preoperative teaching with the child. The nurse should knows that the 5-year-old
would:
A. Expect a simple yet logical explanation regarding the surgery
B. Asks many questions regarding the condition and the procedure
C. Worry over the impending surgery
D. Be uninterested in the upcoming surgery
23. The nine-year-old client is admitted in the hospital for almost 1 week and is on
bed rest. The child complains of being bored and it seems tiresome to stay on bed and
doing nothing. What activity selected by the nurse would the child most likely find
stimulating?
A. Watching a video
B. Putting together a puzzle
C. Assembling handouts with the nurse for an upcoming staff development
meeting
D. Listening to a compact disc
24. The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike
very fast and with one hand. “It is making me crazy!” What would be the best
explanation of the nurse to the behavior of the boy?
A. The adolescent might have an unconscious death wish
B. The adolescent feels indestructible
C. The adolescent lacks life experience to realize how dangerous the behavior
is
D. The adolescent has found a way to act out hostility toward the parent
25. An 8-month-old infant is admitted to the hospital due to diarrhea. The nurse caring
for the client tells the mother to stay beside the infant while making assessment.
Which of the following developmental milestones the infant has reached?
A. Has a three-word vocabulary
B. Interacts with other infants
C. Stands alone
D. Recognizes but is fearful of strangers
26. The community nurse is conducting a health teaching in the group of married
women. When teaching a woman about fertility awareness, the nurse should
emphasize that the basal body temperature:
A.
B.
C.
D.
Should be recorded each morning before any activity
Is the average temperature taken each morning
Can be done with a mercury thermometer but not a digital one
Has a lower degree of accuracy in predicting ovulation than the cervical
mucus test
27. The community nurse is providing an instruction to the clients in the health center
about the use of diaphragm for family planning. To evaluate the understanding of the
woman, the nurse asks her to demonstrate the use of the diaphragm. Which of
following statement indicates a need for further health teaching?
A. “I should check the diaphragm carefully for holes every time I use it.”
B. “The diaphragm must be left in place for at least 6 hours after intercourse.”
C. “I really need to use the diaphragm and jelly most during the middle of my
menstrual cycle
D. “I may need a different size diaphragm if I gain or lose more than 20
pounds”
28. The client visits the clinic for prenatal check-up. While waiting for the physician,
the nurse decided to conduct health teaching to the client. The nurse informed the
client that primigravida mother should go to the hospital when which patter is
evident?
A. Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes
have ruptured
B. Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as
strong menstrual cramps
C. Contractions are 3-5 minutes apart, accompanied by rectal pressure and
bloody show
D. Contractions are 5 minutes apart, lasting 60 seconds, and increasing in
intensity
29. A nurse is planning a home visit program to a new mother who is 2 weeks
postpartum and breastfeeding, the nurse includes in her health teaching about the
resumption of fertility, contraception and sexual activity. Which of the following
statement indicates that the mother has understood the teaching?
A. “Because breastfeeding speeds the healing process after birth, I can have
sex right away and not worry about infection”
B. “Because I am breastfeeding and my hormones are decreased, I may need
to use a vaginal lubricant when I have sex”
C. “After birth, you have to have a period before you can get pregnant again’
D. “Breastfeeding protects me from pregnancy because it keeps my hormones
down, so I don’t need any contraception until I stop breastfeeding”
30. A community nurse enters the home of the client for follow-up visit. Which of the
following is the most appropriate area to place the nursing bag of the nurse when
conducting a home visit?
A. cushioned footstool
B. bedside wood table
C. kitchen countertop
D. living room sofa
31. The nurse in the health center is making an assessment to the infant client. The
nurse notes some rashes and small fluid-filled bumps in the skin. The nurse suspects
that the infant has eczema. Which of the following is the most important nursing goal:
A. Preventing infection
B. Providing for adequate nutrition
C. Decreasing the itching
D. Maintaining the comfort level
32. The nurse in the health center is providing immunization to the children. The
nurse is carefully assessing the condition of the children before giving the vaccines.
Which of the following would the nurse note to withhold the infant’s scheduled
immunizations?
A. a dry cough
B. a skin rash
C. a low-grade fever
D. a runny nose
33. A mother brought her child in the health center for hepatitis B vaccination in a
series. The mother informs the nurse that the child missed an appointment last month
to have the third hepatitis B vaccination. Which of the following statements is the
appropriate nursing response to the mother?
A.
B.
C.
D.
“I will examine the child for symptoms of hepatitis B”
“Your child will start the series again”
“Your child will get the next dose as soon as possible”
“Your child will have a hepatitis titer done to determine if immunization
has taken place.”
34. The community health nurse implemented a new program about effective breast
cancer screening technique for the female personnel of the health department of
Valenzuela. Which of the following technique should the nurse consider to be of the
lowest priority?
A. Yearly breast exam by a trained professional
B. Detailed health history to identify women at risk
C. Screening mammogram every year for women over age 50
D. Screening mammogram every 1-2 years for women over age of 40.
35. Which of the following technique is considered an aseptic practice during the
home visit of the community health nurse?
A. Wrapping used dressing in a plastic bag before placing them in the nursing
bag
B. Washing hands before removing equipment from the nursing bag
C. Using the client’s soap and cloth towel for hand washing
D. Placing the contaminated needles and syringes in a labeled container inside
the nursing bag
36. The nurse is planning to conduct a home visit in a small community. Which of the
following is the most important factor when planning the best time for a home care
visit?
A. Purpose of the home visit
B. Preference of the patient’s family
C. Location of the patient’s home
D. Length of time of the visit will take
37. The nurse assigned in the health center is counseling a 30-year-old client
requesting oral contraceptives. The client tells the nurse that she has an active yeast
infection that has recurred several times in the past year. Which statement by the
nurse is inaccurate concerning health promotion actions to prevent recurring yeast
infection?
A. “During treatment for yeast, avoid vaginal intercourse for one week”
B. “Wear loose-fitting cotton underwear”
C. “Avoid eating large amounts of sugar or sugar-bingeing”
D. “Douche once a day with a mild vinegar and water solution”
38. During immunization week in the health center, the parent of a 6-month-old infant
asks the health nurse, “Why is our baby going to receive so many immunizations over
a long time period?” The best nursing response would be:
A. “The number of immunizations your baby will receive shows how many
pediatric communicable and infectious diseases can now be prevented.”
B. “You need to ask the physician”
C. “The number of immunizations your baby will receive is determined by
your baby’s health history and age”
D. “It is easier on your baby to receive several immunizations rather than one
at a time”
39. The community health nurse is conducting a health teaching about nutrition to a
group of pregnant women who are anemic and are lactose intolerant. Which of the
following foods should the nurse especially encourage during the third trimester?
A. Cheese, yogurt, and fish for protein and calcium needs plus prenatal
vitamins and iron supplements
B. Prenatal iron and calcium supplements plus a regular adult diet
C. Red beans, green leafy vegetables, and fish for iron and calcium needs plus
prenatal vitamins and iron supplements
D. Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins
and iron supplements
40. A woman with active tuberculosis (TB) and has visited the health center for
regular therapy for five months wants to become pregnant. The nurse knows that
further information is necessary when the woman states:
A. “Spontaneous abortion may occur in one out of five women who are
infected”
B. “Pulmonary TB may jeopardize my pregnancy”
C. “I know that I may not be able to have close contact with my baby until
contagious is no longer a problem
D. “I can get pregnant after I have been free of TB for 6 months”
41. The Department of Health is alarmed that almost 33 million people suffer from
food poisoning every year. Salmonella enteritis is responsible for almost 4 million
cases of food poisoning. One of the major goals is to promote proper food preparation.
The community health nurse is tasks to conduct health teaching about the prevention
of food poisoning to a group of mother everyday. The nurse can help identify signs
and symptoms of specific organisms to help patients get appropriate treatment.
Typical symptoms of salmonella include:
A.
B.
C.
D.
Nausea, vomiting and paralysis
Bloody diarrhea
Diarrhea and abdominal cramps
Nausea, vomiting and headache
42. A community health nurse makes a home visit to an elderly person living alone in
a small house. Which of the following observation would be a great concern?
A. Big mirror in a wall
B. Scattered and unwashed dishes in the sink
C. Shiny floors with scattered rugs
D. Brightly lit rooms
43. The health nurse is conducting health teaching about “safe” sex to a group of high
school students. Which of the following statement about the use of condoms should
the nurse avoid making?
A. “Condoms should be used because they can prevent infection and because
they may prevent pregnancy”
B. “Condoms should be used even if you have recently tested negative for
HIV”
C. “Condoms should be used every time you have sex because condoms
prevent all forms of sexually transmitted diseases”
D. “Condoms should be used every time you have sex even if you are taking
the pill because condoms can prevent the spread of HIV and gonorrhea”
44. The department of health is promoting the breastfeeding program to all newly
mothers. The nurse is formulating a plan of care to a woman who gave birth to a baby
girl. The nursing care plan for a breast-feeding mother takes into account that breastfeeding is contraindicated when the woman:
A. Is pregnant
B. Has genital herpes infection
C. Develops mastitis
D. Has inverted nipples
45. The City health department conducted a medical mission in Barangay Marulas.
Majority of the children in the Barangay Marulas were diagnosed with pinworms. The
community health nurse should anticipate that the children’s chief complaint would
be:
A. Lack of appetite
B. Severe itching of the scalp
C. Perianal itching
D. Severe abdominal pain
46. The mother brought her daughter to the health center. The child has head lice. The
nurse anticipates that the nursing diagnosis most closely correlated with this is:
A. Fluid volume deficit related to vomiting
B. Altered body image related to alopecia
C. Altered comfort related to itching
D. Diversional activity deficit related to hospitalization
47. The mother brings a child to the health care clinic because of severe headache and
vomiting. During the assessment of the health care nurse, the temperature of the child
is 40 degree Celsius, and the nurse notes the presence of nuchal rigidity. The nurse is
suspecting that the child might be suffering from bacterial meningitis. The nurse
continues to assess the child for the presence of Kernig’s sign. Which finding would
indicate the presence of this sign?
A. Flexion of the hips when the neck is flexed from a lying position
B. Calf pain when the foot is dorsiflexed
C. Inability of the child to extend the legs fully when lying supine
D. Pain when the chin is pulled down to the chest
48. A community health nurse makes a home visit to a child with an infectious and
communicable disease. In planning care for the child, the nurse must determine that
the primary goal is that the:
A. Child will experience mild discomfort
B. Child will experience only minor complications
C. Child will not spread the infection to others
D. Public health department will be notified
49. The mother brings her daughter to the health care clinic. The child was diagnosed
with conjunctivitis. The nurse provides health teaching to the mother about the proper
care of her daughter while at home. Which statement by the mother indicates a need
for additional information?
A. “I do not need to be concerned about the spreading of this infection to
others in my family”
B. “I should apply warm compresses before instilling antibiotic drops if
purulent discharge is present in my daughter’s eye”
C. “I can use an ophthalmic analgesic ointment at nighttime if I have eye
discomfort”
D. “I should perform a saline eye irrigation before instilling, the antibiotic
drops into my daughter’s eye if purulent discharge is present”
50. A community health nurse is caring for a group of flood victims in Marikina area.
In planning for the potential needs of this group, which is the most immediate
concern?
A. Finding affordable housing for the group
B. Peer support through structured groups
C. Setting up a 24-hour crisis center and hotline
D. Meeting the basic needs to ensure that adequate food, shelter and clothing
are available
PNLE III Nursing Practice
The scope of this Nursing Test III is parallel to the NP3 NLE Coverage:
 Medical Surgical Nursing
1. The nurse is going to replace the Pleur-O-Vac attached to the client with a small,
persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the
following is the best rationale for this?
A. Promote air and pleural drainage
B. Prevent kinking of the tube
C. Eliminate the need for a dressing
D. Eliminate the need for a water-seal drainage
2. The client with acute pancreatitis and fluid volume deficit is transferred from the
ward to the ICU. Which of the following will alert the nurse?
A. Decreased pain in the fetal position
B. Urine output of 35mL/hr
C. CVP of 12 mmHg
D. Cardiac output of 5L/min
3. The nurse in the morning shift is making rounds in the ward. The nurse enters the
client’s room and found the client in discomfort condition. The client complains of
stiffness in the joints. To reduce the early morning stiffness of the joints of the
client,the nurse can encourage the client to:
A. Sleep with a hot pad
B. Take to aspirins before arising, and wait 15 minutes before attempting
locomotion
C. Take a hot tub bath or shower in the morning
D. Put joints through passive ROM before trying to move them actively
4. The nurse is planning of care to a client with peptic ulcer disease. To avoid the
worsening condition of the client, the nurse should carefully plan the diet of the client.
Which of the following will be included in the diet regime of the client?
A.
B.
C.
D.
Eating mainly bland food and milk or dairy products
Reducing intake of high-fiber foods
Eating small, frequent meals and a bedtime snack
Eliminating intake of alcohol and coffee
5. The physician has given instruction to the nurse that the client can be ambulated on
crutches, with no weight bearing on the affected limb. The nurse is aware that the
appropriate crutch gait for the nurse to teach the client would be:
A. Tripod gait
B. Two-point gait
C. Four-point gait
D. Three-point gait
6. The client is transferred to the nursing care unit from the operating room after a
transurethral resection of the prostate. The client is complaining of pain in the
abdomen area. The nurse suspects of bladder spasms, which of the following is the
best nursing action to minimize the pain felt by the client?
A. Advising the client not to urinate around catheter
B. Intermittent catheter irrigation with saline
C. Giving prescribed narcotics every 4 hour
D. Repositioning catheter to relieve pressure
7. A client is diagnosed with peptic ulcer. The nurse caring for the client expects the
physician to order which diet?
A. NPO
B. Small feedings of bland food
C. A regular diet given frequently in small amounts
D. Frequent feedings of clear liquids
8. The nurse is going to insert a Miller-Abbott tube to the client. Before insertion of
the tube, the balloon is tested for patency and capacity and then deflated. Which of the
following nursing measure will ease the insertion to the tube?
A. Positioning the client in Semi-Fowler’s position
B. Administering a sedative to reduce anxiety
C. Chilling the tube before insertion
D. Warming the tube before insertion
9. The physician ordered a low-sodium diet to the client. Which of the following food
will the nurse avoid to give to the client?
A. Orange juice.
B. Whole milk.
C. Ginger ale.
D. Black coffee.
10. Mr. Bean, a 70-year-old client is admitted in the hospital for almost one month.
The nurse understands that prolonged immobilization could lead to decubitus ulcers.
Which of the following would be the least appropriate nursing intervention in the
prevention of decubitus?
A. Giving backrubs with alcohol
B. Use of a bed cradle
C. Frequent assessment of the skin
D. Encouraging a high-protein diet
11. The physician prescribed digoxin 0.125 mg PO qd to a client and instructed the
nurse that the client is on high-potassium diet. High potassium foods are
recommended in the diet of a client taking digitalis preparations because a low serum
potassium has which of the following effects?
A. Potentiates the action of digoxin
B. Promotes calcium retention
C. Promotes sodium excretion
D. Puts the client at risk for digitalis toxicity
12. The nurse is caring for a client who is transferred from the operating room for
pneumonectomy. The nurse knows that immediately following pneumonectomy; the
client should be in what position?
A. Supine on the unaffected side
B. Low-Fowler’s on the back
C. Semi-Fowler’s on the affected side
D. Semi-Fowler’s on the unaffected side
13. A client is placed on digoxin, high potassium foods are recommended in the diet
of the client. Which of the following foods willthe nurse give to the client?
A. Whole grain cereal, orange juice, and apricots
B. Turkey, green bean, and Italian bread
C. Cottage cheese, cooked broccoli, and roast beef
D. Fish, green beans and cherry pie
14. The nurse is assigned to care to a client who undergone thyroidectomy. What
nursing intervention is important during the immediate postoperative period following
a thyroidectomy?
A. Assess extremities for weakness and flaccidity
B. Support the head and neck during position changes
C. Position the client in high Fowler’s
D. Medicate for restlessness and anxiety
15. What would be the recommended diet the nurse will implement to a client with
burns of the head, face, neck and anterior chest?
A. Serve a high-protein, high-carbohydrate diet
B. Encourage full liquid diet
C. Serve a high-fat diet, high-fiber diet
D. Monitor intake to prevent weight gain
16. A client with multiple fractures of both lower extremities is admitted for 3 days
ago and is on skeletal traction. The client is complaining of having difficulty in bowel
movement. Which of the following would be the most appropriate nursing
intervention?
A. Administer an enema
B. Perform range-of-motion exercise to all extremities
C. Ensure maximum fluid intake (3000ml/day)
D. Put the client on the bedpan every 2 hours
17. John is diagnosed with Addison’s disease and admitted in the hospital. What
would be the appropriate nursing care for John?
A. Reducing physical and emotional stress
B. Providing a low-sodium diet
C. Restricting fluids to 1500ml/day
D. Administering insulin-replacement therapy
18. Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he
was transferred to the nursing care unit. The nurse assigned to him knows that 72
hours after the procedure the client should be positioned properly to prevent
contractures. Which of the following is the best position to the client?
A. Side-lying, alternating left and right sides
B. Sitting in a reclining chair twice a day
C. Lying on abdomen several times daily
D. Supine with stump elevated at least 30 degrees
19. A client is scheduled to have an inguinal herniorraphy in the outpatient surgical
department. The nurse is providing health teaching about post surgical care to the
client. Which of the following statement if made by the client would reflect the need
for more teaching?
A. “I should call the physician if I have a cough or cold before surgery”
B. “I will be able to drive soon after surgery”
C. “I will not be able to do any heavy lifting for 3-6 weeks after surgery”
D. “I should support my incision if I have to cough or turn”
20. Ms Jones is brought to the emergency room and is complaining of muscle spasms,
numbness, tremors and weakness in the arms and legs. The client was diagnosed with
multiple sclerosis. The nurse assigned to Ms. Jones is aware that she has to prevent
fatigue to the client to alleviate the discomfort. Which of the following teaching is
necessary to prevent fatigue?
A. Avoid extremes in temperature
B. Install safety devices in the home
C. Attend support group meetings
D. Avoid physical exercise
21. Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difficulty
of breathing. On the assessment of the nurse, his temperature is 38.1 ºC. The
physician ordered Morphine sulfate via patient-controlled analgesia (PCA), and
oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart is risk for infection. A
nursing intervention to assist in preventing infection is:
A. Using standard precautions and medical asepsis
B. Enforcing a “no visitors” rule
C. Using moist heat on painful joints
D. Monitoring a vital signs every 2 hour
22. Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture,
she experience blurring of vision and tiredness. Mrs. Maupin is brought to the
emergency department. On assessment, the nurse notes that the blood pressure of the
client is 139/90. Mrs. Maupin has been diagnosed with essential hypertension and
placed on medication to control her BP. Which potential nursing diagnosis will be a
priority for discharge teaching?
A. Sleep Pattern disturbance
B. Impaired physical mobility
C. Noncompliance
D. Fluid volume excess
23. Following a needle biopsy of the kidney, which assessment is an indication that
the client is bleeding?
A. Slow, irregular pulse
B. Dull, abdominal discomfort
C. Urinary frequency
D. Throbbing headache
24. A client with acute bronchitis is admitted in the hospital. The nurse assigned to the
client is making a plan of care regarding expectoration of thick sputum. Which
nursing action is most effective?
A. Place the client in a lateral position every 2 hour
B. Splint the patient’s chest with pillows when coughing
C. Use humified oxygen
D. Offer fluids at regular intervals
25. The nurse is going to assess the bowel sound of the client. For accurate assessment
of the bowel sound, the nurse should listen for at least:
A. 5 minutes
B. 60 seconds
C. 30 seconds
D. 2 minutes
26. The nurse encourages the client to wear compression stockings. What is the
rationale behind in using compression stockings?
A. Compression stockings promote venous return
B. Compression stockings divert blood to major vessels
C. Compression stockings decreases workload on the heart
D. Compression stockings improve arterial circulation
27. Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is
the best nursing intervention is most likely to assist the client?
A. Placing food in the unaffected side of the mouth
B. Increasing fiber in the diet
C. Asking the patient to speak slowly
D. Increasing fluid intake
28. Following nephrectomy, the nurse closely monitors the urinary output of the
client. Which assessment finding is an early indicator of fluid retention in the
postoperative period?
A. Periorbital edema
B. Increased specific gravity of urine
C. A urinary output of 50mL/hr
D. Daily weight gain of 2 lb or more
29. A nurse is completing an assessment to a client with cirrhosis. Which of the
following nursing assessment is important to notify the physician?
A. Expanding ecchymosis
B. Ascites and serum albumin of 3.2 g/dl
C. Slurred speech
D. Hematocrit of 37% and hemoglobin of 12g/dl
30. Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus.
After the game, the client complains of becoming diaphoretic and light-headedness.
The client asks the nurse how to avoid this reaction. The nurse will recommend to:
A. Allow plenty of time after the insulin injection and before beginning the
match
B. Eat a carbohydrate snack before and during the badminton match
C. Drink plenty of fluids before, during, and after bed time
D. Take insulin just before starting the badminton match
31. A client is rushed to the emergency room due to serious vehicle accident. The
nurse is suspecting of head injury. Which of the following assessment findings would
the nurse report to the physician?
A. CVP of 5mmHa
B. Glasgow Coma Scale score of 13
C. Polyuria and dilute urinary output
D. Insomnia
32. Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She
stepped on a sharp sea shells while walking barefoot along the beach. Mrs. Moore did
not notice that the object pierced the skin until later that evening. What problem does
the client most probably have?
A. Nephropathy
B. Macroangiopathy
C. Carpal tunnel syndrome
D. Peripheral neuropathy
33. A client with gangrenous foot has undergone a below-knee amputation. The nurse
in the nursing care unit knows that the priority nursing intervention in the immediate
post operative care of this client is:
A. Elevate the stump on a pillow for the first 24 hours
B. Encourage use of trapeze
C. Position the client prone periodically
D. Apply a cone-shaped dressing
34. A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo.
What would be the initial nursing intervention by the nurse?
A. Monitor the client’s vital signs
B. Keep the client on bed rest
C. Keep the patient on bed rest
D. Give a stat dose of Sucralfate (Carafate)
35. After a right lower lobectomy on a 55-year-old client, which action should the
nurse initiate when the client is transferred from the post anesthesia care unit?
A. Notify the family to report the client’s condition
B. Immediately administer the narcotic as ordered
C. Keep client on right side supported by pillows
D. Encourage coughing and deep breathing every 2 hours
36. The nurse is providing a discharge instruction about the prevention of urinary
stasis to a client with frequent bladder infection. Which of the following will the nurse
include in the instruction?
A. Drink 3-4 quarts of fluid every day
B. Empty the bladder every 2-4 hours while awake
C. Encourage the use of coffee, tea, and colas for their diuretic effect
D. Teach Kegel exercises to control bladder flow
37. A male client visits the clinic for check-up. The client tells the nurse that there is a
yellow discharge from his penis. He also experiences a burning sensation when
urinating. The nurse is suspecting of gonorrhea. What teaching is necessary for this
client?
A. Sex partner of 3 months ago must be treated
B. Women with gonorrhea are symptomatic
C. Use a condom for sexual activity
D. Sex partner needs to be evaluated
38. A client with AIDS is admitted in the hospital. He is receiving intravenous
therapy. While the nurse is assessing the IV site, the client becomes confused and
restless and the intravenous catheter becomes disconnected and minimal amount of
the client’s blood spills onto the floor. Which action will the nurse take to remove the
blood spill?
A. Promptly clean with a 1:10 solution of household bleach and water
B. Promptly clean up the blood spill with full-strength antimicrobial cleaning
solution
C. Immediately mop the floor with boiling water
D. Allow the blood to dry before cleaning to decrease the possibility of crosscontamination
39. Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the
client to sleep. The night before the scheduled surgery, the nurse gave the premedication. One hour later the client is still unable to sleep. The nurse review the
client’s chart and note the physician’s prescription with an order to repeat. What
should the nurse do next?
A. Rub the client’s back until relaxed
B. Prepare a glass of warm milk
C. Give the second dose of pentobarbital sodium
D. Explore the client’s feelings about surgery
40. The nurse on the night shift is making rounds in the nursing care unit. The nurse is
about to enter to the client’s room when a ventilator alarm sounds, what is the first
action the nurse should do?
A. Assess the lung sounds
B. Suction the client right away
C. Look at the client
D. Turn and position the client
41. What effective precautions should the nurse use to control the transmission of
methicillin-resistant Staphylococcus aureus (MRSA)?
A. Use gloves and handwashing before and after client contact
B. Do nasal cultures on healthcare providers
C. Place the client on total isolation
D. Use mask and gown during care of the MRSA client
42. The postoperative gastrectomy client is scheduled for discharge. The client asks
the nurse, “When I will be allowed to eat three meals a day like the rest of my
family?”. The appropriate nursing response is:
A. “You will probably have to eat six meals a day for the rest of your life.”
B. “Eating six meals a day can be a bother, can’t it?”
C. “Some clients can tolerate three meals a day by the time they leave the
hospital. Maybe it will be a little longer for you.”
D. “ It varies from client to client, but generally in 6-12 months most clients
can return to their previous meal patterns”
43. A male client with cirrhosis is complaining of belly pain, itchiness and his breasts
are getting larger and also the abdomen. The client is so upset because of the
discomfort and asks the nurse why his breast and abdomen are getting larger. Which
of the following is the appropriate nursing response?
A. “How much of a difference have you noticed”
B. “It’s part of the swelling your body is experiencing”
C. “It’s probably because you have been less physically active”
D. “Your liver is not destroying estrogen hormones that all men produce”
44. A client is diagnosed with detached retina and scheduled for surgery. Preoperative
teaching of the nurse to the client includes:
A. No eye pain is expected postoperatively
B. Semi-fowler’s position will be used to reduce pressure in the eye.
C. Eye patches may be used postoperatively
D. Return of normal vision is expected following surgery
45. A 70-year-old client is brought to the emergency department with a caregiver. The
client has manifestations of anorexia, wasting of muscles and multiple bruises. What
nursing interventions would the nurse implement?
A. Talk to the client about the caregiver and support system
B. Complete a gastrointestinal and neurological assessment
C. Check the lab data for serum albumin, hematocrit and hemoglobin
D. Complete a police report on elder abuse
46. A nurse is providing a discharge instruction to the client about the selfcatheterization at home. Which of the following instructions would the nurse include?
A. Wash the catheter with soap and water after each use
B. Lubricate the catheter with Vaseline
C. Perform the Valsalva maneuver to promote insertion
D. Replace the catheter with a new one every 24 hour
47. The nurse in the nursing care unit is assigned to care to a client who is
Immunocompromised. The client tells the nurse that his chest is painful and the
blisters are itchy. What would be the nursing intervention to this client?
A. Call the physician
B. Give a prn pain medication
C. Clarify if the client is on a new medication
D. Use gown and gloves while assessing the lesions
48. A client is admitted and has been diagnosed with bacterial (meningococcal)
meningitis. The infection control registered nurse visits the staff nurse caring to the
client. What statement made by the nurse reflects an understanding of the
management of this client?
A. speech pattern may be altered
B. Respiratory isolation is necessary for 24 hours after antibiotics are started
C. Perform skin culture on the macular popular rash
D. Expect abnormal general muscle contractions
49. A 18-year-old male client had sustained a head injury from a motorbike accident.
It is uncertain whether the client may have minimal but permanent disability. The
family is concerned regarding the client’s difficulty accepting the possibility of long
term effects. Which nursing diagnosis is best for this situation?
A. Nutrition, less than body requirements
B. Injury, potential for sensory-perceptual alterations
C. Impaired mobility, related to muscle weakness
D. Anticipatory grieving, due to the loss of independence
50. A client with AIDS is scheduled for discharge. The client tells the nurse that one
of his hobbies at home is gardening. What will be the discharge instruction of the
nurse to the client knowing that the client is prone to toxoplasmosis?
A.
B.
C.
D.
Wash all vegetables before cooking
Wear gloves when gardening
Wear a mask when travelling to foreign countries
Avoid contact with cats and birds
PNLE IV Nursing Practice
The scope of this Nursing Test IV is parallel to the NP4 NLE Coverage:
 Medical Surgical Nursing
1. Following spinal injury, the nurse should encourage the client to drink fluids to
avoid:
A. Urinary tract infection.
B. Fluid and electrolyte imbalance.
C. Dehydration.
D. Skin breakdown.
2. The client is transferred from the operating room to recovery room after an openheart surgery. The nurse assigned is taking the vital signs of the client. The nurse
notified the physician when the temperature of the client rises to 38.8 ºC or 102 ºF
because elevated temperatures:
A. May be a forerunner of hemorrhage.
B. Are related to diaphoresis and possible chilling.
C. May indicate cerebral edema.
D. Increase the cardiac output.
3. After radiation therapy for cancer of the prostate, the client experienced irritation in
the bladder. Which of the following sign of bladder irritability is correct?
A. Hematuria
B. Dysuria
C. Polyuria
D. Dribbling
4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the
following will the client most likely experience?
A. Visual hallucinations.
B. Receptive aphasia.
C. Hemiparesis.
D. Personality changes.
5. A client with Addison’s disease has a blood pressure of 65/60. The nurse
understands that decreased blood pressure of the client with Addison’s disease
involves a disturbance in the production of:
A. Androgens
B. Glucocorticoids
C. Mineralocorticoids
D. Estrogen
6. The nurse is planning to teach the client about a spontaneous pneumothorax. The
nurse would base the teaching on the understanding that:
A. Inspired air will move from the lung into the pleural space.
B. There is greater negative pressure within the chest cavity.
C. The heart and great vessels shift to the affected side.
D. The other lung will collapse if not treated immediately.
7. During an assessment, the nurse recognizes that the client has an increased risk for
developing cancer of the tongue. Which of the following health history will be a
concern?
A. Heavy consumption of alcohol.
B. Frequent gum chewing.
C. Nail biting.
D. Poor dental habits.
8. The client in the orthopedic unit asks the nurse the reason behind why compact
bone is stronger than cancellous bone. Which of the following is the correct response
of the nurse?
A. Compact bone is stronger than cancellous bone because of its greater size.
B. Compact bone is stronger than cancellous bone because of its greater
weight.
C. Compact bone is stronger than cancellous bone because of its greater
volume.
D. Compact bone is stronger than cancellous bone because of its greater
density.
9. The nurse is reviewing the laboratory results of the client. In reviewing the results
of the RBC count, the nurse understands that the higher the red blood cell count, the :
A. Greater the blood viscosity.
B. Higher the blood pH.
C. Less it contributes to immunity.
D. Lower the hematocrit.
10. The physician advised the client with Hemiparesis to use a cane. The client asks
the nurse why cane will be needed. The nurse explains to the client that cane is
advised specifically to:
A. Aid in controlling involuntary muscle movements.
B. Relieve pressure on weight-bearing joints.
C. Maintain balance and improve stability.
D. Prevent further injury to weakened muscles.
11. The nurse is conducting a discharge teaching regarding the prevention of further
problems to a client who undergone surgery for carpal tunnel syndrome of the right
hand. Which of the following instruction will the nurse includes?
A. Learn to type using your left hand only.
B. Avoid typing in a long period of time.
C. Avoid carrying heavy things using the right hand.
D. Do manual stretching exercise during breaks.
12. A female client is admitted because of recurrent urinary tract infections. The client
asks the nurse why she is prone to this disease. The nurse states that the client is most
susceptible because of:
A. Continuity of the mucous membrane.
B. Inadequate fluid intake.
C. The length of the urethra.
D. Poor hygienic practices.
13. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and
shoulders that occurs at rest, with high body temperature, weak with generalized
sweating and with decreased blood pressure. A myocardial infarction is diagnosed.
The nurse knows that the most accurate explanation for one of these presenting
adaptations is:
A. Catecholamines released at the site of the infarction causes intermittent
localized pain.
B. Parasympathetic reflexes from the infarcted myocardium causes
diaphoresis.
C. Constriction of central and peripheral blood vessels causes a decrease in
blood pressure.
D. Inflammation in the myocardium causes a rise in the systemic body
temperature.
14. Following an amputation of a lower limb to a male client, the nurse provides an
instruction on how to prevent a hip flexion contracture. The nurse should instruct the
client to:.
A. Perform quadriceps muscle setting exercises twice a day.
B. Sit in a chair for 30 minutes three times a day.
C. Lie on the abdomen 30 minutes every four hours.
D. Turn from side to side every 2 hours.
15. The physician scheduled the client with rheumatoid arthritis for the injection of
hydrocortisone into the knee joint. The client asks the nurse why there is a need for
this injection. The nurse explains that the most important reason for doing this is to:
A. Lubricate the joint.
B. Prevent ankylosis of the joint.
C. Reduce inflammation.
D. Provide physiotherapy.
16. The nurse is assigned to care for a 57-year-old female client who had a cataract
surgery an hour ago. The nurse should:
A. Advise the client to refrain from vigorous brushing of teeth and hair.
B. Instruct the client to avoid driving for 2 weeks.
C. Encourage eye exercises to strengthen the ocular musculature.
D. Teach the client coughing and deep-breathing techniques.
17. A client with AIDS develops bacterial pneumonia is admitted in the emergency
department. The client’s arterial blood gases is drawn and the result is PaO2
80mmHg. then arterial blood gases are drawn again and the level is reduced from 80
mmHg to 65 mmHg. The nurse should;
A. Have arterial blood gases performed again to check for accuracy.
B. Increase the oxygen flow rate.
C. Notify the physician.
D. Decrease the tension of oxygen in the plasma.
18. An 18-year-old college student is brought to the emergency department due to
serious motor vehicle accident. Right above-knee-amputation is done. Upon
awakening from surgery the client tells the nurse, “What happened to me? I cannot
remember anything?” Which of the following would be the appropriate initial nursing
response?
A. “You sound concerned; You’ll probably remember more as you wake up.”
B. “Tell me what you think happened.”
C. “You were in a car accident this morning.”
D. “An amputation of your right leg was necessary because of an accident.”
19. A 38-year-old client with severe hypertension is hospitalized. The physician
prescribed a Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client
tells the nurse that there is something wrong with the medication and nursing care.
The nurse recognizes this behavior is probably a manifestation of the client’s:
A. Reaction to hypertensive medications.
B. Denial of illness.
C. Response to cerebral anoxia.
D. Fear of the health problem.
20. Before discharge, the nurse scheduled the client who had a colostomy for
colorectal cancer for discharge instruction about resuming activities. The nurse should
plan to help the client understands that:
A. After surgery, changes in activities must be made to accommodate for the
physiologic changes caused by the operation.
B. Most sports activities, except for swimming, can be resumed based on the
client’s overall physical condition.
C. With counseling and medical guidance, a near normal lifestyle, including
complete sexual function is possible.
D. Activities of daily living should be resumed as quickly as possible to avoid
depression and further dependency.
21. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of
the following statement would alert the nurse that further teaching to the client is
necessary?
A. “I will be limiting my intake to 600 to 800 calories a day once I start eating
again.”
B. “I’m going to have a figure like a model in about a year.”
C. “I need to eat more high-protein foods.”
D. “I will be going to be out of bed and sitting in a chair the first day after
surgery.”.
22. The client who had transverse colostomy asks the nurse about the possible effect
of the surgery on future sexual relationship. What would be the best nursing response?
A.
B.
C.
D.
The surgery will temporarily decrease the client’s sexual impulses.
Sexual relationships must be curtailed for several weeks.
The partner should be told about the surgery before any sexual activity.
The client will be able to resume normal sexual relationships.
23. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks
what chances he had of getting also osteoporosis like his wife. Which of the following
is the correct response of the nurse?
A. “This is only a problem for women.”
B. “You are not at risk because of your small frame.”
C. “You might think about having a bone density test,”
D. “Exercise is a good way to prevent this problem.”
24. An older adult client with acute pain is admitted in the hospital. The nurse
understands that in managing acute pain of the client during the first 24 hours, the
nurse should ensure that:
A. Ordered PRN analgesics are administered on a scheduled basis.
B. Patient controlled analgesia is avoided in this population.
C. Pain medication is ordered via the intramuscular route.
D. An order for meperidine (Demerol) is secured for pain relief.
25. A nurse is caring to an older adult with presbycusis. In formulating nursing care
plan for this client, the nurse should expect that hearing loss of the client that is
caused by aging to have:
A. Overgrowth of the epithelial auditory lining.
B. Copious, moist cerumen.
C. Difficulty hearing women’s voices.
D. Tears in the tympanic membrane.
26. The nurse is reviewing the client’s chart about the ordered medication. The nurse
must observe for signs of hyperkalemia when administering:
A. Furosemide (Lasix)
B. Hydrochlorothiazide (HydroDIURIL)
C. Metolazone (Zaroxolyn)
D. Spironolactone (Aldactone)
27. The physician prescribed Albuterol (Proventil) to the client with severe asthma.
After the administration of the medication the nurse should monitor the client for:
A. Palpitation
B. Visual disturbance
C. Decreased pulse rate
D. Lethargy
28. A client is receiving diltiazem (Cardizem). What should the nurse include in a
teaching plan aimed at reducing the side effects of this medication?
A. Take the drug with an antacid.
B. Lie down after meals.
C. Avoid dairy products in diet.
D. Change positions slowly.
29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication
is effective when there is decrease in:
A. The triglycerides
B. The INR
C. Chest pain
D. Blood pressure
30. A client is taking nitroglycerine tablets, the nurse should teach the client the
importance of:
A. Increasing the number of tablets if dizziness or hypertension occurs.
B. Limiting the number of tablets to 4 per day.
C. Making certain the medication is stored in a dark container.
D. Discontinuing the medication if a headache develops.
31. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate
(Plaquenil) for a 58-year-old male client with arthritis. The nurse provides information
about toxicity of the hydroxychloroquine. The nurse can determine if the information
is clearly understood if the client states:
A. “I will contact the physician immediately if I develop blurred vision.”
B. “I will contact the physician immediately if I develop urinary retention.”
C. “I will contact the physician immediately if I develop swallowing
difficulty.”
D. “I will contact the physician immediately if I develop feelings of
irritability.”
32. The client with an acute myocardial infarction is hospitalized for almost one week.
The client experiences nausea and loss of appetite. The nurse caring for the client
recognizes that these symptoms may indicate the:
A. Adverse effects of spironolactone (Aldactone)
B. Adverse effects of digoxin (Lanoxin)
C. Therapeutic effects of propranolol (Indiral)
D. Therapeutic effects of furosemide (Lasix)
33. A client with a partial occlusion of the left common carotid artery is scheduled for
discharge. The client is still receiving Coumadin. The nurse provided a discharge
instruction to the client regarding adverse effects of Coumadin. The nurse should tell
the client to consult with the physician if:
A. Swelling of the ankles increases.
B. Blood appears in the urine.
C. Increased transient Ischemic attacks occur.
D. The ability to concentrate diminishes.
34. Levodopa is ordered for a client with Parkinson’s disease. Before starting the
medication, the nurse should know that:
A. Levodopa is inadequately absorbed if given with meals.
B. Levodopa may cause the side effects of orthostatic hypotension.
C. Levodopa must be monitored by weekly laboratory tests.
D. Levodopa causes an initial euphoria followed by depression.
35. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used.
The nurse knows that this drug will cause a temporary increase in:
A. Muscle strength
B. Symptoms
C. Blood pressure
D. Consciousness
36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the
management of trigeminal neuralgia by monitoring the client’s:
A. Seizure activity
B. Liver function
C. Cardiac output
D. Pain relief
37. Administration of potassium iodide solution is ordered to the client who will
undergo a subtotal thyroidectomy. The nurse understands that this medication is given
to:
A. Ablate the cells of the thyroid gland that produce T4.
B. Decrease the total basal metabolic rate.
C. Decrease the size and vascularity of the thyroid.
D. Maintain function of the parathyroid gland.
38. A client with Addison’s disease is scheduled for discharge. Before the discharge,
the physician prescribes hydrocortisone and fludrocortisone. The nurse expects the
hydrocortisone to:
A.
B.
C.
D.
Increase amounts of angiotensin II to raise the client’s blood pressure.
Control excessive loss of potassium salts.
Prevent hypoglycemia and permit the client to respond to stress.
Decrease cardiac dysrhythmias and dyspnea.
39. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To
determine if the drug is effective, the nurse should monitor the client’s:
A. Arterial blood pH
B. Pulse rate
C. Serum glucose
D. Intake and output
40. A client with recurrent urinary tract infections is to be discharged. The client will
be taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse
provides discharge instructions to the client. Which of the following instructions will
be correct?
A. Strain urine for crystals and stones
B. Increase fluid intake.
C. Stop the drug if the urinary output increases
D. Maintain the exact time schedule for drug taking.
41. A client with cancer of the lung is receiving chemotherapy. The physician orders
antibiotic therapy for the client. The nurse understands that chemotherapy destroys
rapidly growing leukocytes in the:
A. Bone marrow
B. Liver
C. Lymph nodes
D. Blood
42. The physician reduced the client’s Dexamethasone (Decadron) dosage gradually
and to continue a lower maintenance dosage. The client asks the nurse about the
change of dosage. The nurse explains to the client that the purpose of gradual dosage
reduction is to allow:
A. Return of cortisone production by the adrenal glands.
B. Production of antibodies by the immune system
C. Building of glycogen and protein stores in liver and muscle
D. Time to observe for return of increases intracranial pressure
43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is
expected. The nurse is aware that fluid deficit can most accurately be assessed by:
A. The presence of dry skin
B. A change in body weight
C. An altered general appearance
D. A decrease in blood pressure
44. Which of the following is the most important electrolyte of intracellular fluid?
A. Potassium
B. Sodium
C. Chloride
D. Calcium
45. Which of the following client has a high risk for developing hyperkalemia?
A. Crohn’s disease
B. End-Stage renal disease
C. Cushing’s syndrome
D. Chronic heart failure
46. The nurse is reviewing the laboratory result of the client. The client’s serum
potassium level is 5.8 mEq/L. Which of the following is the initial nursing action?
A. Call the cardiac arrest team to alert them
B. Call the laboratory and repeat the test
C. Take the client’s vital signs and notify the physician
D. Obtain an ECG strip and have lidocaine available
47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a
client in a diabetic ketoacidosis. The primary reason for administering this drug is:
A. Replacement of excessive losses
B. Treatment of hyperpnea
C. Prevention of flaccid paralysis
D. Treatment of cardiac dysrhythmias
48. A female client is brought to the emergency unit. The client is complaining of
abdominal cramps. On assessment, client is experiencing anorexia and weight is
reduced. The physician’s diagnosis is colitis. Which of the following symptoms of
fluid and electrolyte imbalance should the nurse report immediately?
A. Skin rash, diarrhea, and diplopia
B. Development of tetaniy with muscles spasms
C. Extreme muscle weakness and tachycardia
D. Nausea, vomiting, and leg and stomach cramps.
49. The client is to receive an IV piggyback medication. When preparing the
medication the nurse should be aware that it is very important to:
A.
B.
C.
D.
Use strict sterile technique
Use exactly 100mL of fluid to mix the medication
Change the needle just before adding the medication
Rotate the bag after adding the medication
50. The nurse is reviewing the laboratory result of the client. An arterial blood gas
report indicates the client’s pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The
results are consistent with:
A.
B.
C.
D.
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
PNLE V Nursing Practice
The scope of this Nursing Test V is parallel to the NP5 NLE Coverage:
 Psychiatric Nursing
1. A 17-year-old client has a record of being absent in the class without permission,
and “borrowing” other people’s things without asking permission. The client denies
stealing; rationalizing instead that as long as no one was using the items, there is no
problem to use it by other people. It is important for the nurse to understand that
psychodynamically, the behavior of the client may be largely attributed to a
development defect related to the:
A. Oedipal complex
B. Superego
C. Id
D. Ego
2. A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the best
nursing response to this cient?
A. “What are you going to do this time?”
B. Say nothing. Wait for the client’s next comment
C. “You seem upset. I am going to be here with you; perhaps you will want to
talk about it”
D. “Have you felt this way before?”
3. In crisis intervention therapy, which of the following principle that the nurse will
use to plan her/his goals?
A.
B.
C.
D.
Crises are related to deep, underlying problems
Crises seldom occur in normal people’s lives
Crises may go on indefinitely.
Crises usually resolved in 4-6 weeks.
4. The nurse enters the room of the male client and found out that the client urinates
on the floor. The client hides when the nurse is about to talk to him. Which of the
following is the best nursing intervention?
A. Place restriction on the client’s activities when his behavior occurs.
B. Ask the client to clean the soiled floor.
C. Take the client to the bathroom at regular intervals.
D. Limit fluid intake.
5. A young lady with a diagnosis of schizophrenic reaction is admitted to the
psychiatric unit. In the past two months, the client has poor appetite, experienced
difficulty in sleeping, was mute for long periods of time, just stayed in her room,
grinning and pointing at things. What would be the initial nursing action on admitting
the client to the unit?
A. Assure the client that “ You will be well cared for.”
B. Introduce the client to some of the other clients.
C. Ask “Do you know where you are?”
D. Take the client to the assigned room.
6. A 16-year-old girl was diagnosed with anorexia. What would be the first
assessment of the nurse?
A. What food she likes.
B. Her desired weight.
C. Her body image.
D. What causes her behavior.
7. On an adolescent unit, a nurse caring to a client was informed that her client’s
closest roommate dies at night. What would be the most appropriate nursing action?
A. Do not bring it up unless the client asks.
B. Tell the client that her roommate went home.
C. Tell the client, if asked, “You should ask the doctor.”
D. Tell the client that her closest roommate died.
8. A woman gave birth to an unhealthy infant, and with some body defects. The nurse
should expect the woman’s initial reactions to include:
A. Depression
B. Withdrawal
C. Apathy
D. Anger
9. A client in the psychiatric unit is shouting out loud and tells the nurse, “Please, help
me. They are coming to get me.” What would be the appropriate nursing response?
A. “ I won’t let anyone get you.”
B. “Who are they?”
C. “I don’t see anyone coming.”
D. “You look frightened.”
10. A client who is severely obese tells the nurse, “My therapist told me that I eat a lot
because I didn’t get any attention and love from my mother. What does the therapist
mean?” What is the best nursing response?
A. “What do you think is the connection between your not getting enough
love and overeating?”
B. “Tell me what you think the therapist means.”
C. “You need to ask your therapist.”
D. “ We are here to deal with your diet, not with your psychological
problems.”
11. After the discussion about the procedure the physician scheduled the client for
mastectomy. The client tells the nurse, “If my breasts will be removed, I’m afraid my
husband will not love me anymore and maybe he will never touch me.” What should
the nurse’s response?
A. “I doubt that he feels that way.”
B. “What makes you feel that way?”
C. “Have you discussed your feelings with your husband?”
D. Ask the husband, in front of the wife, how he feels about this.
12. The child is brought to the hospital by the parents. During assessment of the nurse,
what parental behavior toward a child should alert the nurse to suspect child abuse?
A. Ignoring the child.
B. Flat affect.
C. Expressions of guilt.
D. Acting overly solicitous toward the child
13. A nurse is caring to a client with manic disorder in the psychiatric ward. On the
morning shift, the nurse is talking with the client who is now exhibiting a manic
episode with flight of ideas. The nurse primarily needs to:
A. Focus on the feelings conveyed rather than the thoughts expressed.
B. Speak loudly and rapidly to keep the client’s attention, because the client is
easily distracted.
C. Allow the client to talk freely.
D. Encourage the client to complete one thought at a time.
14. The nurse is caring to an autistic child. Which of the following play behavior
would the nurse expect to see in a child?
A. competitive play
B. nonverbal play
C. cooperative play
D. solitary play
15. The client is telling the nurse in the psychiatric ward, “I hate them.” Which of the
following is the most appropriate nursing response to the client?
A. “Tell me about your hate.”
B. “I will stay with you as long as you feel this way.”
C. “For whom do you have these feelings?”
D. “I understand how you can feel this way.”
16. The mother visits her son with major depression in the psychiatric unit. After the
conversation of the client and the mother, the nurse asks the mother how it is talking
to her son. The mother tells the nurse that it was a stressful time. During an interview
with the client, the client says, “we had a marvelous visit.” Which of the following
coping mechanism can be described to thestatement of the client?
A. Identification.
B. Rationalization.
C. Denial.
D. Compensation.
17. A male client is quiet when the physician told him that he has stage IV cancer and
has 4 months to live. The nurse determines that this reaction may be an example of:
A. Indifference
B. Denial
C. Resignation
D. Anger
18. A nurse is caring to a female client with five young children. The family member
told the client that her ex-husband has died 2 days ago. The reaction of the client is
stunned silence, followed by anger that the ex-husband left no insurance money for
their young children. The nurse should understand that:
A. The children and the injustice done to them by their father’s death are the
woman’s main concern.
B. To explain the woman’s reaction, the nurse needs more information about
the relationship and breakup.
C. The woman is not reacting normally to the news.
D. The woman is experiencing a normal bereavement reaction.
19. A client who is manic comes to the outpatient department. The nurse is assigning
an activity for the client. What activity is best for the nurse to encourage for a client in
a manic phase?
A. Solitary activity, such as walking with the nurse, to decrease stimulation.
B. Competitive activity, such as bingo, to increase the client’s self-esteem.
C. Group activity, such as basketball, to decrease isolation.
D. Intellectual activity, such as scrabble, to increase concentration.
20. The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client
says, “Why should I take this?” The doctor started me on this 10days ago; it didn’t
help me at all.” Which of the following is the best nursing response:
A. “What were you expecting to happen?”
B. “It usually takes 2-3 weeks to be effective.”
C. “Do you want to refuse this medication? You have the right.”
D. “That’s a long time wait when you feel so depressed.”
21. Which of the following drugs the nurse should choose to administer to a client to
prevent pseudoparkinsonism?
A. Isocarboxazid (Marplan)
B. Chlorpromazine HCI (Thorazine)
C. Trihexyphenidyl HCI (Artane)
D. Trifluoperazine HCI (Stelazine)
22. The nurse is caring to an 80-year-old client with dementia? What is the most
important psychosocial need for this client?
A. Focus on the there-and-then rather the here-and-now.
B. Limit in the number of visitors, to minimize confusion.
C. Variety in their daily life, to decrease depression.
D. A structured environment, to minimize regressive behaviors.
23. A client tells the nurse, “I don’t want to eat any meals offered in this hospital
because the food is poisoned.” The nurse is aware that the client is expressing an
example of:
A. Delusion.
B. Hallucination.
C. Negativism.
D. Illusion.
24. A client is admitted in the hospital. On assessment, the nurse found out that the
client had several suicidal attempts. Which of the following is the most important
nursing action?
A. Ignore the client as long as he or she is talking about suicide, because
suicide attempt is unlikely.
B. Administer medication.
C. Relax vigilance when the client seems to be recovering from depression.
D. Maintain constant awareness of the client’s whereabouts.
25. The nurse suspects that the client is suffering from depression. During assessment,
what are the most characteristic signs and symptoms of depression the nurse would
note?
A. Constipation, increased appetite.
B. Anorexia, insomnia.
C. Diarrhea, anger.
D. Verbosity, increased social interaction.
26. The client in the psychiatric unit states that, “The goodas are coming! I must be
ready.” In response to this neologism, the nurse’s initial response is to:
A.
B.
C.
D.
Acknowledge that the word has some special meaning for the client.
Try to interpret what the client means.
Divert the client’s attention to an aspect of reality.
State that what the client is saying has not been understood and then divert
attention to something that is really bound.
27. A male client diagnosed with depression tells the nurse, “I don’t want to look
weak and I don’t even cry because my wife and my kids can’t bear it.” The nurse
understands that this is an example of:
A. Repression.
B. Suppression.
C. Undoing.
D. Rationalization.
28. A female client tells the nurse that she is afraid to go out from her room because
she thinks that the other client might kill her. The nurse is aware that this behavior is
related to:
A. Hallucination.
B. Ideas of reference.
C. Delusion of persecution.
D. Illusion.
29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows
less awareness of the physical body. What problem would the nurse be most
concerned?
A. Nausea.
B. Gait disturbances.
C. Bowel movements.
D. Voiding.
30. A 6-year-old client dies in the nursing unit. The parents want to see the child.
What is the most appropriate nursing action?
A. Give the parents time alone with the body.
B. Ask the physician for permission.
C. Complete the postmortem care and quietly accompany the family to the
child’s room.
D. Suggest the parents to wait until the funeral service to say “good-bye.”
31. A 20-year-old female client is diagnosed with anxiety disorder. The physician
prescribed Flouxetine (Prozac). What is the most important side effects should a nurse
be concerned?
A. Tremor, drowsiness.
B. Seizures, suicidal tendencies.
C. Visual disturbance, headache.
D. Excessive diaphoresis, diarrhea.
32. A nurse is assigned to activate a client who is withdrawn, hears voices and
negativistic. What would be the best nursing approach?
A. Mention that the “voices” would want the client to participate.
B. Demand that the client must join a group activity.
C. Give the client a long explanation of the benefits of activity.
D. Tell the client that the nurse needs a partner for an activity.
33. A nurse is going to give a rectal suppository as a preoperative medication to a 4year-old boy. The boy is very anxious and frightened. Which of the following
statement by the nurse would be most appropriate to gain the child’s cooperation?
A. “Be a big kid! Everyone’s waiting for you.”
B. “Lie still now and I’ll let you have one of your presents before you even
have your operation.”
C. “Take a nice, big, deep breath and then let me hear you count to five.”
D. “You look so scared. Want to know a secret? This won’t hurt a bit!”
34. A depressed client is on an MAO inhibitor? What should the nurse watch out for?
A. Hypertensive crisis.
B. Diet restrictions.
C. Taking medication with meals.
D. Exposure to sunlight.
35. A 16-year-old girl is admitted for treatment of a fracture. The client shares to the
nurse caring to her that her step-father has made sexual advances to her. She got the
chance to tell it to her mother but refuses to believe. What is the most therapeutic
action of the nurse would be:
A. Tell the client to work it out with her father.
B. Tell the client to discuss it with her mother.
C. Ask the father about it.
D. Ask the mother what she thinks.
36. A client with a diagnosis of paranoid disorder is admitted in the psychiatric
hospital. The client tells the nurse, “the FBI is following me. These people are plotting
against me.” With this statement the nurse will need to:
A. Acknowledge that this is the client’s belief but not the nurse’s belief.
B. Ask how that makes the client feel.
C. Show the client that no one is behind.
D. Use logic to help the client doubt this belief.
37. A nurse is completing the routine physical examination to a healthy 16-year-old
male client. The client shares to the nurse that he feels like killing his girlfriend
because he found out that her girlfriend had another boyfriend. He then laughs, and
asks the nurse to keep this a secret just between the two of them. The nurse reviews
his chart and notes that there is no previously history of violence or psychiatric illness.
Which of the following would be the best action of the nurse to take at this time?
A. Suggest the teen meet with a counselor to discuss his feelings about his
girlfriend.
B. Tell the teen that his feelings are normal, and recommend that he find
another girlfriend to take his mind off the problem.
C. Recall the teenage boys often say things they really do not mean and ignore
the comment.
D. Regard the comment seriously and notify the teen’s primary health care
provider and parents
38. Which of the following person will be at highest risk for suicide?
A.
B.
C.
D.
A student at exam time
A married woman, age 40, with 6 children.
A person who is an alcoholic.
A person who made a previous suicide attempt.
39. A male client is repetitively doing the handwashing every time he touches things.
It is important for a nurse to understand that the client’s behavior is probably an
attempt to:
A. Seek attention from the staff.
B. Control unacceptable impulses or feelings.
C. Do what the voices the patient hears tell him or her to do.
D. Punish himself or herself for guilt feeling.
40. In a mental health settings, the basic goal of nursing is to:
A. Advance the science of psychiatry by initiating research and gathering data
for current statistics on emotional illness.
B. Plan activity programs for clients.
C. Understand various types of family therapy and psychological tests and
how to interpret them.
D. Maintain a therapeutic environment.
41. A 3-year-old boy is brought to the emergency department. After an hour, the boy
dies of respiratory failure. The mother of the boy becomes upset, shouting and
abusive, saying to the nurse, “If it had been your son, they would have done more to
save it. “What should the nurse say or do?
A. Touch her and tell her exactly what was done for her baby.
B. Allow the mother to continue her present behavior while sitting quietly
with her.
C. “No, all clients are given the same good care.”
D. “Yes, you’re probably right. Your son did not get better care.”
42. The nurse is interacting to a client with an antisocial personality disorder. What
would be the most therapeutic approach of the nurse to an antisocial behavior?
A. Gratify the client’s inner needs.
B. Give the client opportunities to test reality.
C. Provide external controls.
D. Reinforce the client’s self-concept.
43. A 55-year-old male client tells the nurse that he needs his glasses and hearing aid
with him in the recovery room after the surgery, or he will be upset for not granting
his request. What is the appropriate nursing response?
A. “Do you get upset and confused often?”
B. “You won’t need your glasses or hearing aid. The nurses will take care of
you.”
C. “I understand. You will be able to cooperate best if you know what is going
on, so I will find out how I can arrange to have your glasses and hearing
aid available to you in the recovery room.”
D. I understand you might be more cooperative if you have your aid and
glasses, but that is just not possible. Rules, you know.”
44. The male client had fight with his roommates in the psychiatric unit. The client
agitated client is placed in isolation for seclusion. The nurse knows it is essential that:
A. A staff member has frequent contacts with the client.
B. Restraints are applied.
C. The client is allowed to come out after 4 hours.
D. All the furniture is removed form the isolation room.
45. A medical representative comes to the hospital unit for the promotion of a new
product. A female client, admitted for hysterical behavior, is found embracing him.
What should the nurse say?
A. “Have you considered birth control?”
B. “This isn’t the purpose of either of you being here.”
C. “I see you’ve made a new friend.”
D. “Think about what you are doing.”
46. A client with dementia is for discharge. The nurse is providing a discharge
instruction to the family member regarding safety measures at home. What suggestion
can the nurse make to the family members?
A. Avoid stairs without banisters.
B. Use restraints while the client is in bed to keep him or her from wandering
off during the night.
C. Use restraints while the client is sitting in a chair to keep him or her from
wandering off during the day.
D. Provide a night-light and a big clock.
47. A 30-year-old married woman comes to the hospital for treatment of fractures.
The woman tells the nurse that she was physically abused by her husband. The
woman receives a call from her husband telling her to get home and things will be
different. He felt sorry of what he did. What can the nurse advise her?
A.
B.
C.
D.
“Do you think so?”
“It’s not likely.”
“What will be different?”
“I hope so, for your sake.”
48. A female client was diagnosed with breast cancer. It is found to be stage IV, and a
modified mastectomy is performed. After the procedure, what behaviors could the
nurse expects the client to display?
A. Denial of the possibility of carcinoma.
B. Signs of grief reaction.
C. Relief that the operation is over.
D. Signs of deep depression.
49. A client is withdrawn and does not want to interact to anybody even to the nurse.
What is the best initial nursing approach to encourage communication with this client?
A. Use simple questions that call for a response.
B. Encourage discussion of feelings.
C. Look through a photo album together.
D. Bring up neutral topics.
50. Which of the following nursing approach is most important in a client with
depression?
A.
B.
C.
D.
Deemphasizing preoccupation with elimination, nourishment, and sleep.
Protecting against harm to others.
Providing motor outlets for aggressive, hostile feelings.
Reducing interpersonal contacts.
PNLE I for 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
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. 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
21.All of the following nursing interventions are correct when using the
Ztrack 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
22.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
23.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
24.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
25.The appropriate needle gauge for intradermal injection is:
A. 20G
B. 22G
C. 25G
D. 26G
26.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
27.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
28.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
29.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
30.Which of the following conditions may require fluid restriction?
A. Fever
B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
D. Dehydration
31.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
32.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
33.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 extendedduration compounds
34.A patient who develops hives after receiving an antibiotic is exhibiting drug:
A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy
35.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 a vital signs every 15 minutes for 2 hours
D. Order a hemoglobin and hematocrit count 1 hour after the arteriography
36.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
37.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
38.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.
39.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
40.Clay colored stools indicate:
A. Upper GI bleeding
B. Impending constipation
C. An effect of medication
D. Bile obstruction
41.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
42.All of the following are good sources of vitamin A except:
A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks
43.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
44.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
45.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
46.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
47.When transferring a patient from a bed to a chair, the nurse should use which
muscles to avoid back injury?
A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles
48.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)
49.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
50.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
PNLE II for 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
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
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
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
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 purple-blue 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)
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
PNLE III for 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-biologic-value 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.
B.
C.
D.
Flank pain radiating in the groin
Distention of the lower abdomen
Perineal edema
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 a 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
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 includes:
A. Accurate dose delivery
B. Shorter injection time
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 tonic-clonic 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
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.
Which of the following would the nurse assess next?
A. Headache
B. Bladder distension
C. Dizziness
D. Ability to move legs
44. 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
45. 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
46. Nurse Faith should recognize that fluid shift in an 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
47. 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
48. 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
49. 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
50. A client has undergone laryngectomy. The immediate nursing priority would be:
A.
B.
C.
D.
Keep trachea free of secretions
Monitor for signs of infection
Provide emotional support
Promote means of communication
PNLE IV for 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.
B.
C.
D.
Hallucinations
Delusions
Loose associations
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
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
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.
B.
C.
D.
Depensiveness
Embarrassment
Shame
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 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 substanceinduced 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
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.
B.
C.
D.
Multiple stimuli
Routine Activities
Minimal decision making
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 self-centered”
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
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.
B.
C.
D.
Length of time on the med.
Name of the ingested medication & the amount ingested
Reason for the suicide attempt
Name of the nearest relative & their phone number