1. A pregnant woman who is at term is admitted to the birthing unit in active labor.

The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time? A. Timing and recording length of contractions. B. Monitoring. C. Preparing for an emergency cesarean birth. D. Checking the perineum for bulging. 2. A client who hallucinates is not in touch with reality. It is important for the nurse to: A. Isolate the client from other patients. B. Maintain a safe environment. C. Orient the client to time, place, and person. D. Establish a trusting relationship. 3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child? A. Cola with ice B. Yellow noncitrus Jello C. Cool cherry Kool-Aid D. A glass of milk 4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of: A. Increased nasal congestion. B. Nasal polyps. C. Bleeding tendencies. D. Tinnitus and diplopia. 5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should: A. Place the client in a private room. B. Wear an N 95 respirator when caring for the client. C. Put on a gown every time when entering the room. D. Don a surgical mask with a face shield when entering the room. 6. Which of the following is the most frequent cause of noncompliance to the medical treatment of open-angle glaucoma? A. The frequent nausea and vomiting accompanying use of miotic drug. B. Loss of mobility due to severe driving restrictions. C. Decreased light and near-vision accommodation due to miotic effects of pilocarpine. D. The painful and insidious progression of this type of glaucoma. 7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a client’s room and notes that the client’s tube has become disconnected from the Pleurovac. What would be the initial nursing action? A. Apply pressure directly over the incision site. B. Clamp the chest tube near the incision site. C. Clamp the chest tube closer to the drainage system. D. Reconnect the chest tube to the Pleurovac. 8. Which of the following complications during a breech birth the nurse needs to be alarmed?

C. 20 years of age. What would be the initial actionof the nurse? A. Ask the physician to call back after the nurse has read the hospital policy manual. Cross training will be available for the staff nurse. The nurse is preparing to give the discharge teaching regarding the proper care at home. D. 11. Abruption placenta. Deemphasizing preoccupation with elimination. What should the staff nurse expect under these conditions? A. C. hostile feelings. Client assignments will be equally divided among the nurses. 9. Reduce interpersonal contacts. and sleep. Protect the client against harm to others. 13. the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not: A. 10. Refuse to take the telephone order. The nurse manager assigned the same nurse to the second client. Pathological hyperbilirubinemia. Pick up and hold a rattle. B. Caput succedaneum. Accept the new assignment and provide the best care. The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. nourishment. Roll over. The senior nurse had conversation with the other staff. Which of the following nursing approach is important in depression? A. Provide the client with motor outlets for aggressive. The emergency department has shortage of staff. B. The float staff nurse will be informed of the situation before the shift begins. D. Hold the head up. B. The nurse should: A. C. B. C. During assessment. Accept the new assignment and complete an incident report describing a shortage of nursing staff. B. B. D. The new nurse does not knowthe physician or the client to whom the order pertains. D. C. 12. Take the telephone order. The staff nurse will be able to negotiate the assignments in the emergency department. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. D. Sit up. The nurse would anticipate that the mother is probably at the: A. 40 years of age. D. B. Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment. Umbilical cord prolapse.A. A 3-month-old client is in the pediatric unit. The physician calls the nursing unit to leave an order. The nurse is caring to a client diagnosed with severe depression. 35 years of age. . A newborn infant with Down syndrome is to be discharged today. 20 years of age. C. D. C. The nurse feels that the client with hypertension requires one-to-one care. Ask the charge nurse or one of the other senior staff nurses to take the telephone order. A new pregnant woman in active labor is admitted in the same unit. Report the incident to the nursing supervisor and request to be floated. 14.

The client is receiving digoxin. B. “Has he been taking diuretics at home?” C. 21. Increase wall suction above 20 cm H2O pressure. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. Which of the following is the earliest and most significant sign of digoxin toxicity? A. The form states. Reassure both mothers. Tinnitus B. Never stop or change the amount of the medication without medical advice. In preparing the client for discharge on prednisone therapy. B. The nurse is assigned to care for a child client admitted in the pediatrics unit. D. The most appropriate nursing action would be to: A. report to the charge nurse. Call the physician to reschedule the surgery. 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. B. Wear sunglasses if exposed to bright light for an extended period of time. Have the client sign another form. the nurse should advise the client to: A. Individual therapy. Record the event in an incident/variance report and notify the nursing supervisor. Vision problem D. “Amputation of the right leg” instead of the left leg that is to be amputated. The fluctuation has stopped. The nurse has administered already the preoperative medications. C. The client with rheumatoid arthritis is for discharge. Call the nearest relative to come in to sign a new form. “Has he been exposed to any childhood communicable diseases in the past 2 -3 weeks?” B.15. Which of the following treatment modality is appropriate for a client with paranoid tendency? A. Raise the apparatus above the chest to move fluid. Have periodic complete blood counts while on the medication. Family therapy. Group therapy. D. and do not record. D. the nurse would: A. What should the nurse do? A. C. C. D. Record detailed notes of the event on the mother ’s medical record. Nausea and vomiting C. “Has he been going to school regularly?” 16. Activity therapy. “Do any of his brothers and sisters have history of cardiac problems?” D. The nurse noticed that the signed consent form has an error. Slowing in the heart rate 20. Take oral preparations of prednisone before meals. Cross out the error and initial the form. 18. D. 19. . C. Vigorously strip the tube to dislodge a clot. B. the nurse completes an assessment to a toddler client for signs and symptoms of digoxin toxicity. 17. The nurse determines that two babies were placed in the wrong cribs. B. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. Before the administration of digoxin. Determine who is responsible for the mistake and terminate his or her employment. C. Ask the client to cough and take a deep breath.

Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems. or blood in the urine. “Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis.” C. avoid unnecessary duplication of services. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. pain on voiding. Which of the following will help the nurse determine that the expression of hostility is useful? A. 24. B. The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. “Placental progesterone causes irritability of the bladder sphincter. Medicate for pain only when needed. 26. C. Which of the following nursing intervention is essential for the client who had pneumonectomy? A. “Frequency is due to bladder irritation fro m concentrate urine and is normal in pregnancy. B. Your symptoms will go away after the baby comes. The nurse is providing an orientation regarding case management to the nursing students. 28. Limit fluids to 1L/daily. Infuse the phenytoin into a smaller vein to prevent purple glove syndrome. Encourage deep breathing and coughing. never cloudy. Which assessment findings will help the nurse determine that the client is in 8-week gestation? A. If you have frequency associated with fever. B. Increase your daily fluid intake to 3L. call your doctor/nurse-midwife. Which characteristics should the nurse include in the discussion in understanding case management? A. 25. D. D. but it also can cause: A. Connect the chest tube to water-seal drainage. B. Main purpose is to identify expected client. In preparing in the administration of the drug. C. Auscultation of fetal heart tones. improve resource utilization and decrease cost. Positive radioimmunoassay test (RIA test). Pneumonia in the newborn. D. The nurse is correct in the statement. The pregnant woman visits the clinic for check –up. Plan to give phenytoin over 30-60 minutes. Expression intimidates others. Flush the IV tubing with normal saline before starting phenytoin.22. Fundal height. Leopold maneuvers. Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care. family and staff performance against the timeline for clients with the same diagnosis. C. A pregnant client tells the nurse that she is worried about having urinary frequency. Notify the physician if the chest drainage exceeds 100mL/hr. Discoloration of baby and adult teeth. D. Check the phenytoin solution to be sure it is clear or light yellow in color. D. Main focus is comprehensive coordination of client care. C.” 23. C. B. . B. which nursing action is not correct? A. using an in-line filter. Expression of anger dissipates the energy. “Pregnant women urinate frequently to get rid of fetal wastes. B. Energy from anger is used to accomplish what needs to be done. The physician orders a dose of IV phenytoin to a child client. What will be the most appropriate nursing response? A. Degree of hostility is less than the provocation.” D. 27.

Functional method. “How will my answer help you?” 30. D. “Have you ever tried or used drugs?” The most correct response of the nurse would be: A. The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The nurse is responsible for the overall planning. The client asks the nurse. 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. once I tried grass. normally secreted during the postpartum period. C. D. same responsibility will be endorsed to the next nurse in charge. Nurses decide nursing care.” B. The team uses the expertise of its members to influence the decisions regarding the client’s care. Hyperthermia.” . The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. “Perhaps you’d like to sit here at the nurse’s station for a while. Which of the following factor explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period? A. giving and evaluating care during the entire shift. C. 29. “Yes.” B. Most accidental pregnancies in couples preferred to use this method have been related to unprotected intercourse before ovulation. B. Most couples are using “natural” family planning methods.” C. Tubal motility. Progesterone. Primary nursing method. physicians decide medical and other treatment for the client. Central hearing defects in infancy. B. The physician makes most of the decisions regarding the client’s care. D. Case method. D. Gas exchange impairment. “No. 32. “I’ll give you a sleeping pill to help you get more sleep now. B. Oxytocin. This describes nursing care delivered via the: A. Snuffles and rhagades in the newborn.C. 34. Which hormone. After the shift. Ovum viability. B. D. the nurse will anticipate emergency care to include assessment for: A. D. Hypoglycemia. 33. 31. Secretory endometrium. While waiting for the ambulance. C. B. C. Which of the following describes a health care team with the principles of participative leadership? A. influences both the milk ejection reflex and uterine involution? A. Team method.” What is the best nursing response to the client? A. Each member of the team can independently make decisions regarding the client’s care without necessarily consulting the other members. 35. I don’t think so. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. Estrogen. C. Spermatozoal viability. Relaxin. Fluid volume excess. “Why do you want to know that?” D.

15 seconds of intermittent suction during catheter withdrawal.” C. Client is oriented when aroused from sleep. Tracheostomy set. “An advance directive is required for a “do not resuscitate” order. but not the rest of the family. B. Which of the following statement by the nurse js correct? A. Wire cutters. Blood pressure is decreased from 160/90 to 110/70. 10 seconds of intermittent suction during catheter withdrawal. C. D. 42. 39. B. D. 38. Suture set. Antihistamines. A mother is in the third stage of labor. may override the advance directive. “I need to go to an appointment.” What is the appropriate nursing intervention? A. 20 seconds of continuous suction during catheter insertion. Examine the woman for signs of a prolapsed cord. C. Ignore this behavior. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor. A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside. C. Suction equipment. D. Take the woman’s radial pulse while still auscultating the FHR. The immediate nursing action is to: A. “The spouse. a form of advance directive. Pulse is increased from 88-96 with occasional skipped beat. her membranes ruptured spontaneously 2 hours ago. B. “A durable power of attorney.” B. C. saying. Salicylates. Escort the client going back into the room. Client refuses dinner because of anorexia. A male client is brought to the emergency department due to motor vehicle accident. The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like: A. “Would you like me to show you where the bathroom is?” D. The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. and goes back to sleep immediately. Which of the following signs will help the nurse determine the signs of placental separation? . Turn the woman on her left side to increase placental perfusion. The nurse anticipates that the most important thing that must be ready at the bedside is: A. B. While auscultating for the point of maximum intensity of fetal heart tones before applying an external fetal monitor. “What woke you up?” 36. Antacids. 41. While monitoring the client. B. Start oxygen by mask to reduce fetal distress. may only be held by a blood relative. D. Tell the client that he cannot bang on the door. 25 seconds of continuous suction during catheter insertion.” D. NSAIDs.” 40. D. 37. the nurse counts 100 beats per minute. Which of the following action is an accurate tracheal suctioning technique? A. B. C. Ask the client to move away from the door.C. “The advance directive may be enforced even in the face of opposition by the spouse. the nurse suspects increasing intracranial pressure when: A. 43. C. D. The client’s jaw and cheekbone is sutured and wired.

The nurse placed the client in a semi-Fowler’s position primarily to: A. Which of the following findings will help the nurse that there is internal bleeding? A. 3+ peripheral pulses. In the inner canthus of the infant’s eye. Thin. Have the client lie on the unaffected side. cloudy. 48. D. B. The umbilical cord is shortened. Push fluid administration to loosen respiratory secretions. The uterus becomes globular. The nurse is assessing on the client who is admitted due to vehicle accident. . Frank blood on the clothing. 46. Maintain the client in high Fowler’s position. C. Which characteristics are typical of the cervical mucus during the “fertile” period of the menstrual cycle? A. B. The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. B. Fully aerate the lungs. good spinnbarkeit. B. Directing and evaluating nursing staff members. Absence of ferning. Writing a letter to the editor of a nursing journal. D. 49. 45. C.A. Splint the wound. Change in level of consciousness and headache. D. Which of the following will best describe a management function? A. The fundus appears at the introitus. Negotiating labor contracts. In the outer canthus of the infant’s eye. Which of the following nursing action will facilitate deep breathing and coughing? A. C. The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Thick. Explaining medication side effects to a client. C. Coordinate breathing and coughing exercise with administration of analgesics. B. D. 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. After therapy with the thrombolytic alteplase (t-PA. A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. what observation will the nurse report to the physician? A. 47. D. B. 44. D. A client who undergone left nephrectomy has a large flank incision. Promote drainage and prevent subdiaphragmatic abscesses. Yellow and sticky. Facilitate movement and reduce complications from immobility. Thirst and restlessness. D. B. Heart rate of 100/bpm. C. B. Directly onto the infant’s sclera. Occasional dysrhythmias. clear. Confusion and altered of consciousness. D. C. Mucoid discharge is increased. Abdominal pain. . 50. C. C.

B. D. It is impossible to determine the fertile period reliably. The nurse who has been with the client must now talk to the family about organ donation. C. Which of the following consideration is necessary? A. The nurse is teaching exercises that are good for pregnant women increasing tone and fitness and decreasing lower backache. In a 28-day cycle. D. After the ileostomy begins to function. 53. When the client is able to begin self-care procedures. Prohibit the behavior. A nurse measures the risk and benefits of various health situations while factoring in cost. Discuss life support systems. 55. Pelvic rock exercise and squats three times a day. Multiple hemangiomas C. C. 56. the client has been declared brain dead. A nurse has the moral obligation to prevent harm and do well for clients. ovulation occurs at or about day 14. The egg lives for about 72 hours and the sperm live for about 24 hours. 54. Which of the following should the nurse exclude in the exercise program? A. Erythema toxicum D. C. C. Stand with legs apart and touch hands to floor three times per day. D. Icterus neonatorum B. What will be the best nursing response? A. Milia 52. D. ovulation occurs at or about day 14. A female client who has a 28-day menstrual cycle asks the community health nurse when she get pregnant during her cycle. B. The nurse charts this as: A. A nurse helps clients gain greater independence and self-determination. D. Include as many family members as possible. Point out the behavior. 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. The fertile period would be approximately between day 11 and day 15. The egg lives for about 24 hours and the sperm live for about 72 hours. the nurse expects that the drainage appliance will be applied to the stoma: A. 24 hours later. In a 28-day cycle. After ileostomy. C. Which of the following statement describes the role of a nurse as a client advocate? A. In a 28. After an hour. ovulation occurs 8 days before the next period or at about day 20. The nurse observes that the skin of the newborn is dry and flaking and there are several areas of an apparent macular rash. C. In the operating room after the ileostomy procedure. B. The fertile period would be approximately between day 13 and 17. . The nurse is completing an assessment to a newborn baby boy. when the swelling subsided. Take the family to the chapel. A nurse may override clients’ wishes for their own good. D.day cycle. The client is brought to the emergency department because of serious vehicle accident. Provide distraction. Support but limit the behavior. Clarify the family’s understanding of brain death. B. Ten minutes of swimming or leg kicking in pool per day. 57. The fertile period is between day 20 and the beginning of the next period. Ten minutes of walking per day with an emphasis on good posture. B.51. B. So it is best to assume that a woman is always fertile.

Fear and tensions are often expressed in disguised form through symbolic processes. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. D. Depression underlines ritualistic behavior. and give to laboratory personnel immediately. 63. 59. . D. Intellectualization. Which of the following instructions is correct regarding collection of a sperm specimen? A. “Penicillin is the drug of choice for treatment. Repression. A postoperative client who is stable needs to ambulate. New admitted client with chest pain. A client who is postoperative hip pinning who is complaining of pain. place in iced container. A confused elderly woman who needs assistance with eating.” C. 10. B. A couple seeks medical advice in the community health care unit. “The organism is associated with later development of hydatidiform mole. The nurse understands that. Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours. C. Unmet needs are discharged through ritualistic behavior.” B. Routine temperature check that must be done for a client at end of shift. A couple has been unable to conceive. Which of the following situations cannot be delegated by the registered nurse to the nursing assistant? A. D.” D. A client with diabetes who has a glucoscan reading of 180. The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. Suppression. “Abstain from intercourse until lesions heal. Collect a specimen at the clinic. B. Treat infection. 64. C. D. D. The nurse assesses the health condition of the female client. Which concept does the nursing staff need to keep in mind in planning nursing intervention for this client? A. 61. C. B. A client who is 3 days postoperative with left calf pain. The physician ordered semen analysis. which of the following client would the nurse give immediate attention? A. Which of the following health teaching must the nurse include to reduce the chances of transmission of herpes simplex 2? A. Reduce the risk of hypertension. women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism? A. B. B. D. the man is being evaluated for possible problems. The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM group therapy sessions. Suppress labor contraction. In the admission care unit. 62. C. Ritualistic behavior makes others uncomfortable. Collect specimen at night. refrigerate. The nurse expects that the drug will: A. B. Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately. Denial. and bring to clinic the next morning. “Therapy is curative. Stimulate the production of surfactant. C.58. C. Client in soft restraint who is very agitated and crying. 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. A community health nurse is providing a health teaching to a woman infected with herpes simplex 2.

B. 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. A tracheostomy cuff is to be deflated. Encourage deep breathing and coughing. 66. The nurse is correct to include in the instruction to empty the urine pouch: A. Twice a day. Have the obdurator available. Inject humor to defuse the intensity. Once before bedtime. 67. After a cystectomy and formation of an ileal conduit. 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. How should the nurse respond to the husband? A. that is. Both client and attending nurse must wear masks at all times. C. D. D. A client with lung cancer is admitted in the nursing care unit. Divert the client’s attention. the nurse provides instruction regarding prevention of leakage of the pouch and backflow of the urine. Suction the trachea and mouth. C. Refer him to the nurse in charge. B. Every 3-4 hours. B. D. excretions. C. Listen without reinforcing the client’s belief.65. Every hour. D. C. and linen. D. which of the following nursing intervention should be implemented before starting the procedures? A. Which of the following signs and symptoms that require immediate attention and may indicate most serious complications during pregnancy? A. and increased vaginal mucus. C. caps and gowns are required during the period of contagion. Gloves are worn when handling the client’s tissue. The husband wants to know the condition of his wife. A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child has head lice. D. B. A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night. “bumps around the areolae. Severe abdominal pain or fluid discharge from the vagina. B. B. Find out what information he already has. 70. This means that: A. B. Excessive saliva. Full isolation. Suggest that he discuss it with his wife. Client is instructed in cough and tissue techniques. Which telephone call from a student’s mother should the school nurse take care of at once? A. . Which is the most therapeutic approach to this client? A. 71. Nurse and visitors must wear masks until chemotherapy is begun. Refer him to the doctor. 68. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. A hospitalized client cannot find his handkerchief and accuses other cient in the room and the nurse of stealing them. Do a pulse oximetry reading. Logically point out that the client is jumping to conclusions. C. 69.

the nurse observes that the mother is beating her child. An extensive. Sagging of the face on the operative side.. which changes would not be expected? A. Be mixed and the nurse must give the injection in three sites. prolonged study of the symptoms will be reassuring to the client. C. B. 74. Flat in bed. 78. 73. The nurse wants to know if the mother of a toddler understands the instructions regarding the administration of syrup of ipecac. B. Inability to close eyelid on operative side. Report the incident to protective agencies. C. DPT. “I’ll give the medicine if my child gets into some vitamin pills. The nurse should position the client: A. Assess the child’s injuries. D. attention and love. On the side only. D. D. What is the priority nursing intervention in this situation? A. What is the initial nursing action? A.” 77. or dependent feelings. Fatigue. The newborn becomes slightly cyanotic. C. “I’ll give the medicine if my child gets into some toilet bowl cleaner. “I’ll give the medicine if my child gets into some plant bulbs. Stimulate him to cry. aggressive. who seeks sympathy. and Haemophilus influenzae type B immunizations should: A. The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual. and urinary frequency at any time during pregnancy. nausea.” D. enlarging varicosities. With the head elevated 45-degrees (semi-Fowler’s). Inability to open eyelids on operative side. B. Be mixed and inject in the same sites. Aspirate his mouth and nose with bulb syringe. Which of the following statement will help the nurse to know that the mother needs additional teaching? A. B.” B. With the foot of the bed elevated. The community health nurse makes a home visit to a family. The client’s symptoms are imaginary and the suffering is faked. B.” C. 76. An infant is brought to the health care clinic for three immunizations at the same time. The nurse is assessing the newborn boy. The major fundamental mechanism is regression. D. The nurse is formulating a plan of care to a client with a somatoform disorder. 72. B. 75. to increase oxygenation. To assess if the cranial nerve VII of the client was damaged. and heartburn. Drooling and drooping of the mouth. . The nurse wants to maintain the implants in the correct position. Not be mixed and the nurse must give three injections in three sites. D. “I’ll give the medicine if my child gets into some aspirin. Apgar scores are 7 and 9. to reduce heat loss. Be drawn in the same syringe and given in one injection. Wrap him in another blanket. C. Ankle edema. The nurse knows that hepatitis B. Elevate his head to promote gravity drainage of secretions. D.C. C. During the visit. A female client with cancer has radium implants. The nurse needs to have knowledge of which psychodynamic principle? A.

“It tells if your renal insufficiency has affected your heart. The nurse is assigned to care for a client with urinary calculi. “I can’t sleep at night because of fear of dying.C. A 24-hour urine collection for Creatinine clearance is to be done.” The best response by the nurse is: A. B. The client has had a right-sided cerebrovascular accident. Tell them it is not appropriate to discuss such things.” What is the best initial nursing response? A. Prevent crystalline irritation to the ureter. In transferring the client from the wheelchair to bed. Only if the nurse agreed that the newborn could be fed formula.” 83. Weakened (R) side of the client next to bed. “Why are you afraid of dying?” D. giving her input about the case. to increase your chances of pregnancy. Always. B. . Many couples get pregnant when they are trying to adopt. because nurses who supervise less-trained individuals are responsible for their mistakes. Always. “Try to sleep. C. “Start planning adoption. Eat well. especially around the time of ovulation. “It must be frightening for you to feel that way. “The test measures the number of particles the kidney filters. exercise. B.” 82.” C. Increase the hydrostatic pressure in the urinary tract. 79. The nurse observes the female client in the psychiatric ward that she is having a hard time sleeping at night. Ignore them. B. “Consult a fertility specialist and start testing before you get any older. D. you won’t die. the primary reason for this is to: A. C. If the nurse failed to determine whether the nursing assistant was competent to take care of the client. What would be the appropriate action for the registered nurse to take? A. especially when the partners are in their mid-30s. The nurse asks the client about it and the client says. 85. What is the best advice the nurse could give to the couple? A.” C.” D. “It tells how well the kidneys filter wastes from the blood. D.” B. The nursing assistant mistakenly gives a formula feeding to a newborn that is on water feeding only. The nurse is counseling a couple in their mid 30’s who have been unable to conceive for about 6 months. and avoid stress. D. You are just here for some test.” D.” B. The nurse is caring for a cient who Is a retired nurse. The nurse is responsible for the mistake of the nursing assistant: A. “I can’t remember what this test is for. “Don’t worry. Refer the family to appropriate support group. You need the rest before tomorrow’s test. The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in giving care to the newborns. 80. Reduce the size of existing stones. Reduce the size of existing stones D.” C.” B. They are concerned that one or both of them may be infertile. Weakened (L) side of the cient next to bed. Join in the conversation. In the hospital lobby. The client tells the nurse. in what position should a client be placed to facilitate safe transfer? A. because they have the right to discuss anything they want to. “Have sex as often as you can.” 84. Tell me more about it. Fluid intake of 2L/day is encouraged to the client. “It provides a way to see if you are passing any protein in your urine. C. 81. Assist the family to identify stressors and use of other coping mechanisms to prevent further incidents. the registered nurse overhears a two staff members discussing about the health condition of her client. “it is no unusual to take 6-12 months to get pregnant. as a representative of the institution. Report this incident to the nursing supervisor.

C. but no changes observed. The LPN/LVN asks the registered nurse why oxytocin (Pitocin). 88. 10 units (IV or IM) must be given to a client after birth fo the fetus. C. B. B. D.C. agitation. 86. This behavior has been reported to the nurse manager several times. Uterine fibroid noted at time of cesarean delivery.” B. 250 mg D. The recommended PO tetracycline dose is 25-50 mg/kg/day. Consider that the obligation to protect the patient from harm has been met by the prior reports and do nothing further. lethargy and unkempt appearance. A toy gun. A ball. 125 mg 90. 87. A stuffed animal. What is the maximum single dose that can be safely administered to this child? A. C. Discuss the situation with friends who are also nurses to get ideas . The nurse should: A. Promotes lactation. Provide external controls. The nurse is planning to talk to the client with an antisocial personality disorder. First labor lasting 24 hours. Gratify the client’s inner needs. Legos. Weakened (R) side of the cient away from bed. 92. D. B. Approach the partner of this medical staff member with these concerns. Can be done with a mercury thermometer but no a digital one. D. B. The physician ordered tetracycline PO qid to a child client who weights 20kg. The nurse is teaching a group of women about fertility awareness. Maintains uterine tone. Minimizes discomfort from “afterpains. The nurse is correct to explain that oxytocin: A. D. Give the client opportunities to test reality. Which of the following toy should be avoided to be in the child’s bed? A. The child client has undergone hip surgery and is in a spica cast. Second birth by cesarean for face presentation. What would be the most therapeutic approach? A. 500 mg C. B. 91. Which event in the obstetric history will help the nurse suspects dysfunctional labor in the current pregnancy? A. C. D. D. The nurse in the nursing care unit is aware that one of the medical staff displays unlikely behaviors like confusion. 89. . Suppresses lactation. Reinforce the client’s self-concept. Total time of ruptured membranes was 24 hours with the second birth. The average temperature taken each morning. 1 g B. The nurse is completing an obstetric history of a woman in labor. the nurse should emphasize that basal body temperature: A. Weakened (L) side of the client away from bed. C. Continue to report observations of unusual behavior until the problem is resolved.

Which of the following is the most likely cause of it? A. which nursing care is least likely to be done? A. C. “I don’t see a bug in your bed. The nurse is correct in imparting the idea that the Good Samaritan law protects the nurse from a suit for malpractice when: A. B. 99. 97. Burp the newborn. The most therapeutic nursing response would be: A. Absolute bed rest. but you seem afraid. “Where’s the bug? I’ll kill it for you. A pregnant client in late pregnancy is complaining of groin pain that seems worse on the right side. The third trimester. D. Beginning of labor. advancement opportunities. Bladder infection. Deep-tendon reflexes once per shift. B. . 93. Constipation. Wha t would be the initial nursing action? A. Should be recorded each morning before any activity. A woman is hospitalized with mild preeclampsia. because that is the responsibility of the interviewer.” 96. The nurse takes into account that the developing fetus is most vulnerable to environment teratogens that cause malformation during: A. and continuing education. The nursing applicant has given the chance to ask questions during a job interview at a local hospital. The nurse stops to render emergency aid and leaves before the ambulance arrives. Daily weight. 98. benefits. C. the nurse keeps on assessing the condition of the client. While feeding a newborn with an unrepaired cardiac defect. B. and working hours first. B. 95. The second trimester. D. Ask as many questions about the facility as possible. D. Stop the feeding. B. 94. The nurse notes that the newborn’s respiration is 72 breaths per minute. because this will help in deciding whether or not to take the job. A male client tells the nurse that there is a big bug in his bed. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test. The nurse is conducting a lecture to a group of volunteer nurses. The nurse acts in an emergency at his or her place of employment. The nurse is grossly negligent at the scene of an emergency. Vital signs and FHR and rhythm q4h while awake. D. Decline to ask questions. B. D.” C. B. D. “You must be seeing things. C. C. The nurse advised the pregnant woman that smoking and alcohol should be avoided during pregnancy. Begin with questions about client care assignments. The entire pregnancy.” D. The nurse is formulating a plan of care for this client. Silence. The nurse refuses to stop for an emergency outside of the scope of employment. Clarify information regarding salary. What should be the most important question to ask that can increase chances of securing a job offer? A. The first trimester.C. Tension on the round ligament. C.

C. 8. D. D. D. A. D. In addition. a nurse should not accept telephone orders. 100. 11. 7. “I am late on my appointment. Citrus. A. 3. the cord may be compressed by the after coming head in a breech birth. A client who undergone appendectomy 3 days ago is scheduled for discharge today. 5. The nurse notes that the client is restless. 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. C. B. and increase the risk of bleeding. The nurse suspects: A. Toxic reaction to an antibiotic. It is important to externalize the anger away from self. 10. After tonsillectomy. D. Answers & Rationale 1. In hypothyroidism. B. with frequent and continued use. The most frequent cause of noncompliance to the treatment of chronic. . follow the hospital’s policy regarding telephone orders. Failure to followhospital policy could be considered negligence. Red liquids should be avoided because they give the appearance of blood if the child vomits. Generally speaking. The oxytocic effect of Pitocin increases the intensity and durations of contractions. Delirium tremens. prolonged contractions will jeopardize the safetyof the fetus and necessitate discontinuing the drug.C. Get a senior nurse who know s the policies. the infant’s muscle tone would be poor and the infant would not be able to achieve this milestone. B. The nurse was also unfamiliar with the doctor and the client. 9. The nurse is obligated to inform the nurse manager about changes in the condition of the client. Because umbilical cord’s insertion site is born before the fetal head. especially with the first pregnancy. B. 13. However. 12. It is of paramount importance to prevent the client from hurting himself or herself or others. Pupillary constriction impedes normal accommodation. Panic reaction. B. cool liquids should be given. and the doctor. carbonated. or open-angle glaucoma is the miotic effects of pilocarpine. Medication overdose. clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube. Continue the feeding. Notify the physician. C. This stops the sucking of air through the tube and prevents the entry of contaminants. Development normally proceeds cephalocaudally. can cause rebound congestion of mucous membranes. 4. clear. B. cause the child to clear the throat. 14. In this case. 6. it is an emergency situation. if it is necessary to take one. no one else is available and B. Therefore the nurse should not take the order unless A. and hot or cold liquids should be avoided because they may irritate the throat. reducing the client’s ability to read for extended periods and making participation in games with fas tmoving objects impossible. making night driving difficult and hazardous. Perinatal risk factors for the development of Down syndrome include advanced maternal age. Assignments should be based on scope of practice and expertise. Milk and milk products including pudding are avoided because they coat the throat. Phenylephrine.” and calling the nurse by the wrong name. B. A. which may change the decision made by the nurse manager. 2. the client. The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator. the nurse was new and did not know the hospital’s policy concerning telephone orders. picking at bedclothes and saying.

32. Every event that exposes a client to harm should be recorded in an incident report. 20. Serum radioimmunoassay (RIA. 28. 18. B. and conjunctivitis from Chlamydia. In preparing the client for discharge that is receiving prednisone. D. This option is least threatening. weight. Smoke inhalation affects gas exchange. Sperm deposited during intercourse may remain viable for about 3 days. B. 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. One of the earliest signs of digoxin toxicity is Bradycardia. is accurate within 7days of conception. 33. C. The child and parents should be taught what foods are high in potassium. B. Surgery and anesthesia can increase mucus production. 26. The responsible for an accurate informed consent is the physician. 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. The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. (C. A. and accuracy is not compromised by confusion with LH. Newborns can get pneumonia (tachypnea. 23. This is the proper use of anger. D. If ovulation occurs during this period. 17. D. but there are no data to support another response. 31. It describes a democratic process in which all members have input in the client’s care. A. The client may perceive this as avoidance. 16. B. conception may result. the child’s serum potassium level should be carefully monitored. This test is specific for HCG. cough. but it is more important to redirect back to the client. . In addition. Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. take oral preparations after meals. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the client’s only remaining lung. There are several models of case management. C. (D. D. In case management. mild hypoxia. C. 34. A. remember that routine checks of vital signs. 21. Women should contact their doctors if they exhibit signs of infection. 22. the nurse should caution the client to (A. Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland. C. B. the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty. A. 19. 24. decrease exacerbations and continually monitor progress overtime. 27. 30. Kegel exercise will help strengthen the perineal muscles. NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE. 25. and lab studies are critical. and the child should be encouraged to eat a high-potassium diet. An exception to this answer would be a life-threatening emergency. especially in light of the manipulative behavior of drug abusers and adolescents. store the medication in a light-resistant container. eosinophiliA. limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.15. (B. A. Phenytoin should be infused or injected into larger veins to avoid the discoloration know as purple glove syndrome. 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. but the commonality is comprehensive coordination of care to better predict needs of high-risk clients. B. D. infusing into a smaller vein is not appropriate. 29. For a toddler.

intermittently. 51. nonpathological macular newborn rash. C. the client should be placed in a semi-Fowler’s position to promote drainage and to prevent possible complications. This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning). and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. D. 50. Under high estrogen levels. The family needs to understand what brain death is before talking about organ donation. Fertilization could occur from sperm deposited before ovulation. Internal bleeding is difficult to recognized and evaluate because it is not apparent. 48. C. 36. 40. during the period surrounding ovulation. An advance directive is a form of informed consent. Protection of the skin from the effects of these enzymes is begun at once. facilitating sperm passage. Skin exposed to these enzymes even for a short time becomes reddened. The priority for this client is being able to establish an airway. B. Monitor clotting times and signs of any gastrointestinal or internal bleeding. 49. Support and limit setting decrease anxiety and provide external control. B. They need time to accept the death of their family member. 42. even if opposed by the spouse. Bleeding is an adverse effect. A. are enforced. If the spouse does not hold the power of attorney. clear. Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to one’s sexual partner. This suggests that the level of consciousness is decreasing. Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive. A. C. 37. D. Directing and evaluation of staff is a major responsibility of a nursing manager. Additionally. 52. This could indicate intracranial bleeding. 47. Bending from the waist in pregnancy tends to make backache worse. A. Suctioning is only done for 10 seconds. It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14. 46. D. 58. coughing and deep-breathing exercises should be planned to maximize the analgesic effects. 53. D. A. The stoma drainage bag is applied in the operating room. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. B. 43. B. C. B. 38. After surgery for a ruptured appendix. and elastic (spinnbarkeit). D. as the catheter is being withdrawn. and supports the client’s best interests. Taking the mother’s pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia. Erythema toxicum is the normal. 54. 56. 57. Because flank incision in nephrectomy is directly below the diaphragm. . the cervical mucus becomes thin. A. D. 45. 39. Antihistamines cause pupil dilation and should be avoided with glaucoma. deep breathing is painful. C. 44.35. A. includes speaking out for the client. Signs of placental separation include a change in the shape of the uterus from ovoid to globular. Thirst and restlessness indicate hypovolemia and hypoxemia. 55. turning. An environment conducive to discussing an emotional issue is needed. sperm life span of 72 hours. 41. egg life span 24 hours. there is a greater incisional pull each time the person moves than there is with abdominal surgery. the decisions of the holder. C. Therefore. An advocate role encourage freedom of choice. B. painful and excoriated. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin.

70. A. Note: some manufacturers make a premixed combination of immunization that is safe and effective. thus necessitating three separate injections in three sites. 62. 78. C. Proper handling of sputum is essential to allay droplet transference of bacilli in the air. 71. as well as legal obligation to provide adequate supervision. or sooner if the adhesive is loose). 60. A. to prevent air contamination. A. The pouch has an outlet valve for easy drainage every 3-4 hours. C. C. Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. A. the secretions may be aspirated. lacerations. Severe abdominal pain may indicate complications of pregnancy such as abortion. 73. B. B. 77. D. are highly corrosive substances. Toilet bowl cleaners. without air recirculation. A. B. A. 63. 80. Inability to open eyelids on operative side is seen with cranial nerve III damage. The registered nurse cannot delegate the responsibility for assessment and evaluation of clients. (the pouch should be changed every 3-5 days. 76. If the ingested substance “burned” the esophagus going down. Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours. Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. A. 61. A. as a collective whole. Listening is probably the most effective response of the four choices. 66. B. bleeding and fractures) is the first priority. The status of the client in restraint requires further assessment to determine if there are additional causes for the behavior. B. 67. A. 81. usually before cultures for tubercle bacilli are negative. Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing.59. Syrup of ipecac is not administered when the ingested substances is corrosive in nature. It is best to establish baseline information first. 75. such as during natural disasters. Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi. Secretions may have pooled above the tracheostomy cuff. C. The client with chest pain may be having a myocardial infarction. Assessment of physical injuries (like bruises. a form of cortisone. it may in greater pathology in a woman with potential breast carcinoma. 72. Betamethasone. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees. Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. D. required for effective gas exchange. 68. acts on the fetal lungs to produce surfactant. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy. Although denial has been found to be an effective mechanism for survival in some instances. ectopic pregnancy. Anxiety is generated by group therapy at 9:00 AM. Client should be in a well-ventilated room. and immediate assessment and intervention is a priority. The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment. it will “burn” the esophagus coming back up when the child begins to vomit after administration of syrup of ipecac. Somatoform disorders provide a way of coping with conflicts. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection. 79. Until chemical isolation is established. If these are not suctioned before deflation. Chemotherapy generally renders the client noninfectious within days to a few weeks. 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. Gentle aspiration of mucus helps maintain a patent airway. Immunization should never be mixed together in a syringe. 64. fluid discharge from the vagina may indicate premature rupture of the membrane. 69. 74. . many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance. C. C. D. 65. or abruption placenta. Older couples will experience a longer time to get pregnant. Urine flow is continuous.

85. The recommended dosage of tetracycline is 25-50mg/kg/day. nursing diagnosis for hemangioma. D. C. About the time of ovulation. An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors. is honest. The first is to remind the staff that confidentiality maybe violated.2-0. 91. C. physical assessment cephalocaudal . 93. Pencils. C. D. tissues. a slight drop in temperature may be seen. 98. backscratchers. 99. the child is being given this medication four times a day. B. or if pregnancy has occurred. 87. B. as a nurse what can i do if the tracheostomy tube is dislodged. 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. Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings. A. and structures. Therefore the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses. D. The BBT usually varies from 36. 89. 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. D. implying a lack of adequate controls.) 90. C. B. A normal respiratory rate for a newborn is 30-40 breaths per minute. With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. This choice implies concern for client care and self-improvement. If the child weighs 20kg and the maximum dose is 50mg/kg. C. 86. Tension on round ligament occurs because of the erect human posture and pressure exerted by the growing fetus. health teaching plan for appendectomy. The first trimester is the period of organogenesis. 100. 84. 83. 96. C. Personality disorders stem from a weak superego.) cephalocaudal assessment format. 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. 95. the BBT rises 0.3ºC during menses and for about 5-7 days afterward. The behavior described is likely to be symptoms of delirium tremens. In this case. therefore nurses who do not stop are not liable for suit. The behavior should be stopped. Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia. nursing exam with rationale. that is.4 ºC. after ovulation in concert with the increasing progesterone levels of the early luteal phase. 92. The Good Samaritan Law does not impose a duty to stop at the scene of an emergency outside of the scope of employment. This response does not contradict the client’s perception. and shows empathy. this would indicate a total daily dose of 1000mg of tetracycline. Oxytocin (Pitocin) is used to maintain uterine tone. A. This elevation remains until 2-3 days before menstruation. D. 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. 88. cell differentiation into the various organs. nursing intervention for hemiplegia. A. she will most probably have bathroom privileges. 94. 97. Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance test.82. C. or alcohol withdrawal (often unsuspected on a surgical unit. C. The client’s good side should be closest to the bed to facilitate the transfer.2 ºC to 36.

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.