1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time?

A. Timing and recording length of contractions.B. Monitoring.C. Preparing for an emergency cesarean birth.D. Checking the perineum for bulging.

2. A client who hallucinates is not in touch with reality. It is important for the nurse to:

A. Isolate the client from other patients.B. Maintain a safe environment.C. Orient the client to time, place, and person.D. Establish a trusting relationship.

3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child?

A. Cola with iceB. Yellow non citrus JelloC. Cool cherry Kool-AidD. A glass of milk

4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of:

A. Increased nasal congestion.B. Nasal polyps.C. Bleeding tendencies.D. Tinnitus and diplopia.

5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should:

A. Place the client in a private room.B. Wear an N 95 respirator when caring for the client.C. Put on a gown every time when entering the room.D. Don a surgical mask with a face shield when entering the room.

6. Which of the following is the most frequent cause of noncompliance to the medical treatment of open-angle glaucoma?

A. The frequent nausea and vomiting accompanying use of miotic drug.B. Loss of mobility due to severe driving restrictions.C. Decreased light and near-vision accommodation due to miotic effects of pilocarpine.D. The painful and insidious progression of this type of glaucoma.

7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a client’s room and notes that the client’s tube has become disconnected from the Pleurovac. What would be the initial nursing action?

A. Apply pressure directly over the incision site.B. Clamp the chest tube near the incision site.

C. Clamp the chest tube closer to the drainage system.D. Reconnect the chest tube to the Pleurovac.

8. Which of the following complications during a breech birth the nurse needs to be alarmed?

A. Abruption placenta.B. Caput succedaneum.C. Pathological hyperbilirubinemia.D. Umbilical cord prolapse.

9. The nurse is caring to a client diagnosed with severe depression. Which of the following nursing approach is important in depression?

A. Protect the client against harm to others.B. Provide the client with motor outlets for aggressive, hostile feelings.C. Reduce interpersonal contacts.D. Deemphasizing preoccupation with elimination, nourishment, and sleep.

10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not:

A. Sit up.B. Pick up and hold a rattle.C. Roll over.D. Hold the head up.

11. The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not knowthe physician or the client to whom the order pertains. The nurse should:

A. Ask the physician to call back after the nurse has read the hospital policy manual.B. Take the telephone order.C. Refuse to take the telephone order.D. Ask the charge nurse or one of the other senior staff nurses to take the telephone order.

12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit. The nurse manager assigned the same nurse to the second client. The nurse feels that the client with hypertension requires one-to-one care. What would be the initial actionof the nurse?

A. Accept the new assignment and complete an incident report describing a shortage of nursing staff.B. Report the incident to the nursing supervisor and request to be floated.C. Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment.D. Accept the new assignment and provide the best care.

13. A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to give the discharge teaching regarding the proper care at home. The nurse would anticipate that the mother is probably at the:

A. 40 years of age.B. 20 years of age.C. 35 years of age.D. 20 years of age.

14. The emergency department has shortage of staff. The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. What should the staff nurse expect under these conditions?

A. The float staff nurse will be informed of the situation before the shift begins.B. The staff nurse will be able to negotiate the assignments in the emergency department.C. Cross training will be available for the staff nurse.D. Client assignments will be equally divided among the nurses.

15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is receiving digoxin. Which of the following questions will be asked by the nurse to the parents of the child in order to assess the client’s risk for digoxin toxicity?

A. “Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”B. “Has he been taking diuretics at home?”C. “Do any of his brothers and sisters have history of cardiac problems?”D. “Has he been going to school regularly?”

16. The nurse noticed that the signed consent form has an error. The form states, “Amputation of the right leg” instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. What should the nurse do?

A. Call the physician to reschedule the surgery.B. Call the nearest relative to come in to sign a new form.C. Cross out the error and initial the form.D. Have the client sign another form.

17. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. The fluctuation has stopped, the nurse would:

A. Vigorously strip the tube to dislodge a clot.B. Raise the apparatus above the chest to move fluid.C. Increase wall suction above 20 cm H2O pressure.D. Ask the client to cough and take a deep breath.

18. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to:

A. Determine who is responsible for the mistake and terminate his or her employment.B. Record the event in an incident/variance report and notify the nursing supervisor.C. Reassure both mothers, report to the charge nurse, and do not record.D. Record detailed notes of the event on the mother’s medical record.

19. Before the administration of digoxin, the nurse completes an assessment to a toddler client for signs and symptoms of digoxin toxicity. Which of the following is the earliest and most significant sign of digoxin toxicity?

A. TinnitusB. Nausea and vomitingC. Vision problemD. Slowing in the heart rate

20. Which of the following treatment modality is appropriate for a client with paranoid tendency?

A. Activity therapy.B. Individual therapy.C. Group therapy.D. Family therapy.

21. The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on prednisone therapy, the nurse should advise the client to:

A. Wear sunglasses if exposed to bright light for an extended period of time.B. Take oral preparations of prednisone before meals.C. Have periodic complete blood counts while on the medication.D. Never stop or change the amount of the medication without medical advice.

22. A pregnant client tells the nurse that she is worried about having urinary frequency. What will be the most appropriate nursing response?

A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife.B. “Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.”C. “Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.”D. “Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy. Increase your daily fluid intake to 3L.”

23. Which of the following will help the nurse determine that the expression of hostility is useful?

A. Expression of anger dissipates the energy.B. Energy from anger is used to accomplish what needs to be done.C. Expression intimidates others.D. Degree of hostility is less than the provocation.

24. The nurse is providing an orientation regarding case management to the nursing students. Which characteristics should the nurse include in the discussion in understanding case management?

A. Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care.B. Main purpose is to identify expected client, family and staff performance against the timeline for clients with the same diagnosis.C. Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost.D. Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems.

25. The physician orders a dose of IV phenytoin to a child client. In preparing in the administration of the drug, which nursing action is not correct?

A. Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.B. Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy.C. Plan to give phenytoin over 30-60 minutes, using an in-line filter.D. Flush the IV tubing with normal saline before starting phenytoin.

26. The pregnant woman visits the clinic for check –up. Which assessment findings will help the nurse determine that the client is in 8-week gestation?

A. Leopold maneuvers.B. Fundal height.

C. Positive radioimmunoassay test (RIA test).D. Auscultation of fetal heart tones.

27. Which of the following nursing intervention is essential for the client who had pneumonectomy?

A. Medicate for pain only when needed.B. Connect the chest tube to water-seal drainage.C. Notify the physician if the chest drainage exceeds 100mL/hr.D. Encourage deep breathing and coughing.

28. The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause:

A. Discoloration of baby and adult teeth.B. Pneumonia in the newborn.C. Snuffles and rhagades in the newborn.D. Central hearing defects in infancy.

29. The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The client asks the nurse, “Have you ever tried or used drugs?” The most correct response of the nurse would be:

A. “Yes, once I tried grass.”B. “No, I don’t think so.”C. “Why do you want to know that?”D. “How will my answer help you?”

30. Which of the following describes a health care team with the principles of participative leadership?

A. Each member of the team can independently make decisions regarding the client’s care without necessarily consulting the other members.B. The physician makes most of the decisions regarding the client’s care.C. The team uses the expertise of its members to influence the decisions regarding the client’s care.D. Nurses decide nursing care; physicians decide medical and other treatment for the client.

31. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution?

A. Oxytocin.B. Estrogen.C. Progesterone.D. Relaxin.

32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is responsible for the overall planning, giving and evaluating care during the entire shift. After the shift, same responsibility will be endorsed to the next nurse in charge. This describes nursing care delivered via the:

A. Primary nursing method.B. Case method.C. Functional method.D. Team method.

33. The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency care to include assessment for:

A. Gas exchange impairment.B. Hypoglycemia.C. Hyperthermia.D. Fluid volume excess.

34. Most couples are using “natural” family planning methods. Most accidental pregnancies in couples preferred to use this method have been related to unprotected intercourse before ovulation. Which of the following factor explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period?

A. Ovum viability.B. Tubal motility.C. Spermatozoal viability.D. Secretory endometrium.

35. An older adult client wakes up at 2 o’clock in the morning and comes to the nurse’s station saying, “I am having difficulty in sleeping.” What is the best nursing response to the client?

A. “I’ll give you a sleeping pill to help you get more sleep now.”B. “Perhaps you’d like to sit here at the nurse’s station for a while.”C. “Would you like me to show you where the bathroom is?”D. “What woke you up?”

36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is to:

A. Start oxygen by mask to reduce fetal distress.B. Examine the woman for signs of a prolapsed cord.C. Turn the woman on her left side to increase placental perfusion.D. Take the woman’s radial pulse while still auscultating the FHR.

37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like:

A. Antihistamines.B. NSAIDs.C. Antacids.D. Salicylates.

38. A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when:

A. Client is oriented when aroused from sleep, and goes back to sleep immediately.B. Blood pressure is decreased from 160/90 to 110/70.C. Client refuses dinner because of anorexia.D. Pulse is increased from 88-96 with occasional skipped beat.

39. The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. Which of the following statement by the nurse js correct?

A. “The spouse, but not the rest of the family, may override the advance directive.”B. “An advance directive is required for a “do not resuscitate” order.”C. “A durable power of attorney, a form of advance directive, may only be held by a blood relative.”D. “The advance directive may be enforced even in the face of opposition by the spouse.”

40. A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, “I need to go to an appointment.” What is the appropriate nursing intervention?

A. Tell the client that he cannot bang on the door.B. Ignore this behavior.C. Escort the client going back into the room.D. Ask the client to move away from the door.

41. Which of the following action is an accurate tracheal suctioning technique?

A. 25 seconds of continuous suction during catheter insertion.B. 20 seconds of continuous suction during catheter insertion.C. 10 seconds of intermittent suction during catheter withdrawal.D. 15 seconds of intermittent suction during catheter withdrawal.

42. The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that the most important thing that must be ready at the bedside is:

A. Suture set.B. Tracheostomy set.C. Suction equipment.D. Wire cutters.

43. A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of placental separation?

A. The uterus becomes globular.B. The umbilical cord is shortened.C. The fundus appears at the introitus.D. Mucoid discharge is increased.

44. After therapy with the thrombolytic alteplase (t-PA. , what observation will the nurse report to the physician?

A. 3+ peripheral pulses.B. Change in level of consciousness and headache.C. Occasional dysrhythmias.D. Heart rate of 100/bpm.

45. A client who undergone left nephrectomy has a large flank incision. Which of the following nursing action will facilitate deep breathing and coughing?

A. Push fluid administration to loosen respiratory secretions.B. Have the client lie on the unaffected side.C. Maintain the client in high Fowler’s position.D. Coordinate breathing and coughing exercise with administration of analgesics.

46. The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Which characteristics are typical of the cervical mucus during the “fertile” period of the menstrual cycle?

A. Absence of ferning.B. Thin, clear, good spinnbarkeit.C. Thick, cloudy.D. Yellow and sticky.

47. A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semi-Fowler’s position primarily to:

A. Facilitate movement and reduce complications from immobility.B. Fully aerate the lungs.C. Splint the wound.D. Promote drainage and prevent subdiaphragmatic abscesses.

48. Which of the following will best describe a management function?

A. Writing a letter to the editor of a nursing journal.B. Negotiating labor contracts.C. Directing and evaluating nursing staff members.D. Explaining medication side effects to a client.

49. The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:

A. In the middle of the lower conjunctival sac of the infant’s eye.B. Directly onto the infant’s sclera.C. In the outer canthus of the infant’s eye.D. In the inner canthus of the infant’s eye.

50. The nurse is assessing on the client who is admitted due to vehicle accident. Which of the following findings will help the nurse that there is internal bleeding?

A. Frank blood on the clothing.B. Thirst and restlessness.C. Abdominal pain.D. Confusion and altered of consciousness.

51. The nurse is completing an assessment to a newborn baby boy. The nurse observes that the skin of the newborn is dry and flaking and there are several areas of an apparent macular rash. The nurse charts this as:

A. Icterus neonatorumB. Multiple hemangiomasC. Erythema toxicumD. Milia

52. The client is brought to the emergency department because of serious vehicle accident. After an hour, the client has been declared brain dead. The nurse who has been with the client must now talk to the family about organ donation. Which of the following consideration is necessary?

A. Include as many family members as possible.B. Take the family to the chapel.C. Discuss life support systems.D. Clarify the family’s understanding of brain death.

53. The nurse is teaching exercises that are good for pregnant women increasing tone and fitness and decreasing lower backache. Which of the following should the nurse exclude in the exercise program?

A. Stand with legs apart and touch hands to floor three times per day.B. Ten minutes of walking per day with an emphasis on good posture.C. Ten minutes of swimming or leg kicking in pool per day.D. Pelvic rock exercise and squats three times a day.

54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking care of the client knows that the primary treatment goal is to:

A. Provide distraction.B. Support but limit the behavior.C. Prohibit the behavior.D. Point out the behavior.

55. After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma:

A. When the client is able to begin self-care procedures.B. 24 hours later, when the swelling subsided.C. In the operating room after the ileostomy procedure.D. After the ileostomy begins to function.

56. A female client who has a 28-day menstrual cycle asks the community health nurse when she get pregnant during her cycle. What will be the best nursing response?

A. It is impossible to determine the fertile period reliably. So it is best to assume that a woman is always fertile.B. In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours and the sperm live for about 72 hours. The fertile period would be approximately between day 11 and day 15.C. In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours and the sperm live for about 24 hours. The fertile period would be approximately between day 13 and 17.D. In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. The fertile period is between day 20 and the beginning of the next period.

57. Which of the following statement describes the role of a nurse as a client advocate?

A. A nurse may override clients’ wishes for their own good.B. A nurse has the moral obligation to prevent harm and do well for clients.C. A nurse helps clients gain greater independence and self-determination.D. A nurse measures the risk and benefits of various health situations while factoring in cost.

58. A community health nurse is providing a health teaching to a woman infected with herpes simplex 2. Which of the following health teaching must the nurse include to reduce the chances of transmission of herpes simplex 2?

A. “Abstain from intercourse until lesions heal.”B. “Therapy is curative.”C. “Penicillin is the drug of choice for treatment.”D. “The organism is associated with later development of hydatidiform mole.

59. The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which concept does the nursing staff need to keep in mind in planning nursing intervention for this client?

A. Depression underlines ritualistic behavior.B. Fear and tensions are often expressed in disguised form through symbolic processes.C. Ritualistic behavior makes others uncomfortable.D. Unmet needs are discharged through ritualistic behavior.

10. The nurse assesses the health condition of the female client. The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse understands that, women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism?

A. Intellectualization.B. Suppression.C. Repression.D. Denial.

61. Which of the following situations cannot be delegated by the registered nurse to the nursing assistant?

A. A postoperative client who is stable needs to ambulate.B. Client in soft restraint who is very agitated and crying.C. A confused elderly woman who needs assistance with eating.D. Routine temperature check that must be done for a client at end of shift.

62. In the admission care unit, which of the following client would the nurse give immediate attention?

A. A client who is 3 days postoperative with left calf pain.B. A client who is postoperative hip pinning who is complaining of pain.C. New admitted client with chest pain.D. A client with diabetes who has a glucoscan reading of 180.

63. A couple seeks medical advice in the community health care unit. A couple has been unable to conceive; the man is being evaluated for possible problems. The physician ordered semen analysis. Which of the following instructions is correct regarding collection of a sperm specimen?

A. Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately.B. Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours.C. Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately.D. Collect specimen at night, refrigerate, and bring to clinic the next morning.

64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. The nurse expects that the drug will:

A. Treat infection.B. Suppress labor contraction.C. Stimulate the production of surfactant.D. Reduce the risk of hypertension.

65. A tracheostomy cuff is to be deflated, which of the following nursing intervention should be implemented before starting the procedures?

A. Suction the trachea and mouth.B. Have the obdurator available.C. Encourage deep breathing and coughing.D. Do a pulse oximetry reading.

66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that:

A. Gloves are worn when handling the client’s tissue, excretions, and linen.B. Both client and attending nurse must wear masks at all times.C. Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in cough and tissue techniques.D. Full isolation; that is, caps and gowns are required during the period of contagion.

67. A client with lung cancer is admitted in the nursing care unit. The husband wants to know the condition of his wife. How should the nurse respond to the husband?

A. Find out what information he already has.B. Suggest that he discuss it with his wife.C. Refer him to the doctor.D. Refer him to the nurse in charge.

68. A hospitalized client cannot find his handkerchief and accuses other cient in the room and the nurse of stealing them. Which is the most therapeutic approach to this client?

A. Divert the client’s attention.B. Listen without reinforcing the client’s belief.C. Inject humor to defuse the intensity.D. Logically point out that the client is jumping to conclusions.

69. After a cystectomy and formation of an ileal conduit, the nurse provides instruction regarding prevention of leakage of the pouch and backflow of the urine. The nurse is correct to include in the instruction to empty the urine pouch:

A. Every 3-4 hours.B. Every hour.C. Twice a day.D. Once before bedtime.

70. Which telephone call from a student’s mother should the school nurse take care of at once?

A. A telephone call notifying the school nurse that the child’ pediatrician has informed the mother that the child will need cardiac repair surgery within the next few weeks.B. A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child has head lice.C. A telephone call notifying the school nurse that a child has a temperature of 102ºF and a rash covering the trunk and upper extremities of the body.D. A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night.

71. Which of the following signs and symptoms that require immediate attention and may indicate most serious complications during pregnancy?

A. Severe abdominal pain or fluid discharge from the vagina.B. Excessive saliva, “bumps around the areolae, and increased vaginal mucus.C. Fatigue, nausea, and urinary frequency at any time during pregnancy.D. Ankle edema, enlarging varicosities, and heartburn.

72. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes slightly cyanotic. What is the initial nursing action?

A. Elevate his head to promote gravity drainage of secretions.B. Wrap him in another blanket, to reduce heat loss.C. Stimulate him to cry,, to increase oxygenation.D. Aspirate his mouth and nose with bulb syringe.

73. The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs to have knowledge of which psychodynamic principle?A. The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings.B. The major fundamental mechanism is regression.C. The client’s symptoms are imaginary and the suffering is faked.D. An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention and love.

74. An infant is brought to the health care clinic for three immunizations at the same time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should:A. Be drawn in the same syringe and given in one injection.B. Be mixed and inject in the same sites.C. Not be mixed and the nurse must give three injections in three sites.D. Be mixed and the nurse must give the injection in three sites.

75. A female client with cancer has radium implants. The nurse wants to maintain the implants in the correct position. The nurse should position the client:

A. Flat in bed.B. On the side only.C. With the foot of the bed elevated.D. With the head elevated 45-degrees (semi-Fowler’s).

76. The nurse wants to know if the mother of a toddler understands the instructions regarding the administration of syrup of ipecac. Which of the following statement will help the nurse to know that the mother needs additional teaching?

A. “I’ll give the medicine if my child gets into some toilet bowl cleaner.”B. “I’ll give the medicine if my child gets into some aspirin.”C. “I’ll give the medicine if my child gets into some plant bulbs.”D. “I’ll give the medicine if my child gets into some vitamin pills.”

77. To assess if the cranial nerve VII of the client was damaged, which changes would not be expected?

A. Drooling and drooping of the mouth.B. Inability to open eyelids on operative side.C. Sagging of the face on the operative side.D. Inability to close eyelid on operative side.

78. The community health nurse makes a home visit to a family. During the visit, the nurse observes that the mother is beating her child. What is the priority nursing intervention in this situation?

A. Assess the child’s injuries.B. Report the incident to protective agencies.C. Refer the family to appropriate support group.D. Assist the family to identify stressors and use of other coping mechanisms to prevent further incidents.

79. The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a newborn that is on water feeding only. The nurse is responsible for the mistake of the nursing assistant:

A. Always, as a representative of the institution.B. Always, because nurses who supervise less-trained individuals are responsible for their mistakes.C. If the nurse failed to determine whether the nursing assistant was competent to take care of the client.D. Only if the nurse agreed that the newborn could be fed formula.

80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is encouraged to the client. the primary reason for this is to:

A. Reduce the size of existing stones.B. Prevent crystalline irritation to the ureter.C. Reduce the size of existing stonesD. Increase the hydrostatic pressure in the urinary tract.

81. The nurse is counseling a couple in their mid 30’s who have been unable to conceive for about 6 months. They are concerned that one or both of them may be infertile. What is the best advice the nurse could give to the couple?

A. “it is no unusual to take 6-12 months to get pregnant, especially when the partners are in their mid-30s. Eat well, exercise, and avoid stress.”B. “Start planning adoption. Many couples get pregnant when they are trying to adopt.”C. “Consult a fertility specialist and start testing before you get any older.”D. “Have sex as often as you can, especially around the time of ovulation, to increase your chances of pregnancy.”

82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for Creatinine clearance is to be done. The client tells the nurse, “I can’t remember what this test is for.” The best response by the nurse is:

A. “It provides a way to see if you are passing any protein in your urine.”B. “It tells how well the kidneys filter wastes from the blood.”C. “It tells if your renal insufficiency has affected your heart.”D. “The test measures the number of particles the kidney filters.”

83. The nurse observes the female client in the psychiatric ward that she is having a hard time sleeping at night. The nurse asks the client about it and the client says, “I can’t sleep at night because of fear of dying.” What is the best initial nursing response?

A. “It must be frightening for you to feel that way. Tell me more about it.”B. “Don’t worry, you won’t die. You are just here for some test.”C. “Why are you afraid of dying?”D. “Try to sleep. You need the rest before tomorrow’s test.”

84. In the hospital lobby, the registered nurse overhears a two staff members discussing about the health condition of her client. What would be the appropriate action for the registered nurse to take?

A. Join in the conversation, giving her input about the case.B. Ignore them, because they have the right to discuss anything they want to.C. Tell them it is not appropriate to discuss such things.D. Report this incident to the nursing supervisor.

85. The client has had a right-sided cerebrovascular accident. In transferring the client from the wheelchair to bed, in what position should a client be placed to facilitate safe transfer?

A. Weakened (L) side of the cient next to bed.B. Weakened (R) side of the client next to bed.C. Weakened (L) side of the client away from bed.D. Weakened (R) side of the cient away from bed.

86. The child client has undergone hip surgery and is in a spica cast. Which of the following toy should be avoided to be in the child’s bed?

A. A toy gun.B. A stuffed animal.C. A ball.D. Legos.

87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be given to a client after birth fo the fetus. The nurse is correct to explain that oxytocin:

A. Minimizes discomfort from “afterpains.”B. Suppresses lactation.C. Promotes lactation.D. Maintains uterine tone.

88. The nurse in the nursing care unit is aware that one of the medical staff displays unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been reported to the nurse manager several times, but no changes observed. The nurse should:

A. Continue to report observations of unusual behavior until the problem is resolved.B. Consider that the obligation to protect the patient from harm has been met by the prior reports and do nothing further.C. Discuss the situation with friends who are also nurses to get ideas .D. Approach the partner of this medical staff member with these concerns.

89. The physician ordered tetracycline PO qid to a child client who weights 20kg. The recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose that can be safely administered to this child?

A. 1 gB. 500 mgC. 250 mgD. 125 mg

90. The nurse is completing an obstetric history of a woman in labor. Which event in the obstetric history will help the nurse suspects dysfunctional labor in the current pregnancy?

A. Total time of ruptured membranes was 24 hours with the second birth.B. First labor lasting 24 hours.C. Uterine fibroid noted at time of cesarean delivery.D. Second birth by cesarean for face presentation.

91. The nurse is planning to talk to the client with an antisocial personality disorder. What would be the most therapeutic approach?

A. Provide external controls.B. Reinforce the client’s self-concept.C. Give the client opportunities to test reality.D. Gratify the client’s inner needs.

92. The nurse is teaching a group of women about fertility awareness, the nurse should emphasize that basal body temperature:

A. Can be done with a mercury thermometer but no a digital one.B. The average temperature taken each morning.C. Should be recorded each morning before any activity.D. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.

93. The nursing applicant has given the chance to ask questions during a job interview at a local hospital. What should be the most important question to ask that can increase chances of securing a job offer?

A. Begin with questions about client care assignments, advancement opportunities, and continuing education.B. Decline to ask questions, because that is the responsibility of the interviewer.C. Ask as many questions about the facility as possible.D. Clarify information regarding salary, benefits, and working hours first, because this will help in deciding whether or not to take the job.

94. The nurse advised the pregnant woman that smoking and alcohol should be avoided during pregnancy. The nurse takes into account that the developing fetus is most vulnerable to environment teratogens that cause malformation during:

A. The entire pregnancy.B. The third trimester.C. The first trimester.D. The second trimester.

95. A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing response would be:

A. Silence.B. “Where’s the bug? I’ll kill it for you.”C. “I don’t see a bug in your bed, but you seem afraid.”D. “You must be seeing things.”

96. A pregnant client in late pregnancy is complaining of groin pain that seems worse on the right side. Which of the following is the most likely cause of it?

A. Beginning of labor.B. Bladder infection.C. Constipation.D. Tension on the round ligament.

97. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct in imparting the idea that the Good Samaritan law protects the nurse from a suit for malpractice when:

A. The nurse stops to render emergency aid and leaves before the ambulance arrives.B. The nurse acts in an emergency at his or her place of employment.C. The nurse refuses to stop for an emergency outside of the scope of employment.D. The nurse is grossly negligent at the scene of an emergency.

98. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan of care for this client, which nursing care is least likely to be done?

A. Deep-tendon reflexes once per shift.B. Vital signs and FHR and rhythm q4h while awake.

C. Absolute bed rest.D. Daily weight.

99. While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on assessing the condition of the client. The nurse notes that the newborn’s respiration is 72 breaths per minute. What would be the initial nursing action?

A. Burp the newborn.B. Stop the feeding.C. Continue the feeding.D. Notify the physician.

100. A client who undergone appendectomy 3 days ago is scheduled for discharge today. The nurse notes that the client is restless, picking at bedclothes and saying, “I am late on my appointment,” and calling the nurse by the wrong name. The nurse suspects:

A. Panic reaction.B. Medication overdose.C. Toxic reaction to an antibiotic.D. Delirium tremens.

Answers & Rationale

1. A. The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safetyof the fetus and necessitate discontinuing the drug.

2. B. It is of paramount importance to prevent the client from hurting himself or herself or others.

3. B. After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding.

4. A. Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes.

5. B. The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator.

6. C. The most frequent cause of noncompliance to the treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the client’s ability to read for extended periods and making participation in games with fast-moving objects impossible.

7. B. This stops the sucking of air through the tube and prevents the entry of contaminants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube.

8. D. Because umbilical cord’s insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth.

9. B. It is important to externalize the anger away from self.

10. D. Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be able to achieve this milestone.

11. D. Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospital’s policy regarding telephone orders. Failure to followhospital policy could be considered negligence. In this case, the nurse was new and did not know the hospital’s policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless A. no one else is available and B. it is an emergency situation.

12. C. The nurse is obligated to inform the nurse manager about changes in the condition of the client, which may change the decision made by the nurse manager.

13. A. Perinatal risk factors for the development of Down syndrome include advanced maternal age, especially with the first pregnancy.

14. B. Assignments should be based on scope of practice and expertise.

15. B. The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the child’s serum potassium level should be carefully monitored.

16. A. The responsible for an accurate informed consent is the physician. An exception to this answer would be a life-threatening emergency, but there are no data to support another response.

17. D. Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded.

18. B. Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again.

19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate holding the medication and notifying the physician.

20. B. This option is least threatening.

21. D. In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (A. take oral preparations after meals; (B. remember that routine checks of vital signs, weight, and lab studies are critical; (C. NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (D. store the medication in a light-resistant container.

22. A. Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.

23. B. This is the proper use of anger.

24. C. There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations and continually monitor progress overtime.

25. A. Phenytoin should be infused or injected into larger veins to avoid the discoloration know as purple glove syndrome; infusing into a smaller vein is not appropriate.

26. C. Serum radioimmunoassay (RIA. is accurate within 7days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH.

27. D. Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the client’s only remaining lung.

28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophiliA. and conjunctivitis from Chlamydia.

29. D. The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents.

30. C. It describes a democratic process in which all members have input in the client’s care.

31. A. Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland.

32. B. In case management, the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty.

33. A. Smoke inhalation affects gas exchange.

34. C. Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result.

35. B. This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning).

36. D. Taking the mother’s pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia.

37. A. Antihistamines cause pupil dilation and should be avoided with glaucoma.

38. A. This suggests that the level of consciousness is decreasing.

39. D. An advance directive is a form of informed consent, and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse, are enforced.

40. C. Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive.

41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.

42. D. The priority for this client is being able to establish an airway.

43. A. Signs of placental separation include a change in the shape of the uterus from ovoid to globular.

44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding.

45. D. Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and deep-breathing exercises should be planned to maximize the analgesic effects.

46. B. Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.

47. D. After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s position to promote drainage and to prevent possible complications.

48. C. Directing and evaluation of staff is a major responsibility of a nursing manager.

49. A. The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac.

50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to recognized and evaluate because it is not apparent.

51. C. Erythema toxicum is the normal, nonpathological macular newborn rash.

52. D. The family needs to understand what brain death is before talking about organ donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed.

53. A. Bending from the waist in pregnancy tends to make backache worse.

54. B. Support and limit setting decrease anxiety and provide external control.

55. C. The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful and excoriated.

56. B. It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur from sperm deposited before ovulation.

57. C. An advocate role encourage freedom of choice, includes speaking out for the client, and supports the client’s best interests.

58. A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to one’s sexual partner.

59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy.

60. D. Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may in greater pathology in a woman with potential breast carcinoma.

61. B. The registered nurse cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraint requires further assessment to determine if there are additional causes for the behavior.

62. C. The client with chest pain may be having a myocardial infarction, and immediate assessment and intervention is a priority.

63. B. Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours.

64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant.

65. A. Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated.

66. C. Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the client noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance. Client should be in a well-ventilated room, without air recirculation, to prevent air contamination.

67. A. It is best to establish baseline information first.

68. B. Listening is probably the most effective response of the four choices.

69. A. Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose).

70. C. A high fever accompanied by a body rash could indicate that the child has a communicable disease and would have exposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection.

71. A. Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may indicate premature rupture of the membrane.

72. D. Gentle aspiration of mucus helps maintain a patent airway, required for effective gas exchange.

73. A. Somatoform disorders provide a way of coping with conflicts.

74. C. Immunization should never be mixed together in a syringe, thus necessitating three separate injections in three sites. Note: some manufacturers make a premixed combination of immunization that is safe and effective.

75. A. Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees.

76. A. Syrup of ipecac is not administered when the ingested substances is corrosive in nature. Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested substance “burned” the esophagus going down, it will “burn” the esophagus coming back up when the child begins to vomit after administration of syrup of ipecac.

77. B. Inability to open eyelids on operative side is seen with cranial nerve III damage.

78. A. Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the first priority.

79. C. The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment, as well as legal obligation to provide adequate supervision.

80. D. Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi.

81. A. Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will experience a longer time to get pregnant.

82. B. Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance test.

83. A. Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings.

84. C. The behavior should be stopped. The first is to remind the staff that confidentiality maybe violated.

85. C. With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. The client’s good side should be closest to the bed to facilitate the transfer.

86. D. Legos are small plastic building blocks that could easily slip under the child’s cast and lead to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are some other narrow or small items that could easily slip under the child’s cast and lead to a break in skin integrity and infection.

87. D. Oxytocin (Pitocin) is used to maintain uterine tone.

88. B. The submission of reports about incidents that expose clients to harm does not remove the obligation to report ongoing behavior as long as the risk to the client continues.

89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of tetracycline. In this case, the child is being given this medication four times a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses.)

90. C. An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors.

91. A. Personality disorders stem from a weak superego, implying a lack of adequate controls.

92. C. The basal body temperature is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature may be seen, after ovulation in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.

93. A. This choice implies concern for client care and self-improvement.

94. C. The first trimester is the period of organogenesis, that is, cell differentiation into the various organs, tissues, and structures.

95. C. This response does not contradict the client’s perception, is honest, and shows empathy.

96. D. Tension on round ligament occurs because of the erect human posture and pressure exerted by the growing fetus.

97. D. The Good Samaritan Law does not impose a duty to stop at the scene of an emergency outside of the scope of employment, therefore nurses who do not stop are not liable for suit.

98. C. Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia, she will most probably have bathroom privileges.

99. B. A normal respiratory rate for a newborn is 30-40 breaths per minute.

100. D. The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal (often unsuspected on a surgical unit.)

1. A 10 year old who has sustained a head injury is brought to the emergency department by his mother. A diagnosis of a mild concussion is made. At the time of discharge, nurse Ron should instruct the mother to:

A. Withhold food and fluids for 24 hours.B. Allow him to play outdoors with his friends.C. Arrange for a follow up visit with the child’s primary care provider in one week.C. Check for any change in responsiveness every two hours until the follow-up visit.

2. A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse Helen should frequency assess the client’s vital signs during the compensatory stage of shock, because:

A. Arteriolar constriction occursB. The cardiac workload decreasesC. Decreased contractility of the heart occursD. The parasympathetic nervous system is triggered

3. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing concerns about being poisoned. The best intervention by nurse Dina would be to:

A. Allow the client to open canned or pre-packaged foodB. Restrict the client to his room until 2 lbs are gainedC. Have a staff member personally taste all of the client’s foodD. Tell the client the food has been x-rayed by the staff and is safe

4. One day the mother of a young adult confides to nurse Frida that she is very troubled by he child’s emotional illness. The nurse’s most therapeutic initial response would be:

A. “You may be able to lessen your feelings of guilt by seeking counseling”B. “It would be helpful if you become involved in volunteer work at this time”C. “I recognize it’s hard to deal with this, but try to remember that this too shall pass”D. “Joining a support group of parents who are coping with this problem can be quite helpful.

5. To check for wound hemorrhage after a client has had a surgery for the removal of a tumor in the neck, nurse grace should:

A. Loosen an edge of the dressing and lift it to see the woundB. Observe the dressing at the back of the neck for the presence of bloodC. Outline the blood as it appears on the dressing to observe any progressionD. Press gently around the incision to express accumulated blood from the wound

6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is labor. To verify that the client is in true labor nurse Trina should:

A. Obtain sides for a fern testB. Time any uterine contractionsC. Prepare her for a pelvic examinationD. Apply nitrazine paper to moist vaginal tissue

7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased pressure:

A. In the pulmonary veinB. In the pulmonary artery

C. On the left side of the heartD. On the right side of the heart

8. An obese client asks nurse Julius how to lose weight. Before answering, the nurse should remember that long-term weight loss occurs best when:

A. Eating patterns are alteredB. Fats are limited in the dietC. Carbohydrates are regulatedD. Exercise is a major component

9. As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset that she cannot control her crying. The most appropriate response by the nurse would be:

A. “Is talking about your problem upsetting you?”B. “It is Ok to cry; I’ll just stay with you for now”C. “You look upset; lets talk about why you are crying.”D. “Sometimes it helps to get it out of your system.”

10. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids is given first?

A. AlbuminB. D5WC. Lactated Ringer’s solutionD. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml

11. During the first 48 hours after a severe burn of 40% of the clients body surface, the nurse’s assessment should include observations for water intoxication. Associated adaptations include:

A. Sooty-colored sputumB. Frothy pink-tinged sputumC. Twitching and disorientationD. Urine output below 30ml per hour

12. After a muscle biopsy, nurse Willy should teach the client to:

A. Change the dressing as neededB. Resume the usual diet as soon as desiredC. Bathe or shower according to preferenceD. Expect a rise in body temperature for 48 hours

13. Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse Joy is aware that:

A. Arm and shoulder muscles must be developedB. Shrinkage of the residual limb must be completedC. Dexterity in the other extremity must be achievedD. Full adjustment to the altered body image must have occurred

14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline lasting 15 seconds. Nurse Cathy should:

A. Change the maternal positionB. Prepare for an immediate birthC. Call the physician immediatelyD. Obtain the client’s blood pressure

15. A male client receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. The best initial action by the nurse would be to:

A. Perform a finger stick to test the client’s blood glucose levelB. Have the physician assess the client for an enlarged prostateC. Obtain a urine specimen from the client for screening purposesD. Assess the client’s lower extremities for the presence of pitting edema

16. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing:

A. AnginaB. Chest painC. Heart blockD. Tachycardia

17. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse Faith knows they should be given:

A. With meals and snacksB. Every three hours while awakeC. On awakening, following meals, and at bedtimeC. After each bowel movement and after postural draianage

18. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the hood, it would be appropriate for nurse Gian to:

A. Hydrate the infant q15 minB. Put a hat on the infant’s headC. Keep the oxygen concentration consistentD. Remove the infant q15 min for stimulation

19. A client’s sputum smears for acid fast bacilli (AFB) are positive, and transmission-based airborne precautions are ordered. Nurse Kyle should instruct visitors to:

A.Limit contact with non-exposed family membersB. Avoid contact with any objects present in the client’s roomC. Wear an Ultra-Filter mask when they are in the client’s roomD. Put on a gown and gloves before going into the client’s room

20. A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli; and exhibits decorticate posturing. Nurse Kate should recognize that these are signs of:

A. Meningeal irritationB. Subdural hemorrhageC. Medullary compressionD. Cerebral cortex compression

21. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully observe for would be:

A. Mediastinal shiftB. Tracheal lacerationC. Open pneumothoraxD. Pericardial tamponade

22. When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal bleeding secondary to placenta previa, the nurse’s primary objective would be:

A. Provide a calm, quiet environmentB. Prepare the client for an immediate cesarean birthC. Prevent situations that may stimulate the cervix or uterusD. Ensure that the client has regular cervical examinations assess for labor

23. When planning discharge teaching for a young female client who has had a pneumothorax, it is important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek medical assistance if she experiences:

A. Substernal chest painB. Episodes of palpitationC. Severe shortness of breathD. Dizziness when standing up

24. After a laryngectomy, the most important equipment to place at the client’s bedside would be:

A. Suction equipmentB. Humidified oxygenC. A nonelectric call bellD. A cold-stream vaporizer

25. Nurse Oliver interviews a young female client with anorexia nervosa to obtain information for the nursing history. The client’s history is likely to reveal a:

A. Strong desire to improve her body imageB. Close, supportive mother-daughter relationshipC. Satisfaction with and desire to maintain her present weightD. Low level of achievement in school, with little concerns for grades

26. Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control the use of ritualistic behavior by:

A. Providing repetitive activities that require little thoughtB. Attempting to reduce or limit situations that increase anxietyC. Getting the client involved with activities that will provide distractionD. Suggesting that the client perform menial tasks to expiate feelings of guilt

27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt revision. Before discharge, nurse John, knowing the expected developmental behaviors for this age group, should tell the parents to call the physician if the child:

A. Tries to copy all the father’s mannerismsB. Talks incessantly regardless of the presence of others

C. Becomes fussy when frustrated and displays a shortened attention spanD. Frequently starts arguments with playmates by claiming all toys are “mine”

28. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan to avoid this complication by:

A. Assessing urine specific gravityB. Maintaining the ordered hydrationC. Collecting a weekly urine specimenD. Emptying the drainage bag frequently

29. A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the emergency response team assess for signs of circulatory impairment by:

A. Turning the client to side lying positionB. Asking the client to cough and deep breatheC. Taking the client’s pedal pulse in the affected limbD. Instructing the client to wiggle the toes of the right foot

30. To assess orientation to place in a client suspected of having dementia of the alzheimers type, nurse Chris should ask:

A. “Where are you?”B. “Who brought you here?”C. “Do you know where you are?”D. “How long have you been there?”

31. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects that disseminated intravascular coagulation (DIC) is occurring when assessments demonstrate:

A. A boggy uterusB. Multiple vaginal clotsC. Hypotension and tachycardiaD. Bleeding from the venipuncture site

32. When a client on labor experiences the urge to push a 9cm dilation, the breathing pattern that nurse Rhea should instruct the client to use is the:

A. Expulsion patternB. Slow paced patternC. Shallow chest patternD. blowing pattern

33. Nurse Ronald should explain that the most beneficial between-meal snack for a client who is recovering from the full-thickness burns would be a:

A. Cheeseburger and a maltedB. Piece of blueberry pie and milkC. Bacon and tomato sandwich and teaD. Chicken salad sandwich and soft drink

34. Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to extrauterine life would be indicated by:

A. flexed extremitiesB. Cyanotic lips and faceC. A heart rate of 130 beats per minuteD. A respiratory rate of 40 breath per minute

35. The laboratory calls to state that a client’s lithium level is 1.9 mEq/L after 10 days of lithium therapy. Nurse Reese should:

A. Notify the physician of the findings because the level is dangerously highB. Monitor the client closely because the level of lithium in the blood is slightly elevatedC. Continue to administer the medication as ordered because the level is within the therapeutic rangeD. Report the findings to the physician so the dosage can be increased because the level is below therapeutic range

36. A client has a regular 30-day menstrual cycles. When teaching about the rhythm method, Which the client and her husband have chosen to use for family planning, nurse Dianne should emphasize that the client’s most fertile days are:

A. Days 9 to 11B. Days 12 to 14C. Days 15 to 17D. Days 18 to 20

37. Before an amniocentesis, nurse Alexandra should:

A. Initiate the intravenous therapy as ordered by the physiscianB. Inform the client that the procedure could precipitate an infectionC. Assure that informed consent has been obtained from the clientD. Perform a vaginal examination on the client to assess cervical dilation

38. While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is essential for nurse Amy to monitor the client’s deep tendon reflexes to:

A. Determine her level of consciousnessB. Evaluate the mobility of the extremitiesC. Determine her response to painful stimuliD. Prevent development of respiratory distress

39. A preschooler is admitted to the hospital with a diagnosis of acute glomerulonephritis. The child’s history reveals a 5-pound weight gain in one week and peritoneal edema. For the most accurate information on the status of the child’s edema, nursing intervention should include:

A. Obtaining the child’s daily weightB. Doing a visual inspection of the childC. Measuring the child’s intake and outputD. Monitoring the child’s electrolyte values

40. Nurse Mickey is administering dexamethasome (Decadron) for the early management of a client’s cerebral edema. This treatment is effective because:

A. Acts as hyperosmotic diureticB. Increases tissue resistance to infectionC. Reduces the inflammatory response of tissuesD. Decreases the information of cerebrospinal fluid

41. During newborn nursing assessment, a positive Ortolani’s sign would be indicated by:

A. A unilateral droop of hipB. A broadening of the perineumC. An apparent shortening of one legD. An audible click on hip manipulation

42. When caring for a dying client who is in the denial stage of grief, the best nursing approach would be to:

A. Agree and encourage the client’s denialB. Allow the denial but be available to discuss deathC. Reassure the client that everything will be OKD. Leave the client alone to confront the feelings of impending loss

43. To decrease the symptoms of gastroesophageal reflux disease (GERD), the physician orders dietary and medication management. Nurse Helen should teach the client that the meal alteration that would be most appropriate would be:

A. Ingest foods while they are hotB. Divide food into four to six meals a dayC.Eat the last of three meals daily by 8pmD. Suck a peppermint candy after each meal

44. After a mastectomy or hysterectomy, clients may feel incomplete as women. The statement that should alert nurse Gina to this feeling would be:

A. “I can’t wait to see all my friends again”B. “I feel washed out; there isn’t much left”C. “I can’t wait to get home to see my grandchild”D. “My husband plans for me to recuperate at our daughter’s home”

45. A client with obstruction of the common bile duct may show a prolonged bleeding and clotting time because:

A. Vitamin K is not absorbedB. The ionized calcium levels fallsC. The extrinsic factor is not absorbedD. Bilirubin accumulates in the plasma

46. Realizing that the hypokalemia is a side effect of steroid therapy, nurse Monette should monitor a client taking steroid medication for:

A. Hyperactive reflexesB. An increased pulse rateC. Nausea, vomiting, and diarrheaD. Leg weakness with muscle cramps

47. When assessing a newborn suspected of having Down syndrome, nurse Rey would expect to observe:

A. long thin fingersB. Large, protruding earsC. Hypertonic neck musclesD. Simian lines on the hands

48. A 10 year old girl is admitted to the pediatric unit for recurrent pain and swelling of her joints, particularly her knees and ankles. Her diagnosis is juvenile rheumatoid arthritis. Nurse Janah recognizes that besides joint inflammation, a unique manifestation of the rheumatoid process involves the:

A. EarsB. EyesC. LiverD. Brain

49. A disturbed client is scheduled to begin group therapy. The client refuses to attend. Nurse Lolit should:

A. Accept the client’s decision without discussionB. Have another client to ask the client to considerC. Tell the client that attendance at the meeting is requiredD. Insist that the client join the group to help the socialization process

50. Because a severely depressed client has not responded to any of the antidepressant medications, the psychiatrist decides to try electroconvulsive therapy (ECT). Before the treatment the nurse should:

A. Have the client speak with other clients receiving ECTB. Give the client a detailed explanation of the entire procedureC. Limit the client’s intake to a light breakfast on the days of the treatmentD. Provide a simple explanation of the procedure and continue to reassure the client

51. Nurse Vicky is aware that teaching about colostomy care is understood when the client states, “I will contact my physician and report ____”:

A. If I notice a loss of sensation to touch in the stoma tissue”B. When mucus is passed from the stoma between irrigations”C. The expulsion of flatus while the irrigating fluid is running out”D. If I have difficulty in inserting the irrigating tube into the stoma”

52. The client’s history that alerts nurse Henry to assess closely for signs of postpartum infection would be:

A. Three spontaneous abortionsB. negative maternal blood typeC. Blood loss of 850 ml after a vaginal birthD. Maternal temperature of 99.9° F 12 hours after delivery

53. A client is experiencing stomatitis as a result of chemotherapy. An appropriate nursing intervention related to this condition would be to:

A. Provide frequent saline mouthwashesB. Use karaya powder to decrease irritationC. Increase fluid intake to compensate for the diarrheaD. Provide meticulous skin care of the abdomen with Betadine

54. During a group therapy session, one of the clients ask a male client with the diagnosis of antisocial personality disorder why he is in the hospital. Considering this client’s type of personality disorder, the nurse might expect him to respond:

A. “I need a lot of help with my troubles”B. “Society makes people react in old ways”

C. “I decided that it’s time I own up to my problems”D. “My life needs straightening out and this might help”

55. A child visits the clinic for a 6-week checkup after a tonsillectomy and adenoidectomy. In addition to assessing hearing, the nurse should include an assessment of the child’s:

A. Taste and smellB. Taste and speechC. Swallowing and smellD. Swallowing and speech

56. A client is diagnosed with cancer of the jaw. A course of radiation therapy is to be followed by surgery. The client is concerned about the side effects related to the radiation treaments. Nurse Ria should explain that the major side effects that will experienced is:

A. FatigueB. AlopeciaC. VomitingD. Leucopenia

57. Nurse Katrina prepares an older-adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. Targeting the most frequent cause of falls, the nurse should:

A. Offer the client assistance to the bathroomB. Move the bedside table closer to the client’s bedC. Encourage the client to take an available sedativeD. Assist the client to telephone the spouse to say “goodnight”

58. When evaluating a growth and development of a 6 month old infant, nurse Patty would expect the infant to be able to:

A. Sit alone, display pincer grasp, wave bye byeB. Pull self to a standing position, release a toy by choice, play peek-a-booC. Crawl, transfer toy from one hand to the other, display of fear of strangersD. Turn completely over, sit momentarily without support, reach to be picked up

59. A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. Nurse Tina should instruct the client to:

A. Manually express milk and feed it to the baby in a bottleB. Stop breastfeeding for two days to allow the nipple to healC. Use a breast shield to keep the baby from direct contact with the nippleD. Feed the baby on the unaffected breast first until the affected breast heals

60. Nurse Sandy observes that there is blood coming from the client’s ear after head injury. Nurse Sandy should:

A. Turn the client to the unaffected sideB. Cleanse the client’s ear with sterile gauzeC. Test the drainage from the client’s ear with DextrostixD. Place sterile cotton loosely in the external ear of the client

61. Nurse Gio plans a long term care for parents of children with sickle-cell anemia, which includes periodic group conferences. Some of the discussions should be directed towards:

A. Finding special school facilities for the childB. Making plans for moving to a more therapeutic climateC. Choosing a means of birth control to avoid future pregnanciesD. Airing their feelings regarding the transmission of the disease to the child

62. The central problem the nurse might face with a disturbed schizophrenic client is the client’s:

A. Suspicious feelingsB. Continuous pacingC. Relationship with the familyD. Concern about working with others

63. When planning care with a client during the postoperative recovery period following an abdominal hysterectomy and bilateral salpingo-oophorectomy, nurse Frida should include the explanation that:

A. Surgical menopause will occurB. Urinary retention is a common problemC. Weight gain is expected, and dietary plan are neededD. Depression is normal and should be expected

64. An adolescent client with anorexia nervosa refuses to eat, stating, “I’ll get too fat.” Nurse Andrea can best respond to this behavior initially by:

A. Not talking about the fact that the client is not eatingB. Stopping all of the client’s privileges until food is eatenC. Telling the client that tube feeding will eventually be necessaryD. Pointing out to the client that death can occur with malnutrition.

65. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a scale of 10 before medication and a 7 on a scale of 10 after being medicated. Nurse Glenda determines that the:

A. Client has a low pain toleranceB. Medication is not adequately effectiveC. Medication has sufficiently decreased the pain levelD. Client needs more education about the use of the pain scale

66. To enhance a neonate’s behavioral development, therapeutic nursing measures should include:

A. Keeping the baby awake for longer periods of time before each feedingB. Assisting the parents to stimulate their baby through touch, sound, and sight.C. Encouraging parental contact for at least one 15-minute period every four hours.D. Touching and talking to the baby at least hourly, beginning within two to four hours after birth

67. Before formulating a plan of care for a 6 year old boy with attention deficit hyperactivity disorder (ADHD), nurse Kyla is aware that the initial aim of therapy is to help the client to:

A. Develop language skillsB. Avoid his own regressive behaviorC. Mainstream into a regular class in schoolD. Recognize himself as an independent person of worth

68. Nurse Wally knows that the most important aspect of the preoperative care for a child with Wilms’ tumor would be:

A. Checking the size of the child’s liverB. Monitoring the child’s blood pressureC. Maintaining the child in a prone positionD. Collecting the child’s urine for culture and sensitivity

69. At 11:00 pm the count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the medication cart and medication administration records, no explanation can be found. The primary nurse should notify the:

A. Nursing unit managerB. Hospital administratorC. Quality control managerD. Physician ordering the medication

70. When caring for the a client with a pneumothorax, who has a chest tube in place, nurse Kate should plan to:

A. Administer cough suppressants at appropriate intervals as orderedB. Empty and measure the drainage in the collection chamber each shiftC. Apply clamps below the insertion site when ever getting the client out of bedD. Encourage coughing, deep breathing, and range of motion to the arm on the affected side

71. According to C.E.Winslow, which of the following is the goal of Public Health?

A. For people to attain their birthrights of health and longevityB. For promotion of health and prevention of diseaseC. For people to have access to basic health servicesD. For people to be organized in their health efforts

72. What other statistic may be used to determine attainment of longevity?

A. Age-specific mortality rateB. Proportionate mortality rateC. Swaroop’s indexD. Case fatality rate

73. 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 hospitalB. Services are provided free of charge to people within the catchment 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.

74. Which of the following is the mission of the Department of Health?

A. Health for all FilipinosB. Ensure the accessibility and quality of health careC. Improve the general health status of the populationD. Health in the hands of the Filipino people by the year 2020

75. Nurse Pauline determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating:

A. EffectivenessB. Efficiency

C. AdequacyD. Appropriateness

76. Lissa is a B.S.N. graduate. She want to become a Public Health Nurse. Where will she apply?

A. Department of HealthB. Provincial Health OfficeC. Regional Health OfficeD. Rural Health Unit

77. As an epidemiologist, Nurse Celeste is responsible for reporting cases of notifiable diseases. What law mandates reporting of cases of notifiable diseases?

A. Act 3573B. R.A. 3753C. R.A. 1054D. R.A. 1082

78. Nurse Fay is aware that isolation of a child with measles belongs to what level of prevention?

A. PrimaryB. SecondaryC. IntermediateD. Tertiary

79. Nurse Gina is aware that the following is an advantage of a home visit?

A. It allows the nurse to provide nursing care to a greater number of people.B. It provides an opportunity to do first hand appraisal of the home situation.C. It allows sharing of experiences among people with similar health problems.D. It develops the family’s initiative in providing for health needs of its members.

80. The PHN bag is an important tool in providing nursing care during a home visit. The most important principle of bag technique states that it:

A. Should save time and effort.B. Should minimize if not totally prevent the spread of infection.C. Should not overshadow concern for the patient and his family.D. May be done in a variety of ways depending on the home situation, etc.

81. Nurse Willy reads about Path Goal theory. Which of the following behaviors is manifested by the leader who uses this theory?

A. Recognizes staff for going beyond expectations by giving them citationsB. Challenges the staff to take individual accountability for their own practiceC. Admonishes staff for being laggardsD. Reminds staff about the sanctions for non performance

82. Nurse Cathy learns that some leaders are transactional leaders. Which of the following does NOT characterize a transactional leader?

A. Focuses on management tasksB. Is a caretaker

C. Uses trade-offs to meet goalsD. Inspires others with vision

83. Functional nursing has some advantages, which one is an EXCEPTION?

A. Psychological and sociological needs are emphasized.B. Great control of work activities.C. Most economical way of delivering nursing services.D. Workers feel secure in dependent role

84. Which of the following is the best guarantee that the patient’s priority needs are met?

A. Checking with the relative of the patientB. Preparing a nursing care plan in collaboration with the patientC. Consulting with the physicianD. Coordinating with other members of the team

85. Nurse Tony stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to?

A. Scalar chainB. DisciplineC. Unity of commandD. Order

86. Nurse Joey discusses the goal of the department. Which of the following statements is a goal?

A. Increase the patient satisfaction rateB. Eliminate the incidence of delayed administration of medicationsC. Establish rapport with patientsD. Reduce response time to two minutes

87. Nurse Lou considers shifting to transformational leadership. Which of the following statements best describes this type of leadership?

A. Uses visioning as the essence of leadershipB. Serves the followers rather than being servedC. Maintains full trust and confidence in the subordinatesD. Possesses innate charisma that makes others feel good in his presence.

88. Nurse Mae tells one of the staff, “I don’t have time to discuss the matter with you now. See me in my office later” when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use?

A. SmoothingB. CompromiseC. AvoidanceD. Restriction

89. Nurse Bea plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?

A. StaffingB. Scheduling

C. RecruitmentD. Induction

90. Nurse Linda tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this?

A. CentralizedB. DecentralizedC. MatrixD. Informal

91. When documenting information in a client’s medical record, the nurse should:

A. erase any errors.B. use a #2 pencil.C. leave one line blank before each new entry.D. end each entry with the nurse’s signature and title.

92. Which of the following factors are major components of a client’s general background drug history?

A. Allergies and socioeconomic statusB. Urine output and allergiesC. Gastric reflex and ageD. Bowel habits and allergies

93. Which procedure or practice requires surgical asepsis?

A. Hand washingB. Nasogastric tube irrigationC. I.V. cannula insertionD. Colostomy irrigation

94. The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis?

A. Holding sterile objects above the waistB. Pouring solution onto a sterile field clothC. Considering a 1″ (2.5-cm) edge around the sterile field contaminatedD. Opening the outermost flap of a sterile package away from the body

95. On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3–, 28 mEq/L. Based on these values,the nurse should formulate which nursing diagnosis for this client?

A. Risk for deficient fluid volumeB. Deficient fluid volumeC. Impaired gas exchangeD. Metabolic acidosis

96. The use of larvivorous fish in malaria control is the basis for which strategy of malaria control?

A. Stream seedingB. Stream clearing

C. Destruction of breeding placesD. Zooprophylaxis

97. In Integrated Management of Childhood Illness, 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. MastoiditisB. Severe dehydrationC. Severe pneumoniaD. Severe febrile disease

98. A mother brought her daughter, 4 years old, 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 drinkB. High grade feverC. Signs of severe dehydrationD. Cough for more than 30 days

99. Food fortification is one of the strategies to prevent micronutrient deficiency conditions. R.A. 8976 mandates fortification of certain food items. Which of the following is among these food items?

A. SugarB. BreadC. MargarineD. Filled milk

100. The major sign of iron deficiency anemia is pallor. What part is best examined for pallor?

A. PalmsB. NailbedsC. Around the lipsD. Lower conjunctival sac

Answers & Rationale

1. C. Check for any change in responsiveness every two hours until the follow-up visitSigns of an epidural hematoma in children usually do not appear for 24 hours or more hours; a follow-up visit usually is arranged for one to two days after the injury.

2. A. Arteriolar constriction occursThe early compensation of shock is cardiovascular and is seen in changes in pulse, BP, and pulse pressure; blood is shunted to vital centers, particularly heart and brain.

3. A. Allow the client to open canned or pre-packaged foodThe client’s comfort, safety, and nutritional status are the priorities; the client may feel comfortable to eat if the food has been sealed before reaching the mental health facility.

4. D. “Joining a support group of parents who are coping with this problem can be quite helpful.Taking with others in similar circumstances provides support and allows for sharing of experiences.

5. B. Observe the dressing at the back of the neck for the presence of bloodDrainage flows by gravity.

6. C. Prepare her for a pelvic examinationPelvic examination would reveal dilation and effacement

7. D. On the right side of the heartPulmonic stenosis increases resistance to blood flow, causing right ventricular hypertrophy; with right ventricular failure there is an increase in pressure on the right side of the heart.

8. A. Eating patterns are alteredA new dietary regimen, with a balance of foods from the food pyramid, must be established and continued for weight reduction to occur and be maintained.

9. B. “It is ok to cry; I’ll just stay with you for now”This portrays a nonjudgmental attitude that recognizes the client’s needs.

10. C. Lactated Ringer’s solutionLactated Ringer’s solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not primary fluid replacement. Dextrose isn’t given to burn patients during the first 24 hours because it can cause pseudodiabetes. The patient is hyperkalemic from the potassium shift from the intracellular space to the plasma, so potassium would be detrimental.

11. C. Twitching and disorientationExcess extracellular fluid moves into cells (water intoxication); intracellular fluid excess in sensitive brain cells causes altered mental status; other signs include anorexia nervosa, nausea, vomiting, twitching, sleepiness, and convulsions.

12. B. Resume the usual diet as soon as desiredAs long as the client has no nausea or vomiting, there are no dietary restriction.

13. B. Shrinkage of the residual limb must be completedShrinkage of the residual limb, resulting from reduction of subcutaneous fat and interstitial fluid, must occur for an adequate fit between the limb and the prosthesis.

14. A. Change the maternal positionStimulation of the sympathetic nervous system is an initial response to mild hypoxia that accompanies partial cord compression (umbilical vein) during contractions; changing the maternal position can alleviate the compression.

15. A. Perform a finger stick to test the client’s blood glucose levelThe client has signs of diabetes, which may result from steroid therapy, testing the blood glucose level is a method of screening for diabetes, thus gathering more data.

16. C. Heart blockThis is the primary indication for a pacemaker because there is an interfere with the electrical conduction system of the heart.

17. A. With meals and snacksPancreases capsules must be taken with food and snacks because it acts on the nutrients and readies them for absorption.

18. B. Put a hat on the infant’s headOxygen has cooling effect, and the baby should be kept warm so that metabolic activity and oxygen demands are not increased.

19. C. Wear an Ultra-Filter mask when they are in the client’s roomTubercle bacilli are transmitted through air currents; therefore personal protective equipment such as an Ultra-Filter mask is necessary.

20. D. Cerebral cortex compressionCerebral compression affects pyramidal tracts, resulting in decorticate rigidity and cranial nerve injury, which cause pupil dilation.

21. A. Mediastinal shiftMediastinal structures move toward the uninjured lung, reducing oxygenation and venous return.

22. C. Prevent situations that may stimulate the cervix or uterusStimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided.

23. C. Severe shortness of breathThis could indicate a recurrence of the pneumothorax as one side of the lung is inadequate to meet the oxygen demands of the body.

24. A. Suction equipmentRespiratory complications can occur because of edema of the glottis or injury to the recurrent laryngeal nerve.

25. A. Strong desire to improve her body imageClients with anorexia nervosa have a disturbed self image and always see themselves as fat and needing further reducing.

26. B. Attempting to reduce or limit situations that increase anxietyPersons with high anxiety levels develop various behaviors to relieve their anxiety; by reducing anxiety, the need for these obsessive-compulsive action is reduced.

27. C. Becomes fussy when frustrated and displays a shortened attention spanShortened attention span and fussy behavior may indicate a change in intracranial pressure and/or shunt malfunction.

28. B. Maintaining the ordered hydrationPromoting hydration maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection.

29. C. Taking the client’s pedal pulse in the affected limbMonitoring a pedal pulse will assess circulation to the foot.

30. A. “Where are you?”“Where are you?” is the best question to elicit information about the client’s orientation to place because it encourages a response that can be assessed.

31. D. Bleeding from the venipuncture siteThis indicates a fibrinogenemia; massive clotting in the area of the separation has resulted in a lowered circulating fibrinogen.

32. D. blowing patternClients should use a blowing pattern to overcome the premature urge to push.

33. A. Cheeseburger and a maltedOf the selections offered, this is the highest in calories and protein, which are needed for increased basal metabolic rate and for tissue repair.

34. B. Cyanotic lips and faceCentral cyanosis (blue lips and face) indicates lowered oxygenation of the blood, caused by either decreased lung expansion or right to left shunting of blood.

35. A. Notify the physician of the findings because the level is dangerously highLevels close to 2 mEq/L are dangerously close to the toxic level; immediate action must be taken.

36. C. Days 15 to 17Ovulation occurs approximately 14 days before the next menses, about the 16th day in 30 day cycle; the 15th to 17th days would be the best time to avoid sexual intercourse.

37. C. Assure that informed consent has been obtained from the clientAn invasive procedure such as amniocentesis requires informed consent.

38. D. Prevent development of respiratory distressRespiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dl; deep tendon reflexes disappear when the serum level is 10 to 12 mg/dl; the drug is withheld in the absence of deep tendon reflexes; the therapeutic serum level is 5 to 8 mg/dl.

39. A. Obtaining the child’s daily weightWeight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 liter of fluid weighs about 2.2 pounds.

40. C. Reduces the inflammatory response of tissuesCorticosteroids act to decrease inflammation which decreases edema.

41. D. An audible click on hip manipulationWith specific manipulation, an audible click may be heard of felt as he femoral head slips into the acetabulum.

42. B. Allow the denial but be available to discuss deathThis does not remove client’s only way of coping, and it permits future movement through the grieving process when the client is ready.

43. B. Divide food into four to six meals a dayThe volume of food in the stomach should be kept small to limit pressure on the cardiac sphincter.

44. B. “I feel washed out; there isn’t much left”The client’s statement infers an emptiness with an associated loss.

45. A. Vitamin K is not absorbedVitamin K, a fat soluble vitamin, is not absorbed from the GI tract in the absence of bile; bile enters the duodenum via the common bile duct.

46. D. Leg weakness with muscle crampsImpulse conduction of skeletal muscle is impaired with decreased potassium levels, muscular weakness and cramps may occur with hypokalemia.

47. D. Simian lines on the handsThis is characteristic finding in newborns with Down syndrome.

48. B. EyesRheumatoid arthritis can cause inflammation of the iris and ciliary body of the eyes which may lead to blindness.

49. A. Accept the client’s decision without discussionThis is all the nurse can do until trust is established; facing the client to attend will disrupt the group.

50. D. Provide a simple explanation of the procedure and continue to reassure the clientThe nurse should offer support and use clear, simple terms to allay client’s anxiety.

51. D. If I have difficulty in inserting the irrigating tube into the stoma”This occurs with stenosis of the stoma; forcing insertion of the tube could cause injury.

52. C. Blood loss of 850 ml after a vaginal birthExcessive blood loss predisposes the client to an increased risk of infection because of decreased maternal resistance; they expected blood loss is 350 to 500 ml.

53. A. Provide frequent saline mouthwashesThis is soothing to the oral mucosa and helps prevent infection.

54. B. “Society makes people react in old ways”The client is incapable of accepting responsibility for self-created problems and blames society for the behavior.

55. A. Taste and smellSwelling can obstruct nasal breathing, interfering with the senses of taste and smell.

56. A. FatigueFatigue is a major problem caused by an increase in waste products because of catabolic processes.

57. A. Offer the client assistance to the bathroomStatistics indicate that the most frequent cause of falls by hospitalized clients is getting up or attempting to get up to the bathroom unassisted.

58. D. Turn completely over, sit momentarily without support, reach to be picked upThese abilities are age-appropriate for the 6 month old child.

59. D. Feed the baby on the unaffected breast first until the affected breast healsThe most vigorous sucking will occur during the first few minutes of breastfeeding when the infant would be on the unaffected breast; later suckling is less traumatic.

60. D. Place sterile cotton loosely in the external ear of the clientThis would absorb the drainage without causing further trauma.

61. D. Airing their feelings regarding the transmission of the disease to the childDiscussion with parents who have children with similar problems helps to reduce some of their discomfort and guilt.

62. A. Suspicious feelingsThe nurse must deal with these feelings and establish basic trust to promote a therapeutic milieu.

63. A. Surgical menopause will occurWhen a bilateral oophorectomy is performed, both ovaries are excised, eliminating ovarian hormones and initiating response.

64. D. Pointing out to the client that death can occur with malnutrition.The client expects the nurse to focus on eating, but the emphasis should be placed on feelings rather than actions.

65. B. Medication is not adequately effectiveThe expected effect should be more than a one point decrease in the pain level.

66. B. Assisting the parents to stimulate their baby through touch, sound, and sight.Stimuli are provided via all the senses; since the infant’s behavioral development is enhanced through parent-infant interactions, these interactions should be encouraged.

67. D. Recognize himself as an independent person of worthAcademic deficits, an inability to function within constraints required of certain settings, and negative peer attitudes often lead to low self-esteem.

68. B. Monitoring the child’s blood pressureBecause the tumor is of renal origin, the rennin angiotensin mechanism can be involved, and blood pressure monitoring is important.

69. A. Nursing unit managerControlled substance issues for a particular nursing unit are the responsibility of that unit’s nurse manager.

70. D. Encourage coughing, deep breathing, and range of motion to the arm on the affected sideAll these interventions promote aeration of the re-expanding lung and maintenance of function in the arm and shoulder on the affected side.

71. A. For people to attain their birthrights of health and longevityAccording to Winslow, all public health efforts are for people to realize their birthrights of health and longevity.

72. C. Swaroop’s indexSwaroop’s index is the percentage of the deaths aged 50 years or older. Its inverse represents the percentage of untimely deaths (those who died younger than 50 years).

73. D. Public health nursing focuses on preventive, not curative, services.The catchment area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services.

74. B. Ensure the accessibility and quality of health careEnsuring the accessibility and quality of health care is the primary mission of DOH.

75. B. EfficiencyEfficiency is determining whether the goals were attained at the least possible cost.

76. D. Rural Health UnitR.A. 7160 devolved basic health services to local government units (LGU’s ). The public health nurse is an employee of the LGU.

77. A. Act 3573Act 3573, the Law on Reporting of Communicable Diseases, enacted in 1929, mandated the reporting of diseases listed in the law to the nearest health station.

78. A. PrimaryThe purpose of isolating a client with a communicable disease is to protect those who are not sick (specific disease prevention).

79. B. It provides an opportunity to do first hand appraisal of the home situation.Choice A is not correct since a home visit requires that the nurse spend so much time with the family. Choice C is an advantage of a group conference, while choice D is true of a clinic consultation.

80. B. Should minimize if not totally prevent the spread of infection.Bag technique is performed before and after handling a client in the home to prevent transmission of infection to and from the client.

81. A. Bag technique is performed before and after handling a client in the home to prevent transmission of infection to and from the client.Path Goal theory according to House and associates rewards good performance so that others would do the same.

82. D. Inspires others with visionInspires others with a vision is characteristic of a transformational leader. He is focused more on the day-to-day operations of the department/unit.

83. A. Psychological and sociological needs are emphasized.When the functional method is used, the psychological and sociological needs of the patients are neglected; the patients are regarded as ‘tasks to be done”

84. B. Preparing a nursing care plan in collaboration with the patientThe best source of information about the priority needs of the patient is the patient himself. Hence using a nursing care plan based on his expressed priority needs would ensure meeting his needs effectively.

85. C. Unity of commandThe principle of unity of command means that employees should receive orders coming from only one manager and not from two managers. This averts the possibility of sowing confusion among the members of the organization.

86. A. Increase the patient satisfaction rateGoal is a desired result towards which efforts are directed. Options AB, C and D are all objectives which are aimed at specific end.

87. A. Uses visioning as the essence of leadershipTransformational leadership relies heavily on visioning as the core of leadership.

88. C. AvoidanceThis strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In effect the problem remains unsolved and both parties are in a lose-lose situation.

89. A. StaffingStaffing is a management function involving putting the best people to accomplish tasks and activities to attain the goals of the organization.

90. B. DecentralizedDecentralized structures allow the staff to make decisions on matters pertaining to their practice and communicate in downward, upward, lateral and diagonal flow.

91. D. end each entry with the nurse’s signature and title.The end of each entry should include the nurse’s signature and title; the signature holds the nurse accountable for the recorded information. Erasing errors in documentation on a legal document such as a client’s chart isn’t permitted by law. Because a client’s medical record is considered a legal document, the nurse should make all entries in ink. The nurse is accountable for the information recorded and therefore shouldn’t leave any blank lines in which another health care worker could make additions.

92. A. Allergies and socioeconomic statusGeneral background data consist of such components as allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present.

93. C. I.V. cannula insertionCaregivers must use surgical asepsis when performing wound care or any procedure in which a sterile body cavity is entered or skin integrity is broken. To achieve surgical asepsis, objects must be rendered or kept free of all pathogens. Inserting an I.V. cannula requires surgical asepsis because it disrupts skin integrity and involves entry into a sterile cavity (a vein). The other options are used to ensure medical asepsis or clean technique to prevent the spread of infection. The GI tract isn’t sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

94. B. Pouring solution onto a sterile field clothPouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

95. C. Impaired gas exchangeThe client has a below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2), supporting the nursing diagnosis of Impaired gas exchange. ABG values can’t indicate a diagnosis of Fluid volume deficit (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing, diagnosis; in any event, these ABG values indicate respiratory, not metabolic, acidosis.

96. A. Stream seedingStream seeding is done by putting tilapia fry in streams or other bodies of water identified as breeding places of the Anopheles mosquito.

97. B. Severe dehydrationThe order of priority in the management of severe dehydration is as follows: intravenous fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol/nasogastric tube, Oresol/orem. When the foregoing measures are not possible or effective, tehn urgent referral to the hospital is done.

98. A. Inability to drinkA sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or difficult to awaken.

99. A. SugarR.A. 8976 mandates fortification of rice, wheat flour, sugar and cooking oil with Vitamin A, iron and/or iodine.

100. A. PalmsThe anatomic characteristics of the palms allow a reliable and convenient basis for examination for pallor.